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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 - PowerPoint PPT Presentation

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Page 1: Happy Year

Happy Year

Page 2: Happy Year

Awatif Jamal, MD, MSc, FRCPC, FIAC Consultant & Associate Professor

Department of PathologyKing Abdulaziz University Hospital

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Hemodynamic Disorders Hemodynamic Disorders Thrombosis & ShockThrombosis & Shock

EdemaEdema Hyperemia and CongestionHyperemia and Congestion

HemorrhageHemorrhage Hemostasis & ThrombosisHemostasis & Thrombosis

EmbolismEmbolism InfarctionInfarction

ShockShock

• EdemaEdema

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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.

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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

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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

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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

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Fluid HomeostasisFluid Homeostasis

Lymphatics

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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

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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))

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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

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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

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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

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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

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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 …….

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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)

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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 .

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Congestive Heart FailureCongestive Heart Failure

CentralVenousPressure

Renal Perfusion

Renin

Renal Vasoconstriction

ADH

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Pathophysiologic Categories ofPathophysiologic Categories ofEdemaEdema

I. Increased Hydrostatic PressureI. Increased Hydrostatic Pressure

III. InflammationIII. Inflammation IV. OthersIV. Others

II. Reduced Plasma Oncotic Pressure

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“…“…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

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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

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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

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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

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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

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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

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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)

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EDEMA - EDEMA - SummarySummary

INCREASEDHYDROSTATICPRESSURE

Congestive Heart FailureAscitesVenous Obstruction

DECREASED ONCOTICPRESSURE

Nephrotic SyndromeCirrhosisProtein Malnutrition

INCREASEDPERMEABILITY

Inflammation

LYMPHATICOBSTRUCTION

InflammatoryNeoplastic

HEARTHEARTLIVERLIVERKIDNEYKIDNEY

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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

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GENERALIZED EDEMAGENERALIZED EDEMA

HEARTHEARTLIVERLIVERKIDNEYKIDNEY

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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

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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

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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

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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

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Normal lung

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Pulmonary Edema

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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”!!!

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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

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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

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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.

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Thank you