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Edema is excess interstitial fluid, for whatever reason. Transudates are fluid accumulations that are essentially salt-water, accumulated because of pressure problems. Exudates are protein-rich fluid accumulations, due to leaky vessels. Thrombi, or blood clots within the vessels or heart, form when the blood flow is abnormal (turbulent or static), or the blood is too coagulable, or the endothelium of the vessels is damaged. Thrombi are said to embolize when they break free and sail downstream to obstruct a vessel. An infarct is an area of tissue that has died because its vascular supply was suddenly occluded. Venous infarcts result when veins can no longer drain an organ, and they tend to be very bloody. Arterial infarcts may be bloody (red) or not (white), depending on whether blood leaks back into the dead tissue (collaterals / dual supply; reperfusion) after the damage is done. In disseminated intravascular coagulation, the clotting cascades are activated throughout the body. This is bad, since it tends to shut down organs due to microthrombi, and also causes bleeding due to consumption of clotting factors and activation of plasmin. Shock is the inability to adequately perfuse the whole body, for any reason. Shock is likely to deteriorate into a vicious cycle of organ failure and subsequent exacerbation of shock
This is a generic term for too much interstitial ("intercellular") fluid. Contrast "cell swelling" or "intracellular edema". You are already familiar with this hallmark of cell injury. Edema may be localized or generalized. Bad generalized edema is called anasarca. Some definitions of edema also include excess fluid in the body cavities ("third space" -- normally, these cavities contain <50 mL or so of fluid). Most people call these effusions. Words to learn now: Ascites: excess free fluid in the peritoneal cavity Hydrothorax ("pleural effusion"): excess free fluid in a pleural cavity. If it's pus, it's called an empyema instead, (less often, pyothorax). If it's blood, you must call it hemothorax instead
Hydropericardium ("pericardial effusion"): excess fluid in the pericardial cavity. Hydrocephalus: Increased volume of cerebrospinal fluid from any cause; dilated cerebral ventricles. More about this at the end of the course. Hydrocele: Excess fluid in the space around the testis Hydrosalpinx: A dilated oviduct full of non-inflammatory fluid Ileus: excess fluid within the small bowel; dilated bowel segments. Seroma: Accumulation of non-infected fluid in a tissue space made by surgery, especially the incision. Loculated effusion: an effusion divided into more than one compartment, generally by scar tissue. A problem for the physician who wishes to drain the fluid using a needle. There is no need to review the volumes of the various body fluid compartments, or their physiology, here. Between cells or in body cavities, accumulations of fluid can be transudates or exudates. Blister: fluid within the epidermis
iatrogenic) Excess aldosterone (tumor. other) Kidney failure Pre-renal Heart failure Prolonged hypotension Antihypertensive therapy (notoriously calcium channel blockers) Renal: Intrinsic kidney disease Post-renal: Urinary obstruction Vascular problems All systemic veins Right-sided heart failure Most pericardial disease Pulmonary veins Left-sided heart failure Leg veins Prolonged standing Pregnancy ("pressure of the uterus".CAUSES OF EDEMA ie TRANSUDATE Excess total body fluid Salt and/or fluid overloading (self. estrogen) Valve failure Portal vein Cirrhosis and certain other liver diseases Obstruction or narrowing of specific veins Decreased plasma protein content Protein malnutrition Malabsorption / protein losing enteropathies Hepatic insufficiency Severe urinary protein wasting ("nephrotic syndrome") Lymphatic obstruction ("lymphedema") Inflammatory scarring (especially from filariasis) . liver failure.
