Hemodynamic Disorders, Thrombosis & Shock Edema Edema Hyperemia and Congestion Hemorrhage Hemostasis & Thrombosis Embolism Infarction Shock

Fluid extravasations and accumulation in the interstitial spaces EDEMA Fluid extravasations and accumulation in the interstitial spaces

EDEMA Increased fluid in the interstitial tissue spaces 15/07/1438 EDEMA Increased fluid in the interstitial tissue spaces Fluid may also accumulate in body cavities: Hydrothorax Hydropericardium Hydroperitoneum is also called Ascites Massive generalized edema is called Anasarca

15/07/1438 Fluid Homeostasis Homeostasis is maintained by the opposing effects of: Vascular Hydrostatic Pressure and Plasma Colloid Osmotic Pressure Lymphatics

Edema Fluid = TRANSUDATE 15/07/1438 Edema Fluid = TRANSUDATE A transudate is protein-poor (specific gravity <1.012) An exudate is protein-rich (specific gravity >1.020) = (inflammatory edema)

Pathophysiologic Categories of Edema 15/07/1438 Pathophysiologic Categories of Edema I. Increased Hydrostatic Pressure I. Increased Hydrostatic Pressure II. Reduced Plasma Oncotic Pressure III. Inflammation IV. Others

Pathophysiologic Categories of Edema 15/07/1438 Pathophysiologic Categories of Edema Increased Hydrostatic Pressure Due to impaired venous return Localized: Venous Thrombosis Generalized: Congestive Heart Failure Due o increased arteriolar dilatation

Increased Hydrostatic Pressure 15/07/1438 Increased Hydrostatic Pressure Congestive Heart Failure: “Generalized increase in venous pressure, with resultant SYSTEMIC EDEMA occurs MOST COMMONLY in CONGESTIVE HEART FAILURE” {*** Thus, Congestive Heart Failure is the most common cause of EDEMA due to Increased Hydrostatic Pressure}

Congestive Heart Failure 15/07/1438 Congestive Heart Failure Overall, there are TWO main effects... 1. Increased Central Venous Pressure 2. Decreased Renal Perfusion

Increased Hydrostatic Pressure: Congestive Heart Failure 15/07/1438 Increased Hydrostatic Pressure: Congestive Heart Failure Mechanism: The Pump is FAILING!!!   Cardiac output Blood backs up, first into the lungs  then into the venous circulation  increasing Central Venous Pressure (CVP)  increased capillary pressure (Hydrostatic Pressure) Leading to Edema

Congestive Heart Failure: & Decreased Renal Perfusion 15/07/1438 Congestive Heart Failure: & Decreased Renal Perfusion Congestive heart failure  Decreased Cardiac Output  Decreased ARTERIAL blood volume  “Less arterial blood…Less renal perfusion... The Kidney doesn’t see enough blood coming through …….

Congestive Heart Failure: & Decreased Renal Perfusion 15/07/1438 Congestive Heart Failure: & Decreased Renal Perfusion Decreased Renal Perfusion activates the Renal Defense Mechanisms: Renin-Angiotensin-Aldosterone axis   Na & H2O retention Renal Vasoconstriction Increased Renal Anti-diuretic Hormone (ADH)

Congestive Heart Failure - Summary 15/07/1438 Congestive Heart Failure - Summary Central Venous Pressure Renal Perfusion ADH Renin Renal Vasoconstriction

Pathophysiologic Categories of Edema 15/07/1438 Pathophysiologic Categories of Edema I. Increased Hydrostatic Pressure II. Reduced Plasma Oncotic Pressure III. Inflammation IV. Other II. Reduced Plasma Oncotic Pressure

Reduced Plasma Osmotic Pressure 15/07/1438 Reduced Plasma Osmotic Pressure “…Albumin: is the serum protein MOST responsible for the maintenance of colloid osmotic pressure.” A decrease in osmotic pressure can result from:  Protein Loss or  Protein Synthesis

