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15 HEMODYNAMIC DISORDERS, THROMBOEMBOLIC PATHOPHYSIOLOGIC CATEGORIES OF EDEMA

DISEASE, AND SHOCK (PART 1)
Dr. Espiritu | September 4, 2018 1. Increased Hydrostatic Pressure
 Mainly caused by disorders that impair venous return
a. Impaired venous return
OUTLINE
I. WELL-BEING  Congestive Heart Failure
II. HEMODYNAMIC DISTURBANCES o Prototype example
o Impaired venous return → greater volume →
I. WELL-BEING greater pressure
 Homeostasis (state of balance) o 2 types of edema:
o Normal fluid balance  Right sided: systemic or peripheral edema
o Unbroken Circulation: intact set of arteries, capillaries,  Left sided: pulmonary edema
and lymphatics o Advance stages: left + right sided heart failure
 Determinants of homeostasis o Forward failure → ↓ cardiac output → edema
o Vessel wall integrity o Backward failure → accumulation of blood in the
o Intravascular pressure venous system → edema
o Osmolarity  Constrictive pericarditis
o Heart contractility is being impeded
II. HEMODYNAMIC DISTURBANCES  Liver cirrhosis (ascites)
 Result of any breach or disruption in any of the determinants o Fibrosis → Disarray of liver architecture →
of homeostasis compression of portal system → water retention
o Edema → ↑ hydrostatic pressure → ascites
o Hemorrhage o May be due to obstruction of lymphatic drainage
o Thrombosis  Venous obstruction or compression
o Embolism o Thrombosis (e.g., deep vein thrombosis)
o Infarction o External pressure (e.g., mass)
o Shock o Lower extremity inactivity with prolonged
dependency
A. EDEMA b. Arteriolar dilation
 60% of lean body weight is water  Heat
o 2/3 or 40% intracellular  Neurohumoral dysregulation
o 1/3 or 20% extracellular
 15% interstitial fluid (3rd space) 2. Reduced Plasma Osmotic Pressure
 5% plasma (Hypoproteinemia)
 Edema is the accumulation of fluid in tissues due to the  Albumin
abnormal increase in interstitial fluid o Most important protein that maintains and regulates
 Effusion is the accumulation of fluid in body cavities colloid oncotic pressure intravascularly
o Name varies depending on the site o Accounts for almost half of the total plasma protein
 Hydrothorax- thoracic cavity a. Increased loss of albumin from circulation
 Hydropericardium- pericardial space  Protein-losing glomerulonephritis
 Hydroperitonium/Ascites- peritoneal space (nephrotic syndrome)
 Anasarca- severe and generalized edema with o Leaky glomerulus → large molecules (albumin)
widespread subcutaneous tissue swelling exit the glomerulus → albuminuria →
 The movement of fluid is determined by 2 opposing forces ↓ oncotic pressure → generalized edema
which maintain fluid balance distribution:  Protein-losing gastroenteropathy
o Vascular hydrostatic pressure b. Inadequate albumin synthesis
 Kicking force  Liver cirrhosis (ascites)
o Plasma colloid osmotic pressure o Dysfunctional liver → inadequate albumin
 Keeping force  Malnutrition
o Edema = ↑ hydrostatic pressure or ↓ oncotic pressure o Low protein intake → inadequate albumin
o Kwashiorkor
Normal Fluid Outflow
 Balance of hydrostatic and  “edematous malnutrition”
colloid pressures
 Little net movement of fluid 3. Sodium and Water Retention
out of vessels into the
interstitium
 Increased salt retention with obligate water retention
 Drainage by lymphatics o Intravascular fluid volume expansion → ↑ hydrostatic
Pathologic Disorders pressure
 ↑ hydrostatic pressure or o Dilution → ↓ vascular colloid osmotic pressure
↓ oncotic pressure
 Fluid extravasation
 Capacity for lymphatic
drainage is exceeded
 Edema

SYSPATH | 1 of 3 NAZIR, HERNANDO, MODGIL

 a. Excessive salt intake with renal insufficiency c. Postsurgical
 No way to excrete excess salt  Trauma: Modified radical mastectomy
 “where sodium goes water follows” o Surgical treatment for breast cancer
 Intervention: minimize salt intake o Removal of entire breast, including skin,
b. Increased tubular reabsorption of sodium areola, nipple, and most axillary lymph
 Renal hypoperfusion nodes; pectoralis major is spared
o Primary kidney disorders o Dissection of axillary lymph nodes → lack of
o Cardiovascular disorders (e.g., congestive lymphatic drainage → fluid accumulation →
heart failure) edema
 Increased renin-angiotensin-aldosterone secretion o Patient is predisposed to multiple infections
o Beneficial in early CHF d. Postirradiation
 Sodium and water retention + ↑ vascular  Fibrosis: caused by radiation and leads to blockage
tone + ↑ ADH = improved cardiac output of lymphatic vessels
= restoration of normal renal perfusion
o Destructive in worsened CHF 5. Increased Vascular Permeability
 Diminished cardiac output a. Inflammatory edema
 Sodium and water retention = ↑ venous  May occur in acute or chronic inflammation
pressure = ↑ hydrostatic pressure =  Caused by inflammatory mediators
edema  Protein-rich exudate
o Noninflammatory edema: protein-poor
 Intervention: decrease salt intake,
administer diuretics transudate
 Usually localized
 Systemic inflammatory states (e.g., sepsis) produce
widespread endothelial injury and dysfunction →
generalized edema
b. Angiogenesis
 Young blood vessels have limited functions, thus
they may be leaky