The worst generalized edema is seen in severe hypoproteinemia (typically from the nephrotic syndrome). In clinical practice. . generalized edema is usually due to heart failure. or salty-food overindulgence by people with marginal kidney function. cirrhosis of the liver. nephrotic syndrome.
edema due to obstruction of the lymphatic vessels. The textbook cause is filaria worms. hence the term "pseudochylous. (Future pathologists: an old exudate can look milky too. an ominous sign. it can be striking.") . When lymphedema involves the extremities. Obstruction of the pulmonary lymphatics by cancer is a common mechanism of death in cancer patients. Cancer of the cervix probably causes more elephantiasis than filariasis does. even in the tropics.e. It'll look milky from the chylomicrons. While we're at it... usually from trauma or cancer involving the thoracic duct. Obstruction of lymphatics in the breast by a cancer produces "orangepeel skin". chylous effusions result from leaking lymphatics. producing elephantiasis.. Lymphedema (i.
You will have many opportunities to observe edema in the clinic. For the bedridden. Renal edema also involves the whole body. and often portions of the brain have been pushed out of their normal positions. Depending on the cause. Cerebral edema causes massive swelling of the brain. At autopsy. Since the primary problem is hydrostatic pressure. cardiac edema is worst in the more dependent portions of the body. which you'll study later. check over the sacrum. Look first around the eyelids. the lungs will be spared). the gyri are flattened against the skull. (If the left ventricle is okay but the right ventricle is out of order. this is especially serious when it affects the larynx. crackle. listen to the lungs for rales -. the brain is heavy. and pop of fluid bubbles in the alveoli. listen to the lungs. since the heart is working fine and the problems are fluid overload and/or hypoproteinemia. which is especially unwholesome since the brain is confined within a bony skull. At autopsy. a familiar problem. and begins to move whenever the patient changes position..the snap. the edema is generalized. Angioedema results from vessels becoming over-permeable. For patients standing up. Cardiac edema involves the whole body. we see heavy lungs.) Pulmonary edema. (Again. check a man's scrotum. with frothy fluid running from their cut surfaces. This time. look over the backs of the feet for "pitting edema". causes patients to cough up froth when the edema fluid escapes into the alveoli. .
resulting in increased blood content. This happens when the arterioles have dilated more than its venules have dilated. Hyperemia ("active hyperemia". See above. Examples are blushing. too many red cells). reddening of skin to disperse heat. Congestion ("passive congestion". a redundancy) is increased blood flow to an organ. Longstanding congestion is likely to result in a few microhemorrhages (or at least with "diapedesis of red cells through the capillary walls"). Congestion can result from any and all the "vascular problems" that produce transudates. and abundant hemosiderin-laden macrophages ("heart failure cells". another redundancy) is decreased blood flow from an organ. at least in the lungs) confirm that congestion has been present for at least a few days . This can include anything from an over-tight necktie to a failing heart to erections (purple and swollen). Congested organs ooze excess blood when cut. resulting in increased blood content. and "rubor" of acute inflammation. This happens when something is interfering with the organ's venous drainage. Or the blood may be hyperviscous (too much IgM.HYPEREMIA AND CONGESTION : The two possible reasons for increased blood volume in a particular part of the body. erections (red and throbbing).
it also refers to other masses. "Big Robbins" does). Hematomas: Enough blood in the tissues to create a palpable mass.) Hemothorax: Blood in a pleural cavity. Hemorrhages range from hickies to exsanguinating hemoptysis. Hemopericardium: Blood in the pericardial cavity. More about this later.HEMORRHAGE There's no need to review the basics of hemostasis here (though for your convenience. (Don't think the suffix "-oma" means only "tumor" -. Hemarthrosis: Bleeding into a joint . Some terms: Hemorrhage: Blood cells that have escaped from a vessel. Hemoperitoneum: Blood in the peritoneal cavity.
others define them to be bruises from trauma.. Others define them to be the multiple surface bleeds that are so common in folks with fragile vessels (including many of the normal elderly). An ecchymosis in a normal person is probably a bruise. a person with a bleeding problem is likely to have ecchymoses despite little (or no?) trauma . Some people define these to be above 10 mm. Ecchymoses: A still bigger hemorrhage in the tissues. also called a "contusion". Some people define these to range from 3-10 mm. Purpura: Bigger hemorrhages in the tissues.
