1. Sammy Case s.case@warwick.ac.uk
Lymph Drainage
Sammy Case

2. What is lymph?
Lymph is a clear fluid formed when interstitial fluid is collected through lymph capillaries. It is then transported through lymph vessels to lymph nodes. (Remember interstitial fluid is formed from the balance between hydrostatic and oncotic pressure pushing water and small solutes between the blood capillaries and the interstitial fluid)
To prevent a build up of this interstitial fluid surrounding the cells, interstitial fluid is free to pass into surrounding lymph vessels via pores.
Lymph consists of sugars, salts, fatty acids, amino acids, coenzymes, hormones, neurotransmitters, as well as waste products from the cells. Most importantly, unlike plasma, it also contains lymphocytes.

3. What is the purpose of the lymphatic system?
To remove excess interstitial fluid from tissues
To return filtered plasma that remained in interstitial fluid back into the circulatory system
To transport white blood cells and antigen presenting cells to the lymph nodes where an immune response is stimulated

4. What is a lymph node?
An organised collection of lymphoid tissue, through which lymph passes on its way back to the blood.
They are located at intervals along the lymphatic system.
They act as filters for foreign particles and cancer cells.

5. What is lymphadenopathy and when are we concerned?
Lymphadenopathy refers to swollen or enlarged lymph nodes.
This increase in size is primarily due to an elevated rate of trafficking of lymphocytes into the node from the blood, exceeding the rate of outflow from the node.
They may also be enlarged secondarily as a result of activation and proliferation of antigen-specific T and B cells (clonal expansion).
Concerning features: Hard, fixed, irregular borders, painless, non-tender

6. Lymphadenopathy History Taking
Where is it?
Is there only one lump? Where are the others?
When did you first notice it?
Has it changed since then?
Are you getting any other symptoms from it? – Pain, heat, redness
RED FLAGS – fever (night sweats), unintentional weight loss, abdominal pain, change in bowel habit
PMH – Are you susceptible to infections? Have you ever been diagnosed with cancer and what treatment did you receive?
SH – Where were you born? Have you travelled recently? Contacts with anybody unwell? What kind of home do you live in? Have you ever injected drugs? Have you ever received a blood transfusion?

7. Lymphoedema Localised fluid retention and tissue swelling
Primary usually results from poorly developed or missing lymph nodes
Secondary usually results from the dissection of lymph nodes during surgery for cancer or other treatments involving radiation

8. Lymph Drainage of the Breast
Apical Nodes
Lateral (humoral) nodes
Central nodes
Posterior (subscapular) nodes
Anterior (pectoral) nodes
Deltopectoral nodes
Parasternal nodes
Remember! The breast drains to the axilla, porasternally, the other breast and occasionally the hepatic nodes and the inguinal nodes.
Breast skin drains to the axillary, deep cervical and infraclavicular nodes.

9. Lymph Drainage of the male genitalia
Scrotum, penile and perineal – superficial inguinal
Glans of penis – deep inguinal
Corpus cavernosum – internal iliac
Testicles – para-aortic (L2)
Urethra – proximal spongy and membranous = internal iliac, distal spongy = deep inguinal
Prostate, seminal vesicles and ductus – internal iliac

10. Lymph Drainage of the female genitalia
Ovaries – Para-aortic nodes (L2)
Fundus and body of uterus – Para-aortic nodes (L2)
Lower portion of uterus – external iliac nodes
Cervix – external and internal iliac and sacral nodes
External genitalia and vagina – external iliac nodes

11. Lymph Drainage of the GI system
Abdominal wall – superficial lymphatics above the umbilicus drain to the axillary nodes where as lymphatics below the umbilicus drain to the superficial inguinal nodes. Deep lymphatics follow the arteries back to parasternal nodes along the internal thoracic artery, lumbar nodes along the abdominal aorta and external iliac nodes along the external iliac artery.
Abdominal viscera drainage is divided up depending on whether its supplied by the coeliac trunk, superior mesenteric artery or inferior mesenteric artery.
Inferior mesenteric artery supplied organs drains to pre-aortic nodes near the origin of the inferior mesenteric artery. These then drain to the superior mesenteric nodes.
Superior mesenteric artery supplied organs drain to pre-aortic nodes near the origin of the superior mesenteric artery. These then drain to the coeliac nodes.
Coeliac trunk supplied organs drains to pre-aortic nodes near the origin of the coeliac trunk. These then enter the cisterna chyli.
Cisterna chyli drains to the thoracic duct which extends from vertebra L2 to the root of the neck. The thoracic duct empties into the junction of the left subclavian and left internal jugular veins

12. Virchow’s Node
A lymph node in the left supraclavicular fossa which takes it supply from lymph vessels in the abdominal cavity
The finding of an enlarged, hard node (Trosier’s sign) is strongly indicative of the presence of cancer in the abdomen, specifically gastric cancer.

13. Lymph Node Examination