Lymph is a clear-to-white fluid made of:
First of all, lymph is important - as important as blood or oxygen. While loss of the lymph system would not be as immediately fatal, it would be fatal nonetheless - in less than 72 hours. Lymph is blood plasma after it has carried its nutrients into the body's tissues, dropped them off for the cells, picked up our metabolic wastes, and re-entered our water reclamation plant, which is the lymph system. Once it has passed through a series of nodes, where it is filtered and detoxified, lymph empties back into the heart where it once again becomes blood plasma.
Keeping the lymph system active is therefore extremely important - the faster we detoxify, the healthier we are. Lymph drainage is always indicated in cases of lymphedema. These can arise following surgery, trauma, or infection. Facial drainage helps with sinusitis and dental problems and is excellent for the skin - even providing a one or two day “face lift.” Lymph drainage hydrates the skin and removes local toxins, softening wrinkles, rejuvenating the skin, and helping to heal acne. It is of particular benefit in clearing cellulite. Drainage also promotes healing, toning, and revitalizing of the internal organs, benefiting irritable bowel syndrome, constipation, Crohn's disease, diverticulosis, gastritis, and chronic pancreatic insufficiency. These are but a few of the benefits - the list goes on almost endlessly.
Mostly lymph is water - about 96%. It is also rich in minerals, about the same as seawater, as well as proteins and white blood cells. All together these make up the other 4%. Lymph is the clear fluid you see seeping out of a scrape or shallow cut, often before there is any blood. The bulk of our lymph fluid circulates just beneath the skin, where it is quickly available as the immune system|immune system's first line of defense and the body's first response to minor injuries.
Our bodies are about 50% water by weight. Of this, about 30% is lymph. The rest is blood plasma, interstitial fluid (in the tissues), and cerebral spinal fluid. By volume, our bodies contain about three times as much lymph as they do blood. But because lymph is clear (the root word is “limpa,” meaning limpid, clear), the vessels that carry it are difficult to see. Thus, it was not really discovered until 1622, when Gasparo Aselli dissected a dog that had just eaten a meal high in fat, temporarily making the largest vessels visible as “milky veins.”
Another way of thinking about the lymph system is to consider it a scavenging system for interstitial fluid. If it fails, even partially, this fluid is not sufficiently collected and the result is an area of swelling known as edema. If it fails altogether, the entire body swells and bloats until the toxic overload becomes too great for life to continue. Too keep it healthy requires drinking plenty of water and exercising, especially swimming and stretching and rhythmic movements. Of course, a good session of lymph drainage does not hurt.
Microscopic lymphatic capillaries create the beginning of the lymphatic system. These lymphatic capillaries are closed ended tubular formations which create large and intricate networks in the intercellular spaces of most of the body’s tissue. An example of this would be within the villi of the small intestines. Here, the lymphactic capillaries are known as lacteals and they are used for the transportation of the products produces by fat absorption away from the GI tract. Endothelial cells create the inner walls of the capillaries, which are porous, absorbed fats, proteins, interstitial fluid, and microorganisms are able to enter the capillaries without much effort. Once fluids begin their journey within the capillary walls, it is referred to as lymph fluid. Over-saturation of interstitial fluid within the capillaries is a medical condition known as edema, and results from poor drainage of the lymph fluid.
Lymph fluid travels through the smaller capillaries which them merges and empties into larger vessels known as lymph ducts. The inner walls of the lymph ducts are very similar to the inner walls of veins. Aside from the valves which are designed to prevent back-flow, they are also designed with the same three layers which create that the walls of veins have. Skeletal muscles and their tendency to contract creates a massaging motion that produces the friction necessary for the flow of the lymph fluid to continuously move throughout the network. Intestinal movement also contributes to the motion, as does the occasional peristaltic action of the lymphatic vessels themselves. The valves keep the lymph fluid flowing in the appropriate direction. The lymph ducts continuously connect and then interconnect until finally they empty into one of two main vessels. The thoracic duct is larger than the right lymphatic duct and drains the lymph fluid received from the lower extremities, the abdominal region, left thoracic area, left upper extremity, as well as the left side of the neck and the left side of the head. This vessel’s main section then follows the spinal column until finally it drains directly into the subclavian vein.