MORPHOLOGY AND CLINICAL FEATURES OF EDEMA

 Grossly: easily recognized
 Microscopically: clearing and separation of extracellular matrix
and subtle cell swelling
 Any organ or tissue can be involved
 Most commonly seen in subcutaneous tissue, lungs, and brain

4. Lymphatic Obstruction
 Disruption of lymphatic vessels → impaired interstitial fluid
clearance → lymphedema (typically localized)
a. Inflammatory
 Infectious agents: microorganisms that reside in
lymphatic vessels
 Filariasis (Wuchereria bancrofti & Brugia malayi):
obstructive fibrosis of lymphatic channels and
lymph nodes → edema of external genitalia and
lower limbs (“elephantiasis”)
1. Subcutaneous Edema
 Most visible form
 Will have different distributions depending on the cause
o Can be diffuse
o More conspicuous in regions with high hydrostatic
pressures
 Dependent form
o Distribution is typically influenced by gravity
o more prominent in the lower extremities
 Signals potential underlying cardiac or renal disease
o Prominent feature of congestive heart failure (bipedal
edema)
 It can impair wound healing or the clearance of infections
 Pitting edema
o Finger pressure over markedly edematous subcutaneous
tissue displaces the interstitial fluid and leaves a
depression

b. Neoplastic
 Invasive tumors: impinge on the lymphatic system

SYSPATH | 2 of 3 NAZIR, HERNANDO, MODGIL

2. Pulmonary Edema
CHECKPOINT
 Lungs turn heavy (2-3 times their normal weight)
TRUE OR FALSE
 Sectioning yields frothy, blood-tinged fluid
o Mixture of air, edema, and extravasated red cells 1. In brain edema there is distended sulci and narrowed
gyri.
 Fluid collection in alveolar septa and capillaries: impediment
2. Edema is an abnormal increase in interstitial fluid.
of oxygen diffusion
3. Anasarca is a severe and localized edema with
 Fluid in alveolar spaces: favorable environment for bacterial
widespread subcutaneous tissue swelling.
infection
4. Increase in plasma colloid osmotic pressure leads to
 Frequently seen in:
o Left ventricular failure (most common) edema.
o Renal failure 5. In advanced stages of CHF, there is both left and right
o Acute respiratory distress syndrome sided heart failure.
o Pulmonary inflammation or infection 6. Albumin is the most important protein to maintain and
regulate hydrostatic pressure intravascularly.
 Pneumonia
7. Formation of ascites in liver cirrhosis is due to
 Tuberculosis
o Hypersensitivity reaction obstruction of lymphatic drainage.
8. Nephrotic syndrome shows generalized edema.
 Type 1: histamine release causes vasodilatation
9. RAA system is meant to protect in the late stages of
 Pulmonary effusions accompany edema of lungs →
compression of lung parenchyma → further compromise of heart failure.
gas exchange 10. Edema due to lymphatic obstruction typically shows
localized edema.
11. Inflammatory edema is exudative and noninflammatory
edema is transudative.
12. Fibrosis as a result of radiation causes edema by
blockage of lymphatic vessels.
13. Pulmonary edema is typically influenced by gravity and
is considered the most prominent feature of CHF.
14. Most common cause of pulmonary edema is right sided
ventricular failure.
15. 65% of lean body weight is water.
IDENTIFICATION
3. Brain Edema 1. Give the three important factors for maintenance of
 Localized or generalized normal fluid homeostasis.
 Narrowed sulci and distended gyri 2. In liver pathology, what is the mechanism of edema?
 Severe brain edema can injure medullary centers and cause 3. In elephantiasis, what is the mechanism of edema?
death 4. Give two pathophysiologic mechanisms of edema in
o herniation of brain substance through the foramen heart failure.
magnum 5. What is the morphologic manifestation of brain edema?
o compression of brain stem vasculature 6. Aside from edema, give two other hemodynamic
disturbances.

sulci, distended gyri (6) hemorrhage, embolism, thrombosis, infarction, shock

decreased plasma osmotic pressure, sodium and water retention (5) narrowed
osmotic pressure (3) lymphatic obstruction (4) increased hydrostatic pressure,
(1) vessel wall integrity, intravascular pressure, osmolarity (2) reduced plasma

(11) T (12) T (13) F (14) F (15) F

(6) F (7) T (8) T (9) F (10) T
(1) F (2) T (3) F (4) F (5) T
ANSWERS:

4. Edema of Renal Dysfunction

 Affects all parts of the body equally References: Dr. Espiritu’s lecture
 Initially appears in parts of the body with loose connective Robbins and Cotran Pathologic Basis of Disease, 9th Ed.,
tissue Kumar, Abbas, & Aster
o Periorbital edema (eyelids)
END

SYSPATH | 3 of 3 NAZIR, HERNANDO, MODGIL