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Physical Agents > Lymphatic Anatomy and Edema Physiology > Flashcards

Lymphatic Anatomy and Edema Physiology Flashcards

1
Q

definition of lymphatic system

A

one-way system composed of tiny vessels which carry fluid from the interstitial fluid to the blood

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2
Q

functions of lymphatic system

A
  • immune surveillance
  • transport system
  • edema prevention
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3
Q

immune surveillance

A
  • Protects body from infection and disease via the immune response
  • Production, maintenance and distribution of lymphocytes
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4
Q

transport system

A

Returns excess water, fats, proteinand large molecules to the venous
blood

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5
Q

edema prevention

A

Edemaresults when the lymphatic loadexceeds the lymphatic
transport capacity

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6
Q

what does edema do?

A
  • impairs cellular nutrition (increases interstitial distance for oxygen and nutrients)
  • impairs tissue viability
  • increases risk for infection
  • causes pain, mobility, and functional impairment
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7
Q

lymphatic levels of organization

A

*Initial lymphatics/lymphatic capillaries
*Pre-collectors
*Collectors
*Nodes
*Trunks
*Ducts

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8
Q

primary function of initial lymphatics/capillaries

A

absorb interstitial fluid from the interstitium

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9
Q

interstitial fluid =

A

lymphatic fluid

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10
Q

what does lymphatic fluid contain?

A

protein, water, fatty acids, salts, WBC, foreign debris, microorganisms

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11
Q

what are initial lymphatics/capillaries composed of?

A

*Composed of a single layer of epithelial cells
*No valvularstructure in the lumen

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12
Q

what do pre-collectors connect?

A

initial lymphatics to the lymphatic collectors

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13
Q

what aids transport in the pre-collectors?

A
  • valvular structure and smooth muscle
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14
Q

do the pre-collectors absorb fluid?

A

not really –> minimal absorption of fluid

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15
Q

what do collectors do?

A

*Transport lymph to the lymph nodes and lymphatic trunks
*Contain contractilesmooth muscle
*Structurally similar to veins
*Contain valves that promote fluid proximally

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16
Q

lymphangion

A

region between the valves; considered the functional unit of the collectors

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17
Q

lymphangiomotoricity

A
  • Frequency of lymphangion contraction
  • Contracts 6-10 times per minute
  • Increases 10 fold when there is an increased lymphatic load
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18
Q

the transport abilities of collectors are enhanced through:

A
  • Respirations/diaphragmatic breathing
  • Arterial/venous pulsations
  • Skeletal muscle movement
  • Newly formed lymphatic fluid
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19
Q

how many lymph nodes are in the human body?

A

600-700 nodes (regional or interval nodes)

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20
Q

can lymphatic vessels regenerate?

A
  • yes (lymphangiogenesis)
  • but lymphedema nodes cannot
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21
Q

functions of lymph nodes

A
  • Removal of chemical, organic, inorganic cell products, viruses and bacteria
  • Production of lymphocytes to support the immune system –introduce systemic immunity
  • Passageway for lymphatic fluid
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22
Q

are lymph nodes normally palpable?

A

no

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23
Q

lymph nodes: practical anatomy

A

*Play an important role in the spread of cancer
*Regional lymph nodes my be invaded by malignant tumors which can result in metastases to other regions of the body
*Removal or irradiation of regional lymph nodes can result in lymphedema

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24
Q

L head and neck lymph nodes drain to

A

L cervical region

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25
Q

R head and neck lymph nodes drain to

A

R cervical region

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26
Q

L upper trunk drains to

A

L axilla

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27
Q

R upper trunk drains to

A

R axilla

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28
Q

L lower trunk quadrant drains to

A

L inguinal

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29
Q

R lower trunk quadrant drains to

A

R inguinal

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30
Q

what are the largest lymphatic vessels?

A

lymphatic trunks

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31
Q

what do lymphatic trunks form?

A

the main parts of the transporting vessels

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32
Q

what is the lymphatic trunks level?