The thoracic duct has an enlargement which resembles a sac within the abdominal region. The enlargement is known as the cisterna chyli and it is responsible for the collection of lymph fluid from the intestinal area and the lower extremities.
The right lymphatic duct is smaller and it is responsible for draining the lymphatic fluid from the right side of the head and neck, the right upper extremity, and the right thoracic region. The right lymphatic duct then drains the collected lymph fluid directly into the subclavian vein, near the area of the jugular vein.
by Alica Di Rado
First, they face body-altering surgery, then months of chemotherapy and finally a regimen of radiation treatments. As the tests and scars fade into memory, though, breast cancer survivors may be hit with a frustrating reminder of their past.
A swelling of the arm or leg (or occasionally another part of the body), lymphedema occasionally follows treatment of a variety of cancers. It is most often linked with breast cancer, and can even develop many years after surgery and radiation therapy.
The majority of women with breast cancer will never experience lymphedema. But some do.
Because lymphedema is more than just an unfortunate side effect, physicians provide patients with the information they need to recognize it, ease its symptoms early and protect themselves from complications. Yet physicians never know in advance who will develop it.
“Lymphedema is unpredictable-an unsolved dilemma,” says Howard Silberman, M.D., professor of surgery and breast cancer specialist at the USC/Norris Comprehensive Cancer Center and Hospital. “We don't know exactly why it happens, but we think we know what factors contribute to it.”
A network of lymph nodes and lymph vessels lace throughout the body carrying lymph fluid, much like blood vessels carry blood. White blood cells course through the pale lymph liquid to help fight infection, while small, bean-shaped lymph nodes trap bacteria and other tiny invaders so the immune system can get rid of them. The lymphatic system also absorbs extra fluid in tissue and returns it to the blood stream.
In a patient with cancer, spreading cancer cells often end up in lymph nodes, so surgeons frequently remove groups of nodes so pathologists can examine them for signs of cancer. In most breast cancer surgeries, doctors remove 10 to 40 axillary lymph nodes, intertwined lymph vessels and tissue from the underarm.
Removing lymph nodes and lymph vessels-or scarring them through radiation therapy-alters the way lymph fluid drains in the body. In breast cancer patients, the lymphatic system struggles to remove fluid from the arm and breast. Sometimes even tumors themselves can interfere with lymph flow.
“In lymphedema, the pressure in the lymph vessels can become so great that fluid oozes through the walls of the vessels,” Silberman says. “It has nowhere to go but into the soft tissue.”
As a result, a woman's shirtsleeves may begin to feel tight, watches no longer fit around the wrist and the arm may feel heavy. One arm may look significantly thicker than the other or feel numb.
Physicians often check the volume of the arm during follow-up office visits after breast cancer surgery, and ask about symptoms of discomfort.
“It's important to catch lymphedema early,” says Brendon Twigden, P.T., a physical therapist who offers a lymphedema program for cancer patients at USC/Norris. “The sooner it is treated, the better the result. It is unwise to allow the condition to progress significantly and then come in for help.”
The mantra for early lymphedema sufferers is simple: elevation, elevation, elevation.
Physicians can show patients exercises that involve elevating the arm above the heart to help circulate fluid, Twigden says. Some patients also benefit from a device that keeps the arm elevated while they sleep.
Since lymph flows in the body through the pumping action of surrounding muscles that push on lymph vessels, moving the affected limb and flexing muscles can help patients.
Twigden keeps an eye on just how much exercise lymphedema patients perform, though. “If a woman wants to go running, for example, I encourage her to do what is prudent,” he says. “I'd suggest she start doing short distances initially to see how things go.”
When symptoms nag patients and do not go away, USC/Norris oncologists refer them to Twigden, who then offers specialized physical therapy at the USC/Norris Hospital.
Twigden often stimulates the limb through the skin and performs a lymph drainage massage to squeeze out lymph fluid. The patient may then be fitted for a custom-made elastic pressure sleeve, which is designed to exert a specific amount of pressure on the limb. In certain cases, an inflatable sleeve can be placed around the limb, and a computer-controlled pump prompts the sleeve to slowly fill with air, pressing on the limb and pushing lymph fluid away.
