Post on 12-Feb-2016
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Happy Year
Awatif Jamal, MD, MSc, FRCPC, FIAC Consultant & Associate Professor
Department of PathologyKing Abdulaziz University Hospital
Hemodynamic Disorders Hemodynamic Disorders Thrombosis & ShockThrombosis & Shock
EdemaEdema Hyperemia and CongestionHyperemia and Congestion
HemorrhageHemorrhage Hemostasis & ThrombosisHemostasis & Thrombosis
EmbolismEmbolism InfarctionInfarction
ShockShock
• EdemaEdema
INTRODUCTIONINTRODUCTION
The health of cells and tissues depend on; The health of cells and tissues depend on;
1-Intact circulation1-Intact circulation ; to deliver oxygen and remove wastes. ; to deliver oxygen and remove wastes.
2-Normal fluid homeostasis2-Normal fluid homeostasis; which encompasses the following;; which encompasses the following;
A-A- maintenance of BV wall integrity . maintenance of BV wall integrity .
B-B- maintenance of intravascular pressure. maintenance of intravascular pressure.
C- C- maintenance of protein content or osmolarity within BV.maintenance of protein content or osmolarity within BV.
D- D- maintenance of blood as a liquid until such time as injury maintenance of blood as a liquid until such time as injury
necessitates clot formation.necessitates clot formation.
EDEMAEDEMAFluid extravasations and Fluid extravasations and accumulation in the interstitial accumulation in the interstitial spacesspaces
60% of body weight is water, distributed as follow: 60% of body weight is water, distributed as follow: Two thirds intracellularTwo thirds intracellular
5% intravascular5% intravascular The rest is interstitialThe rest is interstitial
EDEMAEDEMAIncreased fluid in theIncreased fluid in the interstitial tissue spacesinterstitial tissue spaces
Fluid may also accumulate in Fluid may also accumulate in body cavities:body cavities:
1.1. HydrothoraxHydrothorax
2.2. HydropericardiumHydropericardium
3.3. Hydroperitoneum is also called Hydroperitoneum is also called AscitesAscites
Massive generalized edema is called Massive generalized edema is called AnasarcaAnasarca
PathogenesisPathogenesis
The opposing effects of vascular hydrostatic The opposing effects of vascular hydrostatic pressure and plasma colloid osmotic pressure pressure and plasma colloid osmotic pressure are the major factors that control the movement are the major factors that control the movement of fluid between vascular and interstitial tissues.of fluid between vascular and interstitial tissues.
Normally, the exit of fluid into the interstitium Normally, the exit of fluid into the interstitium from the arteriolar end of microcirculation is from the arteriolar end of microcirculation is nearly balanced by inflow of fluid at the venular nearly balanced by inflow of fluid at the venular end; a small residual amount of excess end; a small residual amount of excess interstitial fluid is drained by the lymphaticsinterstitial fluid is drained by the lymphatics
Fluid HomeostasisFluid Homeostasis
Lymphatics
Fluid HomeostasisFluid HomeostasisHomeostasis is Homeostasis is maintained by the maintained by the opposing effectsopposing effects of: of:Vascular Vascular Hydrostatic Hydrostatic Pressure Pressure – and and Plasma Colloid Plasma Colloid Osmotic PressureOsmotic Pressure
Edema Fluid = Edema Fluid = TRANSUDATETRANSUDATE
transudatetransudate is protein-poor (specific gravity is protein-poor (specific gravity
<1.012)<1.012)
An An exudateexudate is protein-rich (specific is protein-rich (specific
gravity >1.020) = gravity >1.020) = (inflammatory edema(inflammatory edema))
Pathophysiologic Categories of EdemaPathophysiologic Categories of Edema
II. Reduced Plasma Oncotic II. Reduced Plasma Oncotic PressurePressure
III. InflammationIII. Inflammation–IV. OthersIV. Others
I. Increased Hydrostatic PressureI. Increased Hydrostatic Pressure
Patho-physiologic Categories of Patho-physiologic Categories of EdemaEdema
Increased Hydrostatic PressureIncreased Hydrostatic PressureIncreased intravascular pressure may be due to Increased intravascular pressure may be due to 1- 1- Impaired venous return;Impaired venous return;A)A) Localized:Localized: Venous Thrombosis in lower extremities Venous Thrombosis in lower extremities
(local edema). (local edema). B)B) Generalized:Generalized: Congestive Heart Failure (generalized Congestive Heart Failure (generalized
edema).edema).
