Doc-20240131-Wa0 240131 223908
Doc-20240131-Wa0 240131 223908
Doc-20240131-Wa0 240131 223908
In this article...
● H
ow the lymphatic system is structured and how it drains tissue
● Causes, symptoms and treatment of different types of oedema, including lymphoedema
● How the lymphatic system transports fat and contributes to immunity
T
activating immune
responses his is the first article in a six-part Latin word lympha, meaning water (Bit.ly/
series examining the lymphatic CollinsLymphDefinition). Unlike the car-
An over- system and immunity. It pro- diovascular system, the lymphatic system
accumulation of vides an overview of the struc- is not a closed system and does not have a
lymph leads to ture and function of the lymphatic system, discrete pump analogous to the heart.
swelling of the soft focusing primarily on its role in tissue However, in many respects, the lymphatic
tissues called drainage. It also examines factors that can vessels are structurally similar to veins:
oedema; this compromise lymphatic flow, briefly they have relatively thin walls and carry
includes explores the role of the lymphatic system lymph under low pressure. For this
lymphoedema, in fat transportation, and introduces the reason, like veins, most of the larger lym-
which is caused by overlap and synergy between the lym- phatic vessels are equipped with valves to
poor lymphatic phatic and immune systems. prevent the backflow of lymph under the
drainage influence of gravity.
The lymphatic system Lymph flows through several key lym-
The lymphatic system can be thought of phoid organs, where its composition is
as a second circulatory system that runs in monitored and modified. The lymphoid
parallel, and in conjunction, with the car- organs are divided into:
diovascular system; it extends into every l P rimary lymphoid organs (red bone
major region of the body, with the notable marrow and the thymus gland), where
exceptions of the brain and spinal cord lymphocytes are generated from
(Moore and Bertram, 2018). The major ana- immature progenitor cells;
tomical components of the lymphatic l S econdary lymphoid organs (the spleen
system are highlighted in Fig 1. and lymph nodes), where lymphocytes
The lymphatic vessels form the con- reside and are positioned to mount
duits of the lymphatic system, and a immune responses.
watery fluid called lymph runs through The location and roles of the lymphoid
them; the term ‘lymph’ comes from the organs are summarised in Table 1 and will
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Copyright EMAP Publishing 2020
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Clinical Practice
Systems of life
Lymph Secondary Small, bean-shaped lymphoid organs found in major Primarily filter lymph, trapping foreign material
nodes clusters, including the cervical nodes (neck), axial such as bacterial and viral particles
nodes (armpits) and inguinal nodes (groin regions)
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Copyright EMAP Publishing 2020
This article is not for distribution
except for journal club use
Clinical Practice
Systems of life
nitrogenous waste products such as Fig 2. Capillary beds and the structure of lymphatic capillaries
urea and uric acid.
As interstitial fluid is forced out at the
arterial end of the capillary bed, the blood
remaining in the capillaries is thicker and
more viscous, and so moves more slowly. It
also has a higher concentration of soluble
materials, such as plasma proteins
albumin and fibrinogen, which exert an
osmotic pull. As a result, interstitial fluid
rich in waste metabolites returns to the
blood towards the venous end of the capil-
lary bed, eventually draining into the ven-
ules to be carried away in the venous
system.
the physical movements of the body. As time it reaches larger lymphatic vessels, it racic duct, for example through malignan-
with veins, contraction of skeletal muscles has mixed with the products of fat diges- cies such as lymphoma. This increases the
compresses lymphatic vessels, raising the tion and takes on a cloudy or milky appear- hydrostatic lymph pressure and causes
pressure inside with internal valves in the ance; at this stage it is referred to as chyle. chyle leakage (Rudrappa and Paul, 2019).
Nursing Times [online] October 2020 / Vol 116 Issue 10 41 www.nursingtimes.net
Copyright EMAP Publishing 2020
This article is not for distribution
except for journal club use
Nursing Times [online] October 2020 / Vol 116 Issue 10 42 www.nursingtimes.net
Copyright EMAP Publishing 2020
This article is not for distribution
except for journal club use
Clinical Practice
Systems of life
of the arm normally passes through the “Many women experience clinicians. Lymph node assessment can
axilla, therefore, axillary dissection can
lead to pronounced lymphoedema of the
mild oedema in pregnancy; provide valuable diagnostic information
about potential sites of infection – for
arm (Fig 3). this often leads to fluid example, the cervical lymph nodes of the
Symptoms include a heavy, aching limb accumulation and swelling neck commonly show lymphadenopathy
and weakness. Left untreated, it may pro- in the legs” in upper-respiratory-tract or middle-ear
gress to chronic lymphoedema and, in infections. The role of lymph nodes in
severe cases, the formation of hard fibrotic sequestering foreign material and partici-
tissue, which inhibits oxygen supply to the Fat transport pating in immune responses will be exam-
affected areas. Patients may become prone Within the gastrointestinal tract most ined in detail in the third part of this series,
to repeated skin infections and develop nutrient absorption takes place in the which examines antibody-mediated
skin ulcers that are difficult to heal. ilium, which is equipped with tiny, finger- immune responses. NT
Severely obese patients with a body mass like projections called villi that massively
index (BMI) over 50 are also prone to lym- increase its total surface area. Each villus ● Part 2 of this series will focus on the
phoedema which, in many cases, can be contains a complex, highly convoluted major lymphatic organs, including the red
severe and disfiguring. The link between blood capillary network and a central bone marrow, thymus and spleen.
