BODY FLUID

The body is formed by solids and fluids. The fluid part is more than 2/3 of the whole
body. Water is an important component of the human body. About 60% of total body weight is
water, this forms the total body water but this varies with age, sex and degree of obesity. It is less
than 60% in obese people i.e. the fatter the subject, the less the functional water content. This is
because fat cells displace water. In infants, water may account for more than 70% of the total
body weight. The loss of 10-20% of total body water leads to death.
In terms of volume, total body water in adult man (70kg) is about 42 liters. The water
content is related to lean body mass (the total body weight – the total fat i.e. fat free mass of the
body) and it measures about 70% of lean body mass. They are related as follows.

Lean Body Mass (LBM) = Total body water (TBW)

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The Regulation of Water Content

The water content of each individual is maintained constant primarily by mechanisms
which regulate the osmolality (i.e. no of solute particles per kg of water) of the body fluids. The
hormone at the centre of the regulation of the water content of the body is antidiuretic hormones
(ADH).aw
Excess water intake provokes prompt water diuresis (due to suppressed ADH secretion),
while water deprivation provokes thirst, ADH secretion and renal retention of water. The
regulation of Na+ content or ECF volume indirectly regulates water content, since loss or gain of
Na+ is accompanied by changes in osmotically equivalent amount of water (i.e. loss or gain ofa\
Swater).
For a person in proper water balance the water intake equals the water output daily. The
average daily water intake and output in individuals in temperature and tropical climates are
given below

Daily intake source Temperature climate (ml) Tropical climate (ml)

Drinks 1500 2500
Food 750 800
Cellular metabolism 350 350
Total Per day 2600 3650

Daily output source Temperature climate (ml) Tropical climate (ml)

Urine 1600 1350
Sweat 100 1500
Skin 400 400
Lungs 400 300
Faeces 100 100
Total daily output 2600 3,650

In general, most people normally drink more water than the /minimum 400ml required to excrete
urinary solutes (mainly urea and Na+). Tropical heat provokes much sweating, causing thirst and

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some reduction in urine output. This is the main difference between residences in temperate
(cold) and tropical countries. During prolong severe exercise, up to 5L of water may be lost in
sweat and more for those in the tropics. This must be replenished with salt.
Apart from sweat, water is constantly being lost from evaporation of water diffusing
through the skin as well as from the alveoli of the lungs during expiration. Since the individual is
not aware of these losses it is referred to as insensible loss.

BODY FLUID COMPARTMENTS

Fluids consist of water and contained solutes. Body fluid can be divided into 2 main
compartments.
A. Intracellular fluid (ICF) – 40% body wt i.e. 28L, TBW 42L
B. Extracellular fluid (ECF) – 20% body wt 1.e 14L

INTRACELLULAR FLUID (ICF)

Intracellular fluid is the fluid inside the body cells. It volume is about 28L (2/3 of TBW).
The fluid is contained within boundaries of cell membrane and each cell regulates its own
content. It provides body cells their tugor as well as a medium within which biochemical
reactions can take place. The major cations of ICF are K+ and Mg2+ while the major anions are
proteins and organic phosphate (ATP, ADP, and AMP).
The pH of ICF is 7.0

EXTRACELLULAR FLUID (ECF)

This is the fluid outside the cells. Its total volume is about 14L (1/3 of TBW). The ECF
supports the cells and allows transport of nutrients and waste products. The major cation is Na +
and major anions are Cl- and HCO3-. The pH of ECF is 7.4.
The ECF is subdivided into
i. Interstitial fluid (ISF)  10.5L
ii. Plasma ( 3L)  14L
iii. Transcellular Fluid (1 – 2L)

i. Interstitial Fluid (ISF) – Tissue fluid

It is found in the spaces between the cells. It surrounds all cells except blood cells. It is
about ¾ of the ECF volume (10.5L). The composition of ISF is the same as that of plasma
except that it has little protein.
The relationship between plasma and ISF is a delicate one and any imbalance in the two, causes
the accumulation of fluid in the extracellular space leading to edema (oedema)

ii. Plasma
This is the fluid portion of the blood and measures about 3L (i.e. ¼ of ECF). The plasma
and interstitial fluid (ISF) are the 2 largest components of the ECF and are in dynamic
equilibrium with each other through the pores of capillary membranes. The major plasma
proteins are albumin and globulins.

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iii. Transcellular Fluid
The term transcelluar fluid refers to fluid collections secreted by epithelial cells such as
cerebrospinal fluid, intraocular, pericardial, synovial fluid, cochlea fluid etc. Although these fluid
collections lie outside the cell membranes and therefore are “extracellular”, they have little in
common with the rest of the ECF. The electrolyte composition is unique to each fluid and
different from that of the ECF. Its total volume is about 1 – 2 liter.