22- - IncreasedIncreased arteriolar dilatation;arteriolar dilatation;a)a) HeatHeatb)b) Neurohumoral dysregulationNeurohumoral dysregulation
Congestive Heart Failure:Congestive Heart Failure: Congestive Heart Failure is the most common cause of Congestive Heart Failure is the most common cause of
EDEMA due to Increased Hydrostatic PressureEDEMA due to Increased Hydrostatic Pressure
““Generalized increased venous pressure, resulting Generalized increased venous pressure, resulting
in in systemic edemasystemic edema, occur , occur most commonlymost commonly in in
CONGESTIVE HEART FAILURE” CONGESTIVE HEART FAILURE”
Increased Hydrostatic PressureIncreased Hydrostatic Pressure
Increased Hydrostatic Pressure Increased Hydrostatic Pressure Congestive Heart FailureCongestive Heart Failure
Mechanism:Mechanism:
The Pump is FAILING!!! The Pump is FAILING!!! Cardiac output Cardiac output
Blood backs up, first into the lungs Blood backs up, first into the lungs
then into the venous circulation then into the venous circulation
increasing Central Venous Pressure (CVP)increasing Central Venous Pressure (CVP)
increased capillary pressure (Hydrostatic increased capillary pressure (Hydrostatic
Pressure) Pressure)
Leading to Leading to Generalized EdemaGeneralized Edema
Congestive Heart Failure Congestive Heart Failure
& Decreased Renal Perfusion & Decreased Renal Perfusion
Congestive heart failure Congestive heart failure Decreased Cardiac OutputDecreased Cardiac Output Decreased ARTERIAL blood volume Decreased ARTERIAL blood volume
“Less arterial blood…Less renal perfusion...
The Kidney doesn’t see enough blood coming through …….
Congestive Heart FailureCongestive Heart Failure
& Decreased Renal Perfusion& Decreased Renal Perfusion
Decreased Renal Perfusion activates Decreased Renal Perfusion activates
the the Renal Defense Mechanisms:Renal Defense Mechanisms:1.1. Renin-Angiotensin-Aldosterone axis Renin-Angiotensin-Aldosterone axis
Na & H2O retentionNa & H2O retention
2.2. Renal VasoconstrictionRenal Vasoconstriction
3.3. Increased Renal Anti-diuretic Hormone (ADH)Increased Renal Anti-diuretic Hormone (ADH)
Congestive Heart FailureCongestive Heart Failure& Decreased Renal Perfusion& Decreased Renal Perfusion
– The net result will be increased intravascular The net result will be increased intravascular volume to increase the COP.volume to increase the COP.
– The failing heart can’t increase the COP so The failing heart can’t increase the COP so the the extra fluid load will lead to additional increase in extra fluid load will lead to additional increase in the venous pressure and Morethe venous pressure and More EDEMA .EDEMA .
Congestive Heart FailureCongestive Heart Failure
CentralVenousPressure
Renal Perfusion
Renin
Renal Vasoconstriction
ADH
Pathophysiologic Categories ofPathophysiologic Categories ofEdemaEdema
I. Increased Hydrostatic PressureI. Increased Hydrostatic Pressure
III. InflammationIII. Inflammation IV. OthersIV. Others
II. Reduced Plasma Oncotic Pressure
“…“…AlbuminAlbumin::
the serum protein MOST responsible for the the serum protein MOST responsible for the maintenance of maintenance of colloid osmotic pressure.”colloid osmotic pressure.”
A A decrease in osmotic pressuredecrease in osmotic pressure can result from: can result from:
1.1. Protein Loss Protein Loss or or
2222 Protein SynthesisProtein Synthesis
II. Reduced Plasma Oncotic Pressure
1.1. Increased albumin Loss: Increased albumin Loss: – Nephrotic SyndromeNephrotic Syndrome
Increased permeability of the glomerular basement membrane Increased permeability of the glomerular basement membrane loss of protein loss of protein
2.2. Reduced albumin synthesis: Reduced albumin synthesis: – CirrhosisCirrhosis
– Protein malnutritionProtein malnutrition
– EFFECT: EFFECT: – is movement of fluid into the interstitial tissue with resultant is movement of fluid into the interstitial tissue with resultant
plasma volume contraction.plasma volume contraction.
