Hemodynamic Disorders Aj Edema

Happy Year
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
 Shock
INTRODUCTION
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 interstitial
EDEMA
Increased fluid in the interstitial tissue spaces
Fluid may also accumulate in body cavities:
1. Hydrothorax
2. Hydropericardium
3. 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 Homeostasis
Lymphatics
Fluid 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 Edema
I. Increased Hydrostatic Pressure
II. Reduced Plasma Oncotic

Pressure
III. Inflammation
–IV. Others
Patho-physiologic Categories of Edema
Increased Hydrostatic Pressure

Increased intravascular pressure may be due to
1- Impaired venous return;
A) Localized: Venous Thrombosis in lower extremities
(local edema).
B) Generalized: Congestive Heart Failure (generalized
edema).
2- Increased arteriolar dilatation;

a) Heat
b) Neurohumoral dysregulation
Congestive 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”
Congestive Heart Failure
Mechanism:
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

& 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 blood coming
through …….
Decreased Renal Perfusion activates

the Renal Defense Mechanisms:
1. Renin-Angiotensin-Aldosterone axis 
 Na & H2O retention
2. Renal Vasoconstriction
3. Increased Renal Anti-diuretic Hormone (ADH)
– 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 More EDEMA .
Central Renal
Venous Perfusion
Pressure
Renin ADH
Renal
Vasoconstriction
Pathophysiologic Categories of
Edema
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:

1.  Protein Loss
or
2. Protein Synthesis
II. Reduced Plasma
Oncotic Pressure
1. Increased albumin Loss:
– Nephrotic Syndrome
Increased permeability of the glomerular basement membrane 
loss of protein
2. Reduced albumin synthesis:

– Cirrhosis
– Protein malnutrition
– EFFECT:
– is movement of fluid into the interstitial tissue with resultant
plasma volume contraction.
Edema
III. Inflammation
Localized Edema
Increased Vascular Permeability
IV. Others
Edema
III. 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
INCREASED DECREASED
HYDROSTATIC HEART ONCOTIC
PRESSURE PRESSURE
Congestive Heart Failure LIVER Nephrotic Syndrome
Ascites Cirrhosis
Venous Obstruction KIDNEY Protein Malnutrition
LYMPHATIC
INCREASED OBSTRUCTION
PERMEABILITY Inflammatory
Inflammation Neoplastic
Edema Fluid
Transudate Exudate
Cause High hydrostatic Inflammatory

pr.
Protein content Low High
Specific gravity <1.012) >1.020)
Inflammatory Absent Rich

cells
GENERALIZED EDEMA
HEART
LIVER
KIDNEY
Subcutaneous Edema
Edema of the subcutaneous tissue is most easily detected Grossly (not microscopically)
Push your finger into it

and a depression remains
Annoying but Points to

Underlying Disease
It can impair wound healing
or clearance of Infection
Edema
Dependent Edema is a prominent feature of
Congestive Heart Failure; in legs if standing or
sacrum in sleeping patient
Periorbital edema is often the initial

manifestation of Nephrotic Syndrome, while late
cases will lead to generalized edema.
Pulmonary Edema
is most frequently seen in Congestive

Heart Failure
– May also be present in renal failure, adult
respiratory distress syndrome (ARDS),
pulmonary infections and hypersensitivity
reactions
Pulmonary 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
function
Normal lung
Pulmonary Edema
Pulmonary Edema
Clinical 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 Edema
Clinical Correlation
The 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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Happy Year

Awatif Jamal, MD, MSc, FRCPC, FIAC

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

60% of body weight is water, distributed as follow:

Massive generalized edema is called Anasarca

Normally, the exit of fluid into the interstitium

transudate is protein-poor (specific gravity

An exudate is protein-rich (specific

I. Increased Hydrostatic Pressure

II. Reduced Plasma Oncotic

Increased Hydrostatic Pressure

2- Increased arteriolar dilatation;

Congestive Heart Failure:

“Generalized increased venous pressure, resulting

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

Leading to Generalized Edema

Congestive heart failure 

Decreased Renal Perfusion activates

– The failing heart can’t increase the COP so the

II. Reduced Plasma Oncotic Pressure

A decrease in osmotic pressure can result from:

2. Reduced albumin synthesis:

II. Reduced Plasma Oncotic Pressure

II. Reduced Plasma Oncotic Pressure

Impaired lymphatic drainage with resultant

In cases of CA breast the resection and/or radiation of

Cause High hydrostatic Inflammatory

Specific gravity <1.012) >1.020)

Inflammatory Absent Rich

Push your finger into it

Annoying but Points to

Periorbital edema is often the initial

is most frequently seen in Congestive

May cause death by interfering with Oxygen and Carbon

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