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Hemodynamic Disorders Edema Elephantiasis

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Hemodynamic Disorders Edema Elephantiasis 5/15/2020 Edema Hemodynamic Disorders • Excess accumulation of fluid in interstitial space or in serous cavity is called edema. • Types – Local edema Dr. Sadequel Islam Talukder – Generalized edema MBBS, M Phil (Pathology 1995, IPGMR) 5/15/2020 Sadequel Talukder, www.talukderbd.com 1 5/15/2020 Sadequel Talukder, www.talukderbd.com 2 • Generalized edema • Local edema – Hepatic edema – Acute inflammatory edema – Cardiac edema – Allergic edema – Renal edema – Edema due to impaired venous return of leg following – Nutritional deficiency edema • Long journey – Pregnancy edema • Long period of standing – Myxedema – Lymphedema following lymphatic obstruction – Unexplained edema • e.g. Filariasis 5/15/2020 Sadequel Talukder, www.talukderbd.com 3 5/15/2020 Sadequel Talukder, www.talukderbd.com 4 Elephantiasis • Clinical Types of Edema – Pitting edema • A non-pitting edema following lymphtaic – Non-pitting edema obstruction • Causes of edema/Pathophysiological Category • Accumulation of lymph in tissue – Increased hydrostatic pressure • Causes inflammation, fibrosis. – Decreased colloidal osmotic pressure • Fibrosis causes non-pitting edema. – Retention of salt and water – Lymphatic obstruction 5/15/2020 Sadequel Talukder, www.talukderbd.com 5 5/15/2020 Sadequel Talukder, www.talukderbd.com 6 1 5/15/2020 • Serous cavities – Peritoneal cavity - Excess accumulation of fluid is • All causes are found in hepatic edema called ascites. • Normally interstitial space and serous cavity – Pleural cavity - Excess accumulation of fluid is contains small amount of fluid. Excess amount called pleural effusion. of fluid cases edema. – Pericardial cavity - Excess accumulation of fluid is called pericardial effusion. – Synovial cavity - Excess accumulation of fluid is called synovial effusion. 5/15/2020 Sadequel Talukder, www.talukderbd.com 7 5/15/2020 Sadequel Talukder, www.talukderbd.com 8 • Anasarca – Severe generalized edema is called • Fluid comes out from vessels due to anasarca. It is usually seen in nephrotic – Hydrostatic pressure in blood vessels syndrome. – Colloidal osmotic pressure (COP) in interstitial • Primary lymphedema – Edema due to fluid malformation of lymphatics. • Fluid enters in blood vessels due to • Starling postulate- Fluid movement between – Tissue tension extracellular space and blood vessels depends on balance of hydrostatic and osmotic – Colloidal osmotic pressure of plasma (80% COP is pressure. maintained by albumin) 5/15/2020 Sadequel Talukder, www.talukderbd.com 9 5/15/2020 Sadequel Talukder, www.talukderbd.com 10 • Tissue where fluid easily accumulates Hepatic Edema – Eyelids – Scrotum – Ankle etc. • Edema in liver diseases is called hepatic • Tissue where fluid does not easily accumulates edema. – Palm – Cirrhosis – Sole – Hepatitis • Water moves – Carcinoma of liver etc. – From fluid of high hydrostatic pressure to low hydrostatic pressure – From low colloidal osmotic pressure to high colloidal osmotic pressure. 5/15/2020 Sadequel Talukder, www.talukderbd.com 11 5/15/2020 Sadequel Talukder, www.talukderbd.com 12 2 5/15/2020 • Pathogenesis of edema in cirrhosis • Hypoalbuminemia – Portal hypertension – Reduction of hepatic cell mass in cirrhosis • Contraction of liver due to extensive fibrosis in cirrhosis – Decreased albumin synthesis • Portal vein compression at porta hepatis. • Increased hydrostatic pressure in portal system. – Nutritional hypoalbuminemia • Transudation. – Transudation and generalized edema • Accumulation of fluid in peritoneal cavity and ascites. • Lymphatic obstruction at porta hepatis – Compression of porta hepatis – Impaired lymph drainage – Enhancement of ascites 5/15/2020 Sadequel Talukder, www.talukderbd.com 13 5/15/2020 Sadequel Talukder, www.talukderbd.com 14 • Secondary hypertension Cardiac Edema – Reduction of hepatic cell mass – Delayed aldosterone metabolism. Thus half life of • Edema due to heart disease is called cardiac aldosterone is increased. edema. – Aldosterone acts upon renal tubules and • Example – Right-heart failure/Congestive absorption of sodium and water. cardiac failure (CCF) – Increased volume of blood – Increased hydrostatic pressure – Transudation and generalized edema. 5/15/2020 Sadequel Talukder, www.talukderbd.com 15 5/15/2020 Sadequel Talukder, www.talukderbd.com 16 – Salt and water retention • Pathogenesis of cardiac edema • Impaired venous return • Decreased cardiac output – Increased hydrostatic pressure • Decreased renal blood flow -> Renin secretion from • Right heart failure causes impaired venous return juxtraglomerular system. • Increased blood volume in venous system. • Activation of renin angiotensin axis. • Increased hydrostatic pressure in blood. • Secretion of aldosterone -> absorption of sodium and • Transudation and generalized edema. water from renal tubules. • Increased blood volume. • Increased hydrostatic pressure in blood. • Transudation and generalized edema. 