At the same time, Twigden puts patients on a program of exercises that can help get them back to comfortably performing their daily activities, whether carrying groceries or combing their hair.
“About 50 percent of the patients get better right away,” Twigden says. Others take more consistent work, and even then, lymphedema may never completely recede.
These patients-and any at risk for lymphedema-need to avoid infection, which prompts the body to make extra lymph fluid and, in turn, can set lymphedema in motion.
To reduce the likelihood of infection, doctors suggest keeping the cuticles and skin on the hands moisturized and clean. Bug bites and animal scratches should be avoided or treated with antibacterial cream. Protective gloves for gardening and yard work can help prevent cuts, too. Physicians also suggest shunning saunas and hot tubs.
Injections and blood draws should be done on the unaffected arm; some patients even wear a bracelet or necklace that alerts health professionals not to perform injections on a certain arm or leg.
In rare cases, limbs can swell so much that fluid begins to leak from the skin surface and break down the skin itself.
Physicians have recognized certain factors that may precipitate lymphedema or put patients at greater risk, Silberman says: obesity, vascular disease, high blood pressure, airline travel, advanced age, and having the breast tumor on the side of the dominant arm. The number of lymph nodes removed in surgery might be another factor.
As oncologists gain more experience with sentinel node biopsy-a new method to gauge cancer spread by removing only one or two lymph nodes-researchers suggest that cases of lymphedema will decline.
“Some people think that if you remove fewer lymph nodes in surgery, there is less chance of lymphedema,” Silberman says. “But the current evidence is not clear.”
Until more is known, patients at risk for lymphedema are best advised to watch for symptoms and discuss any problems with their physician-while moving on with life after cancer
Lymphatic capillaries are present in nearly all tissues. Significant exceptions are the central nervous system and bone. Small interstitial channels are present in the brain and the fluid flows into the CSF and then passes back into the circulation via the arachnoid villi.
The lymph capillaries are blind-ending and possess flap valves between adjacent lymphatic endothelial cells. These functional valves permit entry of ISF but prevent its return to the interstitium. The pressure inside the lymph capillary is about 1 mmHg at rest and the flap valves are closed. The lymph capillaries interconnect and join together to form lymph venules, and then large lymph veins which drain via lymph nodes into the thoracic duct (on the left) and the right lymphatic duct. By these two final pathways, lymph returns into the circulation.
There is no central pump in the lymphatic system
Forward flow is due to a pressure gradient within lymph vessels aided by one-way valves which prevent backflow
Lymph enters lymph capillaries when the pressure in the tissue in low (up to 2mmHg) as the flap valves between lymph capillary cells are
ISF enters lymphatic capillaries in the phase after the external pressure has passed as external connective tissue fibres tend to tent open the lymph capillaries, opening the flap valves
When ISF pressure increases beyond +2 mmHg then these flap valves close (passively due to the pressure gradient)
With flap valves closed, the increased external (ISF) pressure tends to promote forward lymph flow provided pressure is not too high (eg ⇐2 mmHg). At higher pressures, the unevenness of the pressure tends to close proximal lymph channels and lymph does not flow (Starling resistor effect)
The main sources of suitable levels of external pressure to promote flow are arterial pulsations and muscular contractions
The close association of lymph channels with arteries tends to favour flow Larger lymph vessels have smooth muscle in their walls. 'Intrinsic contraction' of these smooth muscle cells assists forward flow
Lymph vessels have bi-leaflet valves every few mm and these are extremely important: no forward flow is ever lost
The three functions of the lymphatic system are -
Return of protein and fluid from the ISF to the circulation to maintain a low interstitial fluid protein concentration and maintain the oncotic pressure gradient across the capillary membrane. Oedema will occur if ISF oncotic pressure is not kept low.
Role in absorption and transport of fat from the small intestine.