A

Level at which the lymphatic fluid is mixed into the venous blood
via lymphovenous anastamoses

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33
Q

what innervates the lymphatic trunks

A

sympathetics

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34
Q

R lymphatic duct

A
  • Drains R head, neck, trunk, arm
  • Enters R internal jugular and subclavian veins
    – right venous angle
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35
Q

left lymphatic duct (thoracic duct)

A
  • Begins at the cisterna chyliat L2-T10
  • Empties ~3L of lymph/day into L venous angle
  • Drains lower half of body, L head, neck, trunk, arm
  • Enters L internal jugular and subclavian veins
    — Left venous angle
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36
Q

what are lympho-lymphatic anastomoses?

A

shared connections allowing drainage between two adjacent territories

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37
Q

why are lympho-lymphatic anastomoses a potential barrier to flow?

A
  • Dilated avalvularcapillary network
  • Shared connections are few but existent in the superficial collectors
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38
Q

what do lymph-lymphatic anastomoses include?

A
  • Inter-axillary/Axillo-axillary
  • Axillo-inguinal/Inguino-axillary
  • Inter-inguinal/Inguino-inguinal
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39
Q

lymphatic watersheds

A

*Theoretical boundary between lymphatic territories
*Scarcity of lymphatic vessels
*Areas that are crossed by the lymphatic capillaries but not the deep collectors

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40
Q

what do lymphatic watersheds include

A
  • Median sagittal
  • Transverse
  • Clavicular
  • Spine of scapula
  • chaps (“gluteal”)
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41
Q

microcirculation - diffusion

A
  • Passive event
  • Molecules move from higher to lower concentration, moving towards equilibrium
  • Primary method of exchange of nutrients and metabolic end products across the capillary membrane
  • Small molecules diffuse more rapidly
  • Higher temperature –faster diffusion
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42
Q

Osmosis

A
  • Unidirectional diffusion through a semi-permeable membrane to effect and equilibrium based on the concentration of protein molecules
43
Q

Osmotic Pressure

A

Energy by which the more concentrated solution attracts water; the
lower the water concentration, the higher the osmotic pressure

44
Q

hydrostatic pressure

A

Pressure exerted by fluid; blood pressure

45
Q

what are colloids

A

protein molecules

46
Q

colloidal osmosis

A

Semi-permeable membrane allows diffusion of water; prevents diffusion of protein molecules resulting in colloidal osmotic pressure
* Water molecules pas through the membrane increasing the pressure on the protein side

47
Q

starlings law

A

*Rate and direction of fluid exchange between the capillaries and the interstitial space are determined by the hydrostatic and osmotic pressures of the two fluids
*Describes the balance of capillary filtration and capillary absorption

48
Q

filtration

A
  • Process by which fluid leaves the vessel
  • Occurs when hydrostatic pressureforces water across a membrane
  • Typically occurs at the arterial endwhere blood pressure is the highest
49
Q

absorption

A
  • Process by which fluid re-enters the vessel
  • Result of osmosis
  • Typically occurs at the venous end
50
Q

what is blood capillary pressure

A
  • Fluid pressure in the capillary at both the arteriole and venous ends
  • Major determinant of fluid movement in normal circulation
51
Q

what determines blood capillary pressure

A
  • Determined by arterial pressure, venous pressure, pre-and post-capillary resistance
52
Q

what is normal blood capillary pressure

A
  • Normally around 35mmHg in the arteriole capillary which favors FILTRATION
  • Normally around 15 mmHg in the venous capillary
53
Q

what is blood capillary pressure practical application

A

Increases in venous capillary BCP with venous insufficiency will result in decreased absorption –> leading to edema

54
Q

Interstitial pressure

A
  • Fluid pressure in the interstitium
  • Normally around 0-2 mmHg
  • Minimal effect on filtration or absorption
55
Q

plasma colloidal osmotic pressure

A
  • Osmotic force due to plasma protein concentration
  • Normally around 20-28 mmHg, which favors ABSORPTION in the venous end of the capillary
56
Q

interstitial colloidal osmotic pressure

A
  • Osmotic force due to interstitial fluid protein concentration
  • normally around 3 mmHg
57
Q

practical application of CPOi

A

COPi increases with lymphedema due to decreased uptake of proteins
in the lymphatic system, resulting in decreased absorption, leading to
edema

58
Q

normal circulation results in

A

net filtration

59
Q

what absorbs 90% of fluid and cells?

A

venous system

60
Q

what absorbs 10% of fluid and cells?