Reduced Plasma Osmotic Pressure 15/07/1438 Reduced Plasma Osmotic Pressure Increased albumin loss: Nephrotic Syndrome Increased permeability of the glomerular capillary wall  loss of protein Reduced albumin synthesis Cirrhosis Protein malnutrition

Pathophysiologic Categories of Edema 15/07/1438 Pathophysiologic Categories of Edema I. Increased Hydrostatic Pressure II. Reduced Plasma Oncotic Pressure III. Inflammation IV. Other III. Inflammation

Pathophysiologic Categories of Edema 15/07/1438 Pathophysiologic Categories of Edema I. Increased Hydrostatic Pressure II. Reduced Plasma Oncotic Pressure III. Inflammation IV. Others IV. Others: - Lymphatic Obstruction - Sodium & water retention

Lymphatic Obstruction 15/07/1438 Lymphatic Obstruction Impaired lymphatic drainage with resultant lymphedema usually localized usually due to: INFLAMMATION or NEOPLASTIC OBSTRUCTION

Lymphatic Obstruction 15/07/1438 Lymphatic Obstruction Filariasis – A parasitic infection affecting inguinal lymphatics resulting in elephantiasis

Lymphatic Obstruction Neoplastic 15/07/1438 Lymphatic Obstruction Neoplastic Resection and/or radiation to axillary lymphatics in breast cancer patients can lead to -- arm edema Carcinoma of breast with obstruction of superficial lymphatics can lead to edema of breast skin -- --with an unusual appearance: “peau d’orange” (orange peel)

EDEMA - Summary HEART LIVER KIDNEY INCREASED DECREASED HYDROSTATIC 15/07/1438 EDEMA - Summary INCREASED HYDROSTATIC PRESSURE Congestive Heart Failure Ascites Venous Obstruction DECREASED ONCOTIC PRESSURE Nephrotic Syndrome Cirrhosis Protein Malnutrition HEART LIVER KIDNEY LYMPHATIC OBSTRUCTION Inflammatory Neoplastic INCREASED PERMEABILITY Inflammation

15/07/1438 GENERALIZED EDEMA HEART LIVER KIDNEY

Edema Morphology Subcutaneous Edema 15/07/1438 Edema Morphology Subcutaneous Edema Edema of the subcutaneous tissue is most easily detected Grossly (not microscopically) Push your finger into it and a depression remains Dependent Edema is a prominent feature of Congestive Heart Failure Facial Edema is often the initial manifestation of Nephrotic Syndrome

Edema Clinical Correlation: Subcutaneous Edema 15/07/1438 Edema Clinical Correlation: Subcutaneous Edema Annoying but Points to Underlying Disease However, it can impair wound healing or clearance of Infection

Edema Morphology Pulmonary Edema 15/07/1438 Edema Morphology Pulmonary Edema is most frequently seen in Congestive Heart Failure May also be present in renal failure, adult respiratory distress syndrome (ARDS), pulmonary infections and hypersensitivity reactions

Pulmonary Edema Gross: 15/07/1438 Pulmonary Edema Gross: The Lungs are typically 2-3 times the normal weight Cross sectioning causes an outpouring of frothy, sometimes blood-tinged fluid

Normal Pulmonary Edema 15/07/1438 Normal Pulmonary Edema

Edema Clinical Correlation: Pulmonary Edema 15/07/1438 Edema Clinical Correlation: Pulmonary Edema May cause death by interfering with Oxygen and Carbon Dioxide exchange Creates a favorable environment for infection THINK it resembles “Culture Media”!!!

15/07/1438 Edema of the Brain Trauma, Abscess, Neoplasm, Infection (Encephalitis due to say… West Nile Virus), etc

Clinical Correlation: Edema of the Brain 15/07/1438 Clinical Correlation: Edema of the Brain The big problem is: There is no place for the fluid to go! Herniation into the foramen magnum will kill