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Chatri Settasatian, Ph.D.

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Chatri Settasatian, Ph.D.

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    1. Chatri Settasatian, Ph.D. Department. of Pathology Faculty of Medicine KKU

    4. Fluid Homeostasis maintained by opposing effects of vascular hydrostatic pressure and plasma colloid osmotic pressure

    7. Edema Development Picture Fig 4.1

    8. EDEMA Increased fluid in the interstitial tissue spaces Massive edema is called Anasarca

    9. EDEMA Fluid may also accumulate in body cavities These collections of fluid are referred to based on location as: Pleural Cavity : Hydrothorax Pericardial Cavity : Hydropericardium Peritoneum : Hydroperitoneum, also called Ascites

    10. Edema Fluid = TRANSUDATE A transudate is protein-poor (specific gravity <1.012) An exudate is protein-rich (specific gravity >1.020)

    11. Pathophysiologic Categories of Edema I. Increased Hydrostatic Pressure II. Reduced Plasma Oncotic Pressure III. Inflammation IV. Other

    12. Pathophysiologic Categories of Edema I. Increased Hydrostatic Pressure A. Congestive Heart Failure B. Portal Hypertension C. Venous Thrombosis

    13. Increased Hydrostatic Pressure “Generalized increases in venous pressure, Congestive Heart Failure is the most common cause of EDEMA due to Increased Hydrostatic Pressure

    14. Congestive Heart Failure The Pump is FAILING Blood backs up, first into the lungs, then into the venous circulation - increasing Central Venous Pressure (CVP)

    15. Congestive Heart Failure Increased CVP leads to increased capillary pressure (Hydrostatic Pressure) Leading to Edema

    19. Congestive Heart Failure Overall, there are TWO main effects...

    20. Congestive Heart Failure Decreased Renal Perfusion Decreased Cardiac Output (see Fig 4.2) Leads to decreased ARTERIAL blood volume

    21. Congestive Heart Failure Decreased Renal Perfusion Decreased Renal Perfusion activates the Renal Defense Mechanisms: Renin-Angiotensin-Aldosterone Axis Renal Vasoconstriction Increased Renal Anti-diuretic Hormone (ADH)

    22. Congestive Heart Failure Renin-Angiotensin-Aldosterone Axis

    23. Congestive Heart Failure Renal Vasoconstriction

    24. Congestive Heart Failure Anti-Diuretic Hormone

    25. Congestive Heart Failure

    26. Pathophysiologic Categories of Edema I. Increased Hydrostatic Pressure A. Congestive Heart Failure B. Portal Hypertension C. Venous Thrombosis

    27. Portal Hypertension “Ascites (Liver Cirrhosis)” Portal Hypertension is “Increased resistance to portal blood flow” The most common cause of Portal Hypertension is CIRRHOSIS

    28. Portal Hypertension leads to ASCITES Pathogenesis of Ascites is complex Increased Portal Pressure (hydrostatic pressure) leads to increased liver sinusoidal hypertension. Fluid moves into the Space of Disse then into lymphatics

    29. Pathogenesis of Ascites is complex The hepatic lymph percolates into the peritoneal cavity Normal thoracic duct lymph = 1 Liter/d In cirrhosis, hepatic lymph flow far exceeds Thoracic duct capacity

    30. Pathogenesis of Ascites is complex Cirrhosis leads to hypoalbuminemia (next category) And ultimately, there is decreased renal perfusion leading to secondary hyperaldosteronism (increased renin etc.)

    31. Portal Hypertension

    32. Pathophysiologic Categories of Edema I. Increased Hydrostatic Pressure A. Congestive Heart Failure B. Portal Hypertension C. Venous Thrombosis

    33. Venous Thrombosis Impaired venous outflow increases hydrostatic pressure

    34. Pathophysiologic Categories of Edema I. Increased Hydrostatic Pressure II. Reduced Plasma Oncotic Pressure III. Inflammation IV. Other

    35. Reduced Plasma Osmotic Pressure “…Albumin is the serum protein MOST responsible for the maintenance of colloid osmotic pressure.” Kumar p 80 A decrease in osmotic pressure can result from increased protein loss or decreased protein synthesis

    36. Reduced Plasma Osmotic Pressure Increased albumin Loss: Nephrotic Syndrome Increased protein permeability of the glomerular basement membrane Reduced albumin synthesis Cirrhosis Protein malnutrition

    37. Pathophysiologic Categories of Edema I. Increased Hydrostatic Pressure II. Reduced Plasma Oncotic Pressure III. Inflammation IV. Other

    38. Inflammation Both Acute and Chronic Inflammation are associated with EDEMA

    39. Pathophysiologic Categories of Edema I. Increased Hydrostatic Pressure II. Reduced Plasma Oncotic Pressure III. Inflammation IV. Other Lymphatic Obstruction

    40. Lymphatic Obstruction Impaired lymphatic drainage with resultant lymphedema, usually localized Usually due to INFLAMMATION or NEOPLASTIC OBSTRUCTION

    41. Lymphatic Obstruction Inflammation Filariasis - A parasitic infection affecting inguinal lymphatics resulting in elephantiasis

    42. Picture of Elephantiasis

    43. Lymphatic Obstruction Neoplasia Resection and/or radiation to axillary lymphatics can lead to arm edema Carcinoma of breast with obstruction of superficial lymphatics can lead to an unusual appearance of the breast - “peau d’orange” (orange peel)

    44. EDEMA HEART LIVER KIDNEY

    45. GENERALIZED EDEMA HEART LIVER KIDNEY

    46. Edema Morphology Edema of the Subcutaneous Tissue is most easily detected Grossly (not microscopically) Push your finger into it and a depression remains

    47. Edema Photo

    48. Dependent Edema is a prominent feature of Congestive Heart Failure Facial edema is often the initial manifestation of Nephrotic Syndrome Edema Morphology

    49. Edema Morphology 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

    50. Pulmonary Edema The Lungs are typically 2-3 times normal weight Cross sectioning causes an outpouring of frothy, sometimes blood-tinged fluid

    51. Gross Picture of Pulmonary Edema

    52. Normal Pulmonary Edema

    53. Edema of the Brain Trauma, Abscess, Neoplasm, Infection (Encephalitis due to say… West Nile Virus), etc

    54. Clinical Correlation Subcutaneous Edema Annoying but Points to Underlying Disease However, it can impair wound healing or clearance of Infection

    55. Clinical Correlation Pulmonary Edema May cause death by interfering with Oxygen and Carbon Dioxide exchange Creates a favorable environment for infection THINK “Culture Media”

    56. Clinical Correlation Edema of the Brain The big problem is: There is no place for the fluid to go! Herniation into the foramen ovale will kill

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