A
  • lymphatics (ultra filtrate)
  • Ultrafiltrate includes large proteins and lipids that cannot be reabsorbed through the venous system
61
Q

ultra filtrate =

A

Lymph obligatory load
- 2-4 L liquid, 80-200g protein per 24 hrs

62
Q

key factors influencing lymphatic system

A
  • lymphatic load
  • transport capacity
  • functional reserve
63
Q

Lymphatic load

A

Amount of substances that have to be removed from the interstitium by the lymphatic system (water, proteins, fat, cells)

64
Q

transport capacity

A

Maximum amount of lymph volume that can be transported by the lymphatics per unit of time

65
Q

functional reserve

A

FR = TC - LL

66
Q

lymphatic sufficiency

A
  • LL < TC
    healthy lymphatic system
67
Q

dynamic insufficiency

A

LL > TC
healthy lymphatic system
low protein edema
(lymphatic load increases)

68
Q

mechanical insufficiency

A

LL > TC
diseased lymphatic system = lymphedema
high protein edema
(transport capacity decreases)

69
Q

combined insufficiency

A

LL > TC former healthy lymphatic system
LL > TC diseased lymphatic system
high protein edema

70
Q

normal lymphatic compensations

A

*Increase of transport capacity
*Collateral circulation
*Lympho-lymphatic anastomoses
*Lympho-venous anastomoses
*Plasma protein reduction by macrophages

71
Q

edema results when

A

lymphatic and venous systems can no longer absorb fluid
increased filtration, decreased absorption, or both

72
Q

proteins that are not absorbed

A

will increase the interstitial osmotic pressure

73
Q

long standing edema will change

A

from pitting edema to fibrosis due to the accumulation in the interstitial space

74
Q

general edema (requires medical management)

A
  • Congestive heart failure
  • Renal failure
  • Cirrhosis of the liver (salt and water retention)
  • Nephroticsyndrome (low plasma oncotic pressure)
75
Q

venous stasis (localized edema)

A
  • Increased venous capillary hydrostatic pressure
  • Resultant decrease in absorption
  • Fluid accumulates in interstitial space = EDEMA
  • Clinical picture: lower leg edema (unilateral/bilateral), hemosiderin staining
  • Activates lymphatic functional reserve
  • Longstanding edema will overwhelm lymphatic functional reserve => lymphedema
  • Clinical picture: lower leg edema, fibrosis in tissues
76
Q

how to treat venous stasis edema

A

compression

77
Q

localized edema - inflammation

A
  • Vasodilation of microcirculation leading to increased blood flow
  • Increased capillary membrane permeability to fluid and proteins
  • Net filtration of plasma into the interstitial space = EDEMA
  • Chemotaxis through exit of leukocytes from venulesinto interstitial fluid; Phagocytosis to destroy bacteria; Tissue repair
  • Clinical picture: edema localized to area of injury
    from post surgical, trauma (strains, sprains)
78
Q

how to treat inflammation

A

MLD and compression

79
Q

localized edema - lymphedema

A
  • Inability of lymphatic system to absorb lymph obligatory load
  • Lymphatic load exceeds lymphatic transport capacity
  • Increased interstitial osmotic pressure due to increase in interstitial proteins
  • High protein fluid accumulates in interstitial space = EDEMA
  • Clinical picture: edema may be unilateral or asymmetrical if bilateral; may involve whole extremity; history of lymphatic incapacity
80
Q

how to treat lymphedema

A

treat with complete decongestive therapy

81
Q

what is lymphedema?

A

*A swelling of a body part, most often found in the extremities
*An accumulation of protein-rich fluid in the interstitium which causes chronic inflammation and reactive fibrosis of the affected tissues

82
Q

primary lymphedema

A
  • Developmental abnormality of the lymphatic system
  • Hereditary
  • At birth
  • < 35 years of age = lymphedema praecox
  • > 35 years of age = lymphedema tarda
  • Can often develop later in life without a cause
83
Q

secondary edema

A
  • Known cause of injury to lymphatic system
  • Surgery and/or radiation
  • Cancer
  • Trauma
  • Infection
  • Filariasis
  • Immobility
  • Chronic venous insufficiency
  • self induced
84
Q

where can lymphedema develop

A

Only occurs in regions of body that affected lymph vessels and
nodes are responsible for draining