extreme obesity and lymphoedema is blind-ended lymphatic vessel called a lac-
unclear. However it has been hypothesised teal (Fig 4). References
that increased adipose tissue accumulation Following the processes of mechanical Aviles F (2019) Managing the ‘weepy leg’ of
may collapse lymphatic vessels, reducing and chemical digestion, the products of chronic wound edema. Today’s Wound Clinic; 13: 9,
30-31.
tissue drainage, while increased inflamma- carbohydrate digestion (monosaccharide Greene AK et al (2015) Obesity-induced
tion may damage lymphatic vessels, sugars such as glucose) and protein diges- lymphedema nonreversible following massive
reducing their tissue density and ability to tion (amino acids) are absorbed directly weight loss. Plastic and Reconstructive Surgery –
collect and pump lymph (Nitti et al, 2016; through the walls of the villi into the blood Global Open; 3: 6, e426.
Greene et al, 2015). The complete blockage capillary network and transported to the Herlihy B (2018) Lymphatic system. In: The Human
Body in Health and Illness. Elsevier.
of lymphatic vessels can lead to an extreme liver via the hepatic portal vein.
Ilahi M et al (2020) Anatomy, Thorax, Thoracic
lymphoedema called elephantiasis. Larger-chain fatty acids do not enter Duct. Treasure Island, FL: StatPearls Publishing.
the blood directly; instead they enter the Johnson OW et al (2016) The thoracic duct:
Filarial elephantiasis columnar epithelial cells lining the villi, clinical importance, anatomic variation, imaging,
In tropical regions, the bites of infected and are coated and packaged with a mix- and embolization. European Radiology; 26: 8,
2482-2493.
mosquitoes transmit microscopic, ture of cholesterol and protein to form
Knight J et al (2018) Effects of bedrest 1:
threadlike, filarial worms. The parasites small spherical aggregates called chylomi- introduction and the cardiovascular system.
enter the lymphatic vessels and are carried crons which are then absorbed directly Nursing Times; 114: 12, 55-58.
to regional lymph nodes, where they cause into the lymphatic system’s central lac- Mohammad FI (2018) Filarial worms. Journal of
significant blockages in a disease called teals (Nigam et al, 2019). The lymphatic International Pharmaceutical Research; 45, 89-93.
lymphatic filariasis, which can result in system is a major route for the transporta- Mohseni S et al (2014) Peripheral
lymphadenopathy: approach and diagnostic tools.
lymphoedema (Mohammad, 2018). tion of the products of fat digestion and, Iranian Journal of Medical Sciences; 39: 2(Suppl),
Because lymphatic filariasis predomi- although it carries large amounts of modi- 158-170.
nantly occurs within poor urban and rural fied lipids, it does not appear to be suscep- Moore JE, Bertram CD (2018) Lymphatic system
populations, the lymphoedema often tible to the build-up of fatty plaque that flows. Annual Review of Fluid Mechanics; 50: 1,
remains untreated and develops into irre- can affect arteries. 459-482.
Nigam Y et al (2019) Gastrointestinal tract 4:
versible elephantiasis. In 2018, 893 million
anatomy and role of the jejunum and ileum.
people in 49 countries were living in areas Immune responses Nursing Times; 115: 9, 41-44.
that required preventive chemotherapy to Virtually all tissues in the human body are Nitti MD et al (2016) Obesity-induced lymphatic
stop the spread of infection (Bit.ly/WHO- drained by the lymphatic system, there- dysfunction is reversible with weight loss. The
LymphFil). fore, any infections within organs or tis- Journal of Physiology; 594: 23, 7073-7087.
Rudrappa M, Paul M (2019) Chylothorax. Treasure
sues usually result in the pathogenic parti-
Island, FL: StatsPearls Publishing.
Treatment of lymphoedema cles – bacteria, viruses or fungal cells Scallan JP et al (2016) Lymphatic pumping:
There are several treatments available for – circulating in the lymph. Throughout mechanics, mechanisms and malfunction. The
relieving chronic lymphoedema, including: the lymphatic system, strategically located Journal of Physiology; 594: 20, 5749-5768.
l M anual lymphatic drainage (MLD), collections of lymphoid tissue called
which involves gentle, rhythmic lymph nodes trap and process pathogens CLINICAL
massage to encourage the flow of and activate specific immune responses SERIES Lymphatic system series
lymph; that ultimately lead to pathogen destruc-
Part 1: Structure, function and oedema Oct
l C omplete decongestive therapy, which tion. Adults usually have around 600 of Part 2: Lymphatic organs Nov
incorporates therapeutic exercise, these bean-shaped nodes, which vary in Part 3: Immunity Dec
application of short-stretch size and typically enlarge and become Part 4: Allergies, anaphylaxis and
compression bandages, skincare and tender and inflamed in the presence of anaphylactic shock Jan 2021
MLD; infection (Mohseni et al, 2014). Enlarge- Part 5: Vaccinations and
l S equential gradient pump therapy, ment of the lymph nodes is called lym- immunological memory Feb
which helps break up fibrotic tissue to phadenopathy; swollen, tender nodes are Part 6: Immunotherapies Mar
re-enable movement of lymph. usually readily palpable by experienced
Nursing Times [online] October 2020 / Vol 116 Issue 10 43 www.nursingtimes.net