MEASUREMENT OF BODY FLUID VOLUMES/COMPARTMENTS

This is usually done using indicator dilution technique. This technique is based on the
relationship between the amount of a substance injected intravenously (A), the volume in which
that substance is distributed (V) and the final concentration attained (C)
The equation for this relationship is
C=A or V=A
V C
Where V is the volume (ml or L), in which the quantity A (g, kg or mEq), is distributed to yield
the concentration C (in g/ml or L or in mEq/ml or L)
Eg: If 25mg of glucose is added to an unknown volume of distilled water and the final
concentration of glucose after mixing is 0.05mg/ml, then the volume of solvent is

V= 25mg
0.05mg/ml = 500ml
Procedure:
a. Inject known amount of substance A (marker either dye or radioactive isotope etc)
b. Allow adequate time for mixing uniformly through the compartment.
c. Take a sample and measure the new concentration (c)
Eg II: Sample calculation:
A patient is injected with the 500mg or mannitol. After a 2 hours equilibration period, the
concentration of mannitol in plasma is 3.2mg /100ml. (During equilibration period 10% i.e.
50mg of the injected mannitol is excreted in urine). What is the ECF volume?

Volume = Amount (A) 500

=
Concentration (c) 3.2mg/100ml

500 – 50mg
32mg/100ml = 14.1L

Correction factor: Some amount of marker substance is lost through the urine, during distribution
so the formula is corrected as follows.
Volume = Amount of substance injected – Amount excreted
Concentration of substance in sample of fluid

The Plasma volume, ECF volume, and total body water can be measured using this dilution
technique while ISF and ICF volumes cannot be measured using this technique ISF and ICF
volumes can be derived as follows
ICF = TBW – ECF

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 ISF = ECF – Plasma

Criteria / Properties of Marker Substances

Regardless of compartment, desirable markers share, the following qualities
i. It must not be toxic
ii. It must remain in the compartment being measured
iii. It must mix evenly throughout the compartment being measured
iv. It must not be excreted rapidly
v. It must not be metabolized or transformed during the period of the experiment
vi. It must not influence the distribution of water
vii. It should be fairly easy to measure.

Compartments / volume / suitable indicators

a. TBW - Radioactive water – tritium oxide (3H20), Heavy water (2H20), antipyrine
b. ECF - Radioactive Sodium (22Na), Inulin, Mannitol
c. Plasma - Radioactive iodine albumin (125 1-albumine), Evans blue dye (T – 1824).

Compositions of body fluid compartments

The electrolyte composition of the main divisions of the body fluid is given below. Na and
Chloride constitute the bulk of the ions in ECF, while potassium and phosphate form the bulk of
ions inside the cells.
There are variations from textbooks to textbooks.

Electrolytes ECF (Plasma) - mEq ICF (Skeletal)

CATIONS
Na+ 142 10
K+ 4 160
Ca+ 5 2
Mg2+ 3 26
Total 154 198
ANIONS
Cl- 103 3
Hco3- 27 10
Hpo42- 2 100
So42- 1 20
Organic acid 5 65
Protein 16 65
Total 154 198

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The reason for the unique distribution of major cations is the presence of specific transport
systems in the all membrane, for instance, the ATPase – mediated Na-K pump which actively
transport K+ from ECF into the cell and Na + out of the cell. There are other forces which affect
the distribution of electrolytes across cell membranes, and this include the passive forces of
diffusion, osmosis and Gibbs – Donnan equilibrium (caused by the presence of non diffusible
protein anions, inorganic phosphates i.e. product of ions inside = product of ions (cations and
anions) outside and sulphates inside the cell and to lesser extent in the plasma.

Question 1: Discuss the body’s various fluid compartments. Describe briefly how the various
fluid compartments may be measured. Discuss the composition of body fluid compartment.

TONICITY

All
fluid compartments of the body are in or nearly in Osmotic equilibrium. The term tonicity is used
to describe the osmolality of a solution relative to plasma.
Osmolality refers to the numbers of solute particles (osmole) per kilogram of water.
Osmolarity refers to the number of solute particles per liter of solution. Solutions that have the
same osmolality as plasma are said to be isotonic e.g. 0.9% NaCl (normal saline): 5.2g
glucose/100ml (5% glucose solution). Those with greater osmolality are hypertonic eg 2% NaCl
solution while those with lesser osmolality are described as hypotonic eg 0.3% NaCl. Normal
Osmolality of plasma is approximately 300m Osm/L.
When a cell eg RBC is placed into an isotonic solution, there will be no change in volume
of the cell but if it is placed in hypotonic solution, the cell will swell due to movement of water
into the cell and if the solution is sufficiently diluted, the cell will burst (lyse). Whereas if the cell
is placed in hypertonic solution, solution, the cell shrinks due to movement of water molecules
from the cell into the solution through the process of osmosis.