85
Q

multiple classifications of primary lymphedema

A
  • Onset time
  • Clinical Manifestations
  • Family History
  • Lymphatic Malformation as seen in MR lymphangiography
86
Q

filariasis treatment

A

*Global program to eliminate lymphatic filariasis
—– WHO sponsored
—– Mass drug administration of 2-drug treatment annually for 4-6 years
—— Ivermectinand Albendazole
*Hygiene to prevent infections
—– Infections increase fluid and decrease elastin in affected tissues
*Elevation, Exercise, Compression

87
Q

characteristics of lymphedema

A

*Slow onset, progressive
*Pitting in the early stages
*Distal → Proximal
*Squaring of toes, (+)
Stemmer’s sign
*Dorsum of foot “Buffalo
hump”
*Loss of ankle contour
*Asymmetric (if bilateral)
*Cellulitis is common
*Rarely painful
*Discomfort common (heaviness, achiness)
*Hyperkeratosis, Papillomas, PeauD’Orange
*Ulcerations unusual

88
Q

classification of lymphedema

A

slide 63

89
Q

unilateral leg edema differential diagnosis

A
  • Deep vein thrombosis
  • Venous disease
  • Arterial disease
  • Lymphedema
  • Trauma
  • Surgery
  • Obstruction of inguinal lymph nodes
90
Q

bilateral leg edema differential diagnosis

A
  • Cardiac disease
  • Kidney disease
  • Liver disease
  • Immune/Nutritional/Endocrine disease
  • Venous disease
  • Lipedema
  • Lymphedema
  • Medications
  • Obstruction of pelvic/abdominal lymph nodes
91
Q

lipedema

A

*Found almost exclusively in females
*Bilateral accumulation of fat deposition in the LE and buttocks
*Insidious onset in adolescence
*Progressive swelling of the lower extremities; sparing of the feet; non-pitting
*Painful, varicose veins, weight gain

92
Q

why is early diagnosis of lipedema important

A

to prevent impaired mobility, arthritis, and lymphatic insufficiency

93
Q

lipedema treatment

A
  • Weight control
  • Complete Decongestive Therapy
  • Liposuction
  • Outcomes –improvement in pain, sensitivity to pressure, swelling, bruising and functional mobility
94
Q

what is lymphangitis

A

*Infection of the lymphatic vessels
* Potential pathogens: bacteria, mycobacteria, fungi, parasites

95
Q

signs and symptoms of lymphangitis

A
  • Fever and chills
  • Swollen lymph nodes
  • Malaise
  • Loss of appetite
  • Headache
    *aching muscles
96
Q

cellulitis

A
  • Common but potentially serious bacterial skin infection
  • Infection can spread through lymphatic system into blood stream –> life threatening if untreated
97
Q

signs and symptoms of cellulitis

A
  • Erythema
  • Edema
  • Pain and tenderness
  • Warmth
  • Fever
  • Skin dimpling
  • blisters
98
Q

what is obesity associated with?

A

sleep apnea and venous insufficiency

99
Q

FACT-B +4

A
  • Functional Assessment of Cancer Therapy –Breast
  • Consists of 36 items across 5 domains
  • Physical well-being, social/family well-being, emotional well-being, functional well-being and arm morbidity (4 questions on swelling and tenderness)
100
Q

DASH

A
  • Disability of Arm, Shoulder and Hand Questionnaire
  • 30-item self report evaluating patient symptoms and functional tasks associated with limitations of the arm, shoulder and hand
101
Q

Perometry

A

*Optoelectric device utilizing infrared light to create a 3D silhouette of the limb
*Can detect changes of less than 150 ml in a limb

102
Q

Bioimpedance: ImpediMed

A

L-Dex® U400 is a bioimpedance analyzer designed to assist in the clinical assessment of extracellular fluid differences in the arm

103
Q

volumetric girth

A

Volume = h . ((Ct . Ct) + (Ct . Cb) + (Cb . Cb)) / (12 . Π)
Interraterand intraraterreliability = .91-.99 (ICC 2,1)
Standard Error of Measurement = 116 mL

104
Q

water displacement

A
  • Water volume considered “gold standard”
  • Provides an accurate way to include volumetric data of the foot and hand in the total limb volume measurement
  • Cannot be performed with open wounds
  • Time consuming and cumbersome

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