Hemodynamic Disorders

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Happy Year
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Pathology 301

• Awatif Jamal, MD, MSc, FRCPC, FIAC
• Consultant Associate Professor
• Department of Pathology
• King Abdulaziz University Hospital

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Hemodynamic Disorders Thrombosis Shock

• Edema
• Hyperemia and Congestion
• Hemorrhage
• Hemostasis Thrombosis
• Embolism
• Infarction
• Shock

• Edema

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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.

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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
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EDEMA

• Increased fluid in the interstitial tissue
  spaces
• Fluid may also accumulate in body cavities
• Hydrothorax
• Hydropericardium
• Hydroperitoneum is also called Ascites
• Massive generalized edema is called Anasarca

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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

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Fluid Homeostasis
Lymphatics
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Fluid Homeostasis

• Homeostasis is maintained by the opposing effects
  of
• Vascular Hydrostatic Pressure
• and
• Plasma Colloid Osmotic Pressure

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Edema Fluid TRANSUDATE

• transudate is protein-poor (specific gravity
  lt1.012)
• An exudate is protein-rich (specific gravity
  gt1.020) (inflammatory edema)

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Pathophysiologic Categories of Edema
I. Increased Hydrostatic Pressure

• II. Reduced Plasma Oncotic
• Pressure
• III. Inflammation
• IV. Others

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Patho-physiologic Categories of Edema

• Increased Hydrostatic Pressure
• Increased intravascular pressure may be due to
• 1- Impaired venous return
• Localized Venous Thrombosis in lower extremities
  (local edema).
• Generalized Congestive Heart Failure
  (generalized edema).
• 2- Increased arteriolar dilatation
• Heat
• Neurohumoral dysregulation

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Increased Hydrostatic Pressure

• 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

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Increased Hydrostatic Pressure 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

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Congestive Heart Failure Decreased Renal
Perfusion

• Congestive heart failure ?
• Decreased Cardiac Output ?
• Decreased ARTERIAL blood volume ?

Less arterial bloodLess renal perfusion... The
Kidney doesnt see enough blood coming through .
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Congestive Heart Failure Decreased Renal
Perfusion

• Decreased Renal Perfusion activates
• the Renal Defense Mechanisms
• Renin-Angiotensin-Aldosterone axis ?
• ? Na H2O retention
• Renal Vasoconstriction
• Increased Renal Anti-diuretic Hormone (ADH)

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Congestive Heart Failure Decreased Renal
Perfusion

• The net result will be increased intravascular
  volume to increase the COP.
• The failing heart cant increase the COP so the
  extra fluid load will lead to additional increase
  in the venous pressure and More EDEMA .

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Congestive Heart Failure
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Pathophysiologic Categories ofEdema

• I. Increased Hydrostatic Pressure

II. Reduced Plasma Oncotic Pressure

• III. Inflammation
• IV. Others

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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
• ? Protein Loss
• or
• ? Protein Synthesis

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II. Reduced Plasma Oncotic Pressure

• Increased albumin Loss
• Nephrotic Syndrome
• Increased permeability of the glomerular basement
  membrane ? loss of protein
• Reduced albumin synthesis
• Cirrhosis
• Protein malnutrition
• EFFECT
• is movement of fluid into the interstitial tissue
  with resultant plasma volume contraction.

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Pathophysiologic Categories ofEdema
I. Increased Hydrostatic Pressure
II. Reduced Plasma Oncotic Pressure
III. Inflammation Localized Edema Increased
Vascular Permeability

• IV. Others

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Pathophysiologic Categories ofEdema
I. Increased Hydrostatic Pressure
II. Reduced Plasma Oncotic Pressure
III. Inflammation

• IV. Others
• Lymphatic Obstruction
• Water and Sodium Retention

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Lymphatic Obstruction

• Impaired lymphatic drainage with resultant
  lymphedema
• LOCALIZED EDEMA
• caused by
• INFLAMMATION
• or
• NEOPLASTIC OBSTRUCTION

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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

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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 dorange (orange peel)

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EDEMA - Summary
INCREASED HYDROSTATIC PRESSURE Congestive Heart
Failure Ascites Venous Obstruction
DECREASED ONCOTIC PRESSURE Nephrotic
Syndrome Cirrhosis Protein Malnutrition

• HEART
• LIVER
• KIDNEY

LYMPHATIC OBSTRUCTION Inflammatory Neoplastic
INCREASED PERMEABILITY Inflammation
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Edema Fluid
Exudate Transudate
Inflammatory High hydrostatic pr. Cause
High Low Protein content
gt1.020) lt1.012) Specific gravity
Rich Absent Inflammatory cells
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GENERALIZED EDEMA

• HEART
• LIVER
• KIDNEY

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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

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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.

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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

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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

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Normal lung
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Pulmonary Edema
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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!!!

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Brain Edema

• Trauma, Abscess, Neoplasm, Infection
  (Encephalitis due to say West Nile Virus), etc

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Brain Edema

• Clinical Correlation The big problem is There
  is no place for the fluid to go!
• Herniation into the foramen magnum will kill

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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.

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Thank you