SHIFTS / MOVEMENT OF WATER BETWEEN

COMPARTMENTS

Water shifts between ECF and ICF so that the osmolality of the two compartments become
equal. The osmolarity of ICF and ECF are assumed to be equal after a brief period of
equilibration.
The general clinical terms for volume abnormalities are dehydration and overhydration.
Dehydration is defined as a significant decrease in water content of the body while
overhydration is a significant increase in water content of the body (both condition are associate
with a charge in ECF volume)

FORMS OF DEHYDRATION

1. Iso-osmotic Dehydration: (loss of isotonic fluid). This is water deficit caused by loss of
isotonic fluid eg Diarrhea, hemorrhage, vomiting. It is also called Iso-osmotic volume
contraction. Each of the above examples causes the following effects.
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 a. ECF volume decrease but there will be no change in osmolality of ECF and
ICF. Because osmolality in unchanged, there will be no shift of water between
ECF and ICF.

b. Plasma protein concentration and hematocrit (Packed Cell Volume) increase

because, the loss of ECF concentrate and RBC (only when the cause is
vomiting or diarrhea). But because ECF volume osmolality is unchanged, the
RBC will not swell or shrink
c. Arterial blood pressure decreases because of the decreases ECF volume

2. HYPER OSMOTIC DEHYDRATION:

This is water deficit caused by decrease water intake, excessive sweating (exercise
heavy), and fever. It is also called hyper osmotic volume contraction .Effects;
a. Osmolality of ECF increases because sweat is hypo osmotic i.e. relatively
more water than salt is lost during sweating.
b. ECF volume decreases because of the loss of volume in the sweat.
c. Because ECF osmolality increases, water shifts out of ICF into the ECF. As a result,
ICF osmolality increases until it is equal ECF osmolality.
d. As a result of the shift of water out of the cells, ICF volume decreases.
e. Protein concentration increases because of the loss ECF volume

3. HYPO-OSMOTIC DEHYDRATION (loss of NaCl)

Causes include renal loss of NaCl because of adrenal insufficiency (eg as occurs in
primary hypo adrenocorticalism - Addison’s disease). Adrenal cortex fails to secrete the
corticosteroid – aldosterone (Aldosterone aid in renal reabsorption of NaCl). It is also
called hypo osmotic volume contraction. As a result of this;
a. Osmolality of ECF decreases because the kidneys loss more NaCl than water
as a result of the lack of aldosterone in adrenocortical insufficiency.
Aldosterone is important in renal reabsorption of NaCl.
b. ECF volume decreases. Water shifts into the cells because of decrease in ECF
osmolality and as result of this shift, ICF osmolality decreases until it equals
ECF osmolality and ICF volume increases.
c. Protein concentration increases because of the decrease in ECF volume.
Hematocrit increases because of the decreased ECF volume and the swelling
of the RBCs caused by water entry.

FORMS OF OVER HYDRATION

4. Isosmotic overhydration eg. Infusion of Isotonic fluid eg 0.9% NaCl (normal saline),
infusion of 3L of 0.9% NaCl will cause iso-osmotic overhydration. It is also called
isosmotic volume expansion. The following effects will be observed.
a. ECF volume increases but there will be no changes in osmolality of ECF or
ICF. Because osmolality is unchanged, there will be no shift of water between
ECF and ICF.

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 b. Plasma protein concentration and hematocrit decreases because the addition of
fluid to ECF dilutes the protein and RBCs. Because ECF Osmolality is un
changed, the RBCs will not shrink or swell
c. Arterial blood pressure increases because ECF volume increases.

5. Hyper osmotic over hydration- (Excessive NaCl intake, oral or parenteral intake e.g.
drinking sea water) of large amounts of hypertonic fluid. It is also called hyper osmotic
volume expansion. Effects ;
a. Osmolality of ECF increases because there has been addition of osmoles to
the ECF.
b. Water shifts from ICF to ECF. As a result of this shift, ICF osmolality
increases until it is equal to ECF osmolarity.
c. As a result of the shift of water out of the cells, the volume of the ECF
increases (volume expansion) and the volume of the ICF decreases.

6. HYPOSMOTIC OVERHYDRATION: Causes: ingestion of a large volume of water

and during renal retention of water due to the syndrome of inappropriate antidiuretic
hormone secretion (SIADH) water retention.
a. Osmolality of ECF decreases because of the retention of excess water.
b. ECF volume increases because of the water retention and water shifts into the
cells (because of higher ICF osmolarity). As a result of this shift, ICF
osmolarity decreases until it is equal to ECF osmolality, and ICF volume
increases.
c. Protein concentration decreases because of the increase in ECF volume.
Although hematocrit might also be expected to decrease, in fact it will be
unchanged because water shifts into the RBCs, increasing their volume and
offsetting the diluting effect of ECF volume expansion.