Lymph from most parts of the body usually has a low protein concentration. Liver lymph is different because:
It normally has a high protein concentration (due to low reflection coefficient)
It contributes more than half of all the thoracic duct lymph
The thoracic duct carries about 80% of the total lymph flow. This total flow at rest is about 120 mls/hr. If interstitial hydrostatic pressure rises (ie becomes less negative) due to excess fluid filtration & accumulation, the total lymph flow can increase quite markedly.
Chyle is lymph from the intestines which has a milky-while appearance due to the presence of large numbers of chylomicrons. Chylomicrons are 100nm diameter complexes of mostly triglycerides (containing the long chain fatty acids) enclosed in a hydrophobic protein coat. Chylomicrons enter the lymphatic lacteals in the villi, travel in the lymph and then enter the circulation via the thoracic duct.
Absorption of snake venoms (for Australian elapid snakes) occurs principally via lymph channels. If the bite is on a limb, the rate of venom absorption can be very much retarded by firm external compression of the lymph channels (pressure) and by not exercising the muscles of the limb (immobilisation). The aim of this 'pressure-immobilisation technique' for bites on limbs is to minimise entry of venom into the circulation and to 'buy time' so the person can reach medical care where specific anti-venom is available. As absorption is not directly into the venous system at the bite site, a torniquet is unnecessary and should NOT be used.
'Fluid Physiology' by Kerry Brandis -from http://www.anaesthesiaMCQ.com
Leaky lymphatic vessels are the leading cause of the adult onset obesity observed in a laboratory model developed by investigators at St. Jude Children's Research Hospital. The findings suggest that the abnormal leakage of lymph fluid from the ruptured lymphatic vessels stimulates the accumulation of fat, particularly in regions of the body rich in lymphatics, the researchers said. The lymphatic vasculature (system of capillaries and vessels) that drains lymph is essential for the immune response in inflammation, and is the main route for the spreading of metastatic tumors to the lymph nodes.
The St. Jude investigators showed that removal of one of the two copies of the gene Prox1 disrupts normal development of the lymphatic vasculature, leading to leakage of lymph from ruptured lymphatic vessels, and subsequent obesity. Specifically, the researchers found that adipocytes (fat cells) near leaking lymphatic vessels under the skin and in the abdomen were significantly larger than normal, and therefore able to store more lipids (e.g., fatty acids and triglycerides, used as an energy source).
“This is the first such evidence in an in vivo model showing that defects in the integrity of the lymphatic vasculature could lead to adult obesity,” said Guillermo Oliver, Ph.D., an associate member of the Genetics and Tumor Cell Biology Department at St. Jude. “And therefore, this is the first model available for studying obesity linked to faulty lymphatic vessels. It will be an important tool for studying this novel form of adult-onset obesity, as well as diseases of lymphatic vessels, and eventually, extending those findings to humans.” Oliver is senior author of a report on this work that appears in the September 18 online issue of Nature Genetics.
The laboratory model (Prox1+/- ) lacked one of two copies of the Prox1 gene, which is required for proper development of the lymphatic system. Previously, Oliver's laboratory reported that Prox1 activity is necessary for the normal development of cells making up the lymphatic vasculature; and that it is the subsequent budding and sprouting of those cells that give rise to the lymphatic system (Cell :769-778; 1999).
Most Prox1+/- heterozygous (i.e., having only one copy of the gene) models die quickly in the postnatal period as a consequence of extensive lymphatic leakage that accumulates in the abdomen and thorax (chest). “However, those with a milder disruption of their lymphatic vasculature were able to survive and become obese with age,” Oliver said.
“Interestingly, those that survived did not develop diabetes, as commonly seen in different types of obesity,” he added. “This told us that the type of obesity we were seeing in this laboratory model was different from forms of obesity that are commonly associated with diabetes.” The researchers also demonstrated that lymph removed from the abdominal cavity of the Prox1+/- models and added to cultured cells can promote adipocyte differentiation, most likely due to certain factors present in the collected lymph.
“Our findings might encourage physicians to consider that at least some of their obese patients might be suffering from a problem that can't be solved by eating less and exercising more,” Oliver said. Just as many vascular disorders arise because of blood vessel defects, other defects of the closely related lymphatic vessels in addition to edema could also occur in humans, he added.
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