II. Reduced Plasma Oncotic Pressure
Pathophysiologic Categories ofPathophysiologic Categories ofEdemaEdema
IV. OthersIV. Others
I. Increased Hydrostatic PressureI. Increased Hydrostatic Pressure
II. Reduced Plasma Oncotic Pressure
III. Inflammation Localized Edema
Increased Vascular Permeability
Pathophysiologic Categories ofPathophysiologic Categories ofEdemaEdema
I. Increased Hydrostatic PressureI. Increased Hydrostatic Pressure
II. Reduced Plasma Oncotic Pressure
III. Inflammation IV. Others
• Lymphatic Obstruction• Water and Sodium Retention
Impaired lymphatic drainage with resultant Impaired lymphatic drainage with resultant
lymphedemalymphedema
LOCALIZED EDEMALOCALIZED EDEMA
caused by :caused by : INFLAMMATION INFLAMMATION
or or
NEOPLASTIC OBSTRUCTION NEOPLASTIC OBSTRUCTION
Lymphatic Obstruction
Inflammatory Lymphatic Inflammatory Lymphatic ObstructionObstruction
FilariasisFilariasis – – – A parasitic infection which A parasitic infection which
leads to lymphatic and leads to lymphatic and
lymph node fibrosis in the lymph node fibrosis in the
inguinal region resulting in inguinal region resulting in
edema of the external edema of the external
genitalia and lower genitalia and lower
extremity called extremity called
ELEPHANTIASISELEPHANTIASIS
Neoplastic Lymphatic ObstructionNeoplastic Lymphatic Obstruction
In cases of CA breast the resection and/or radiation of In cases of CA breast the resection and/or radiation of
axillary lymphatic channels and lymph nodes can lead to axillary lymphatic channels and lymph nodes can lead to
-- -- arm edemaarm edema
Carcinoma of breast with obstruction of superficial Carcinoma of breast with obstruction of superficial
lymphatics can lead to edema of the skin with an lymphatics can lead to edema of the skin with an
unusual appearance of the breast skin - unusual appearance of the breast skin -
““peau d’orange” (orange peel)peau d’orange” (orange peel)
EDEMA - EDEMA - SummarySummary
INCREASEDHYDROSTATICPRESSURE
Congestive Heart FailureAscitesVenous Obstruction
DECREASED ONCOTICPRESSURE
Nephrotic SyndromeCirrhosisProtein Malnutrition
INCREASEDPERMEABILITY
Inflammation
LYMPHATICOBSTRUCTION
InflammatoryNeoplastic
HEARTHEARTLIVERLIVERKIDNEYKIDNEY
Edema FluidEdema Fluid
TransudateTransudate ExudateExudate
CauseCause High hydrostatic High hydrostatic pr.pr.
InflammatoryInflammatory
Protein contentProtein content LowLow HighHigh
Specific gravitySpecific gravity <1.012)<1.012) >1.020)>1.020)
Inflammatory Inflammatory cellscells
AbsentAbsent RichRich
GENERALIZED EDEMAGENERALIZED EDEMA
HEARTHEARTLIVERLIVERKIDNEYKIDNEY
Subcutaneous EdemaSubcutaneous EdemaEdema of the subcutaneous tissue is most easily detected Edema of the subcutaneous tissue is most easily detected GrosslyGrossly (not microscopically) (not microscopically)
Push your finger into it Push your finger into it
and a depression remainsand a depression remains
Annoying but Points toAnnoying but Points to
Underlying DiseaseUnderlying Disease
It can impair wound healing It can impair wound healing
or clearance of Infectionor clearance of Infection
Dependent EdemaDependent Edema is a prominent feature of is a prominent feature of
Congestive Heart Failure; in legs if standing or Congestive Heart Failure; in legs if standing or
sacrum in sleeping patientsacrum in sleeping patient
Periorbital edemaPeriorbital edema is often the initial is often the initial
manifestation of Nephrotic Syndrome, while late manifestation of Nephrotic Syndrome, while late cases will lead to generalized edema.cases will lead to generalized edema.
EdemaEdema
Pulmonary EdemaPulmonary Edema
is most frequently seen in Congestive is most frequently seen in Congestive Heart FailureHeart Failure– May also be present in renal failure, adult May also be present in renal failure, adult
respiratory distress syndrome (ARDS), respiratory distress syndrome (ARDS),
pulmonary infections and hypersensitivity pulmonary infections and hypersensitivity reactionsreactions
Pulmonary EdemaPulmonary EdemaThe Lungs are The Lungs are typically 2-3 times typically 2-3 times normal weightnormal weightCross sectioning Cross sectioning causes an causes an outpouring of frothy, outpouring of frothy, sometimes blood-sometimes blood-tinged fluidtinged fluidIt may interfere It may interfere
with pulmonary with pulmonary functionfunction
Normal lung
Pulmonary Edema
Pulmonary EdemaPulmonary Edema
Clinical CorrelationClinical Correlation
May cause May cause deathdeath by interfering with by interfering with
Oxygen and Carbon Dioxide exchangeOxygen and Carbon Dioxide exchange
Creates a favorable environment for Creates a favorable environment for
infectioninfectionTHINK it resembles “Culture Media”!!!THINK it resembles “Culture Media”!!!
Brain EdemaBrain Edema
Trauma, Abscess, Neoplasm, Infection Trauma, Abscess, Neoplasm, Infection (Encephalitis due to say… West Nile Virus), etc(Encephalitis due to say… West Nile Virus), etc
Brain EdemaBrain Edema
Clinical CorrelationClinical Correlation The big problem is: The big problem is: There is no place for There is no place for the fluid to go!the fluid to go!
Herniation into the Herniation into the
foramen magnum foramen magnum will will killkill
Clinical Correlation of Edema Clinical Correlation of Edema
The effect of edema may be just annoying to fatal The effect of edema may be just annoying to fatal
condition. condition.
It usually points to an underlying disease.It usually points to an underlying disease.
However, it can impair wound healing or clearance of However, it can impair wound healing or clearance of
Infection.Infection.
Creates a favorable environment for Creates a favorable environment for infection.infection.THINK “Culture Media”THINK “Culture Media”
May cause death by interfering with Oxygen and Carbon May cause death by interfering with Oxygen and Carbon
Dioxide exchange.Dioxide exchange.
Thank you