Question 2
Discuss the changes in EC volume, EC osmolarity, ICF volume, ICF osmolarity caused
by
a. Infusion of 3L of 0.9% NaCl
b. Ingestion of a large volume of water
c. Diarrhea
d. Heavy exercise
e. Excessive NaCl intake
f. Addisson’s disease

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 EDEMA
Edema is an abnormal expansion of ISF volume. The forces that govern capillary fluid exchange
acts in both directions within the capillary and the interstitial space. These forces are called
starling forces (interstitial pressures). They are related by the following equation.

Fluid movement = k [(Pc + π i) – (Pi + π c)]

Outward forces inward forces

Where Pc = Capillary hydrostatic pressure

Pi = Interstitial hydrostatic pressure
πc = Capillary oncotic pressure
πi = interstitial oncotic pressure
K = capillary filtration coefficient.

Arteriole venule
Interstitial space

Capillary

Oncotic pressure = 25mmHg

37mmHg 17mmHg

+++ Interstitial
Pressure = 1mmHg

A typically muscle capillary hydrostatic pressure (Pc) at arterial end is 37 mmHg and at venous
end, it is 17mmHg. The hydrostatic pressure is acting outwards, tending to push fluid out the
capillary. The plasma oncotic pressure is 25mmHg and for practical purposes, this can be taken
as equal at both the arterial and venous end of the capillary.

Thus, at the arterial end of the capillary, there is a net outward force of 11mmHg [(37-1) – 25].
At the venous end there is a net inward force of 9mmHg [25- (17-1)] which causes most of the
fluid filtered at the arterial end to be absorbed back into the capillary lumen. From these
calculations, net filtration force (outward) is 11mmHg while net reabsorption force is 9mmHg
(inward). Therefore more fluid is filtered than reabsorbed. Approx. 24L of fluid is filtered per
day. 85% of this is reabsorbed. The remainder forms the lymph which is drained by the
lymphatics and return to the circulation via the thoracic duct in the neck.

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Causes of edema
There are 3 major causes of edema.
a. Factors that increase capillary hydrostatic pressure.
b. Factors that decrease osmotic gradient (colloid osmotic pressure of plasma –
colloid osmotic pressure of ISF) across the capillaries.
c. Inadequate tissue drainage.

a. Factors that increase capillary hydrostatic pressure.

i. Increase in venous pressure – This can be localized eg obstruction by clot
* travelling*. Generalized, eg peripheral edema as in right heart failure.
ii. Arteriolar dilation eg during heat and if standing, may increase both (i)
and (ii) leading to edema in the legs.
iii. Salt and water retention lead to increase ECF Volume which will increase
accumulation of tissue fluid.

b. Factors that decrease osmotic gradient across capillaries.

i. Nutrition – (malnutrition eg lack of protein) – as seen in the terminal stage
of kwashiorkor.
ii. Kidney diseases eg nephrosis – condition where large amount of protein
(mainly albumin) leak into the urine (lost).
iii. Increase capillary permeability – causes proteins to leak into the interstitial
space thus decreasing osmotic gradient as occur in burns, insect bites etc.
iv. Liver disease – causes inadequate protein production.

c. Inadequate tissue drainage.

i. Obstruction of lymphatics (lymphoedema) eg infection of the lymphatics
by parasites eg filariasis leading to elephantiasis of the leg.
ii. Surgical removal of lymph nodes eg in radical mastectomy- for breast
cancer treatment. During the treatment some lymph nodes may need to be
removed leading to problems with lymphatic drainage of the arm.

Edema can be intracellular or extracellular

1) Intracellular edema. Caused by depression of the metabolic system of the tissue and
lack of adequate nutrition to the cells eg decrease blood flow delivery. This hampers the
function of the cell membrane ionic pump (Na + - K+ ATPase) that pumps out Na+ which
normally diffuses into the cell. Thus the accumulation of Na+ will lead to water moving
into the cell (by osmosis) causing intracellular edema.

2) Extracellular edema: This type occurs from any condition which causes the interstitial
fluid pressure to become substantially positive i.e. the above mentioned causes of edema
will lead to these substantial positive interstitial pressures.

Edema can also be described as pitting and non pitting.

a. Pitting – This is noticed, when pressure is applied by the finger and this leaves a
depression after removal and takes about 30 secs to disappear. The depression is due

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 to disappearance of free fluid to other area which later flows back after removal of
the pressure.
b. Non Pitting – In this form of edema, no depression occurs after applying pressure
with the fingers. This is because the fluid has coagulated (clotted).

Question 3.
i. What is edema? Give an account of the various factors which causes it.
ii. Write an essay on edema formation.

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