5/15/2020 Sadequel Talukder, www.talukderbd.com 17 5/15/2020 Sadequel Talukder, www.talukderbd.com 18 3 5/15/2020 Renal Edema • Pathogenesis of edema in nephritic syndrome • Edema following renal diseases is called renal – Proteinuria in nephrotic syndrome edema. • Mild to moderate proteinuria • Hypoalbuminemia • Renal diseases associated with edema • Decreased colloidal osmotic pressure – Nephritic syndrome (Syndrome in AGN) • Transudation and edema – Nephrotic syndrome 5/15/2020 Sadequel Talukder, www.talukderbd.com 19 5/15/2020 Sadequel Talukder, www.talukderbd.com 20 • Pathogenesis of edema in nephrotic syndrome – Massive proteinuria or heavy proteinuria • Oligouria in nephritic syndrome • Hypoalbuminemia – Retention of salt and water in blood. • Decreased colloidal osmotic pressure in blood. – Increased volume of blood • Transudation and edema • Massive or heavy proteinuria – Increased hydrostatic pressure in blood » Passage of protein (albumin) > 3.5 gm in 24 hours. – Transudation and edema 5/15/2020 Sadequel Talukder, www.talukderbd.com 21 5/15/2020 Sadequel Talukder, www.talukderbd.com 22 Clinical Importance of Edema Angioedema • Cardiac edema – 1st appear in dependent part, • Edema in Type-I and Type-III hypersensitivity like, ankle. reaction. • Renal edema - 1st appear in face • Edema involves in dermis and subcutaneous • Hepatic edema - 1st appear in abdomen tissue. [ascites] 5/15/2020 Sadequel Talukder, www.talukderbd.com 23 5/15/2020 Sadequel Talukder, www.talukderbd.com 24 4 5/15/2020 Pulmonary Edema Hypoxia in pulmonary edema • Accumulation of fluid in lung alveoli is called • Fluid in alveolar spaces cause scarcity of gas in pulmonary edema. alveoli. • Causes • Blood in interalveolar septal capillaries can not – Left ventricular failure obtain sufficient oxygen thus cellular hypoxia – Cerebral damage etc. throughout the body. 5/15/2020 Sadequel Talukder, www.talukderbd.com 25 5/15/2020 Sadequel Talukder, www.talukderbd.com 26 Cerebral Edema • Example of vesogenic edema – edema in – Primary and metastatic tumors of brain • Brain is susceptible to edema , because of – Brain abscess – Little room to expand – Infarction of brain etc. – Absence of lymphatics to carry away any excess fluid that accumulates. • Cytotoxic edema • Types – Accumulation of fluid in cells of gray matter. – Vesogenic edema – loss of blood brain barrier – Example – edema in ischemic brain function results from damage of capillaries or newly formed capillaries that have not yet established barrier causes edema. 5/15/2020 Sadequel Talukder, www.talukderbd.com 27 5/15/2020 Sadequel Talukder, www.talukderbd.com 28 • Interstitial edema Infarct and Infarction – Example – Edema in noncommunicating type hydrocephalus. Fluid comes out across the • Localized area of ischemic necrosis either due ependymal lining of ventricles and accumulates in to sudden arterial occlusion or impaired the periventricular white matter. venous return is called infarct and the phenomenon is called infarction. *Cerebral edema is more dangerous, because, the • Types cerebrum may herniate through foramen magnum and patient may die. • Based on presence or absence of infarction – Septic infarct – presence of infection in infarct. – Bland infarct - absence of infection in infarct. 5/15/2020 Sadequel Talukder, www.talukderbd.com 29 5/15/2020 Sadequel Talukder, www.talukderbd.com 30 5 5/15/2020 • Based on color – Pale or anemic infarct • Effects of abnormal blood flow – Red or hemorrhagic infarct – Arterial dilatation causes increased blood flow. It is called hyperemia. Most common cause of infarct – Sudden arterial occlusion causes infarction. – Arterial occlusion, caused by thrombus or – Diminised arterial blood flow cases atrophy embolus 5/15/2020 Sadequel Talukder, www.talukderbd.com 31 5/15/2020 Sadequel Talukder, www.talukderbd.com 32 • Characteristics of pale infarct • Characteristics of red infarcts – Caused by arterial occlusion – Caused by impaired venous return – Occurs in solid organs – heart, kidney, liver, spleen – Occurs in loose and previously congested tissue, etc. like – Edema usually absent. • Intestine (in strangulated inguinal hermia, intestinal • Atheroma and myocardial infarction obstruction) • Lung – Superimposed thrombus formation on coronary • Testis (in testicular torsion) artery atheroma -> occlusion of artery and • Overy (in twisting of ovary) ischemic necrosis. • Valva etc. – Usually, edema present. 5/15/2020 Sadequel Talukder, www.talukderbd.com 33 5/15/2020 Sadequel Talukder, www.talukderbd.com 34 • Impaired venous return and infarct • Oxygen content of blood – Impaired venous return causes stasis of
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