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Happy Year. Pathology 301. Awatif Jamal, MD, MSc, FRCPC, FIAC Consultant & Associate Professor Department of Pathology King Abdulaziz University Hospital. Hemodynamic Disorders Thrombosis & Shock. Edema. Edema Hyperemia and Congestion Hemorrhage Hemostasis & Thrombosis
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Happy Year Pathology 301
  • Awatif Jamal, MD, MSc, FRCPC, FIAC
  • Consultant & Associate Professor
  • Department of Pathology
  • King Abdulaziz University Hospital
  • Hemodynamic Disorders Thrombosis & Shock
  • Edema
  • Edema Hyperemia and Congestion Hemorrhage Hemostasis & Thrombosis Embolism Infarction ShockINTRODUCTION
  • The health of cells and tissues depend on;
  • 1-Intact circulation ; to deliver oxygen and remove wastes.
  • 2-Normal fluid homeostasis; which encompasses the following;
  • A- maintenance of BV wall integrity .
  • B- maintenance of intravascular pressure.
  • C- maintenance of protein content or osmolarity within BV.
  • D- maintenance of blood as a liquid until such time as injury necessitates clot formation.
  • EDEMA
  • Fluid extravasations and accumulation in the interstitial spaces
  • 60% of body weight is water, distributed as follow: Two thirds intracellular 5% intravascular The rest is interstitialEDEMAIncreased fluid in theinterstitial tissue spaces
  • Fluid may also accumulate in body cavities:
  • Hydrothorax
  • Hydropericardium
  • Hydroperitoneum is also called Ascites
  • Massive generalized edema is called Anasarca
  • Pathogenesis
  • The opposing effects of vascular hydrostatic pressure and plasma colloid osmotic pressure are the major factors that control the movement of fluid between vascular and interstitial tissues.
  • Normally, the exit of fluid into the interstitium from the arteriolar end of microcirculation is nearly balanced by inflow of fluid at the venular end; a small residual amount of excess interstitial fluid is drained by the lymphatics
  • Fluid HomeostasisLymphaticsFluid Homeostasis
  • Homeostasis is maintained by the opposing effects of:
  • Vascular Hydrostatic Pressure
  • and
  • Plasma Colloid Osmotic Pressure
  • Edema Fluid = TRANSUDATE
  • transudate is protein-poor (specific gravity <1.012)
  • An exudate is protein-rich (specific gravity >1.020) = (inflammatory edema)
  • Pathophysiologic Categories of EdemaII. Reduced Plasma Oncotic Pressure
  • III. Inflammation
  • IV. Others
  • I. Increased Hydrostatic PressurePatho-physiologic Categories of EdemaIncreased Hydrostatic PressureIncreased intravascular pressure may be due to 1- Impaired venous return;
  • Localized:Venous Thrombosis in lower extremities (local edema).
  • Generalized:Congestive Heart Failure (generalized edema).
  • 2- Increasedarteriolar dilatation;
  • Heat
  • Neurohumoral dysregulation
  • Increased Hydrostatic PressureCongestive Heart Failure:Congestive Heart Failure is the most common cause of EDEMA due to Increased Hydrostatic Pressure“Generalized increased venous pressure, resulting in systemic edema, occur most commonly in CONGESTIVE HEART FAILURE” Increased Hydrostatic Pressure Congestive Heart FailureMechanism:
  • 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 Generalized Edema
  • 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 bloodcoming through …….Congestive Heart Failure & Decreased Renal PerfusionDecreased 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 & Decreased Renal Perfusion
  • The net result will be increased intravascular volume to increase the COP.
  • The failing heart can’t increase the COP so the extra fluid load will lead to additional increase in the venous pressure and MoreEDEMA .
  • ReninADHCentralVenousPressureRenal PerfusionRenal VasoconstrictionCongestive Heart FailurePathophysiologic Categories ofEdema
  • I. Increased Hydrostatic Pressure
  • II. Reduced Plasma Oncotic Pressure
  • III. Inflammation
  • IV. Others
  • II. Reduced Plasma Oncotic Pressure
  • “…Albumin:
  • 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
  • II. Reduced Plasma Oncotic Pressure
  • Increased albumin Loss:
  • Nephrotic Syndrome
  • Increased permeability of the glomerular basement membrane  loss of protein
  • Reduced albumin synthesis:
  • Cirrhosis
  • Protein malnutrition
  • EFFECT:
  • is movement of fluid into the interstitial tissue with resultant plasma volume contraction.
  • Pathophysiologic Categories ofEdemaIV. OthersI. Increased Hydrostatic PressureII. Reduced Plasma Oncotic PressureIII. Inflammation Localized EdemaIncreased Vascular PermeabilityPathophysiologic Categories ofEdemaI. Increased Hydrostatic PressureII. Reduced Plasma Oncotic PressureIII. Inflammation
  • IV. Others
  • Lymphatic Obstruction
  • Water and Sodium Retention
  • Lymphatic Obstruction
  • Impaired lymphatic drainage with resultant lymphedema
  • LOCALIZED EDEMA
  • caused by :
  • INFLAMMATION
  • or
  • NEOPLASTIC OBSTRUCTION
  • Inflammatory Lymphatic Obstruction
  • Filariasis –
  • A parasitic infection which leads to lymphatic and lymph node fibrosis in the inguinal region resulting in edema of the external genitalia and lower extremity called ELEPHANTIASIS
  • Neoplastic Lymphatic Obstruction
  • In cases of CA breast the resection and/or radiation of axillary lymphatic channels and lymph nodes can lead to -- arm edema
  • Carcinoma of breast with obstruction of superficial lymphatics can lead to edema of the skin with an unusual appearance of the breast skin -
  • “peau d’orange” (orange peel)EDEMA - Summary
  • HEART
  • LIVER
  • KIDNEY
  • INCREASEDHYDROSTATICPRESSURECongestive Heart Failure Ascites Venous ObstructionDECREASED ONCOTICPRESSURENephrotic Syndrome Cirrhosis Protein MalnutritionLYMPHATICOBSTRUCTIONInflammatory NeoplasticINCREASEDPERMEABILITYInflammationEdema FluidGENERALIZED EDEMA
  • HEART
  • LIVER
  • KIDNEY
  • Edema of the subcutaneous tissue is most easily detected Grossly (not microscopically)Push your finger into it and a depression remainsAnnoying but Points to Underlying DiseaseIt can impair wound healing or clearance of InfectionSubcutaneous EdemaDependent Edemais a prominent feature of Congestive Heart Failure; in legs if standing or sacrum in sleeping patientPeriorbital edemais often the initial manifestation of Nephrotic Syndrome, while late cases will lead to generalized edema.EdemaPulmonary Edemais most frequently seen in Congestive Heart FailureMay also be present in renal failure, adult respiratory distress syndrome (ARDS), pulmonary infections and hypersensitivity reactionsPulmonary Edema
  • The Lungs are typically 2-3 times normal weight
  • Cross sectioning causes an outpouring of frothy,
  • sometimes blood-tinged fluid
  • It may interfere
  • with pulmonary functionNormal lungPulmonary EdemaPulmonary EdemaClinical Correlation May cause death by interfering with Oxygen and Carbon Dioxide exchange
  • Creates a favorable environment for infection
  • THINK it resembles “Culture Media”!!!
  • Brain Edema
  • Trauma, Abscess, Neoplasm, Infection (Encephalitis due to say… West Nile Virus), etc
  • Brain EdemaClinical CorrelationThe big problem is: There is no place for the fluid to go!
  • Herniation into the foramen magnum will kill
  • Clinical Correlation of Edema
  • The effect of edema may be just annoying to fatal condition.
  • It usually points to an underlying disease.
  • However, it can impair wound healing or clearance of Infection.
  • Creates a favorable environment for infection.
  • THINK “Culture Media”
  • May cause death by interfering with Oxygen and Carbon Dioxide exchange.
  • Thank you
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