tarry. lack of platelets. Hematochezia: Bright red blood out the rectum. Hematemesis: Vomiting blood. Petechiae: Little hemorrhages in the tissues. In addition to trauma. From upper GI bleeding.) Hemoptysis: Bleeding from the trachea. You will learn about the causes of hemorrhage soon enough. (If you ever need the singular. Melena: Black. acquired. * Serosanguineous is a natural term pathologists use for watery effusions that contain a bit of visible blood. cancers). there are diseases of blood vessels themselves (from the petechiae of scurvy to the rupture of a syphilitic aortic aneurysm into the throat). generally defined to be under 3 mm across. DIC). it's petechia. (). diseases around blood vessels (infections. From lower GI bleeding. lack of clotting factors (congenital. and high blood pressure . partially-digested blood out the rectum.
a periorbital hematoma (the familiar "black eye") merely presents an illustration of bilirubin's colorful breakdown products. another really bad place to have a hemorrhage . By contrast. Bleeds into the brain are devastating.The significance of hemorrhage depends on "where" and "how much". hemorrhage into the pituitary. Bleeds into the vitreous lead to blindness. A few cc of blood forced into the pericardial sac under left-heart pressures causes instant death by occluding the return of blood to the right side of the heart.
.. Thank you. You will probably go into hypovolemic shock . 20%. How much of your ~5 L of blood can you lose at once? 10%.. You donated a unit of blood.... 40%. You will probably feel a little sick.
and a solid outside the vessels. Blood is very special juice" (Goethe's Faust). Among other properties. You can review the clotting cascade and platelet activities in "Big Robbins". blood must be a liquid inside the vessels.THROMBOSIS : The transformation of flowing blood from a liquid to a solid within the vessels or heart. .
e. how it works in life most of the time. TF binds VII/VIIa. you don't get born . Plasma contacts Tissue Factor (TF).. We didn't pay any attention to TF until recently... And the rest happens like in your old textbooks. since if you lack it... The REAL clotting cascade (i... VII/VIIa complex with TF activates IX and X...): Vessel severed.
(Sloppy usage allows you to call thrombi "clots".) Three conditions predispose to thrombus formation: (1) injured endothelium. (3) hypercoagulable blood. and worth remembering (even for real life). (2) alterations in normal blood flow. at least when talking to non-physicians. Thrombus: Blood that has solidified within the vascular lumens or cardiac chambers. These are Virchow's triad. . Clot: Blood that has solidified anywhere else.
including the platelets. Activated coagulation factors. Finally. probably accumulate in pockets of turbulence. away from the endothelial surface. You remember from physiology that blood physics keeps the formed elements. which are ordinarily cleared by the onward flow of blood. while sufficiently anti-clotting proteins probably cannot reach these pockets. turbulence itself might physically damage endothelium . When the flow is turbulent. the platelets meet the endothelium.
Altered blood flow ("turbulence and stasis") Myocardial infarcts (dead wall balloons out) Quivering ("fibrillating") cardiac atria Over big ruptured atherosclerotic plaques In dilated cardiac chambers (valve or muscle disease) In weakened arteries that have ballooned ("aneurysms") Over-viscous blood Sickle cell disease Hypercoagulable blood Congenital factor deficiencies Lack of antithrombin III Lack of protein S Lack of protein C (even heterozygotes:) Pregnancy and after childbirth Tissue damage After severe trauma or burns After surgery . etc.The causes of thrombosis : Injured endothelium Myocardial infarcts Myocarditis sites Cardiac jet lesions (abnormal flow) Inflamed or prosthetic cardiac valves Ruptured atherosclerotic plaques Vasculitis syndromes Radiation injury High blood pressure itself (?) (Indwelling lines.
(When flow is laminar. especially after the factor .) Ante-mortem thrombi tend to be rather hard and crumbly ("friable". swirling layers with more or fewer red cells and/or platelets included.What do thrombi look like? Ante-mortem thrombi generally have formed in irregular.. when flow is turbulent. fewer red cells are incorporated. more red cells are incorporated.) These are the famous lines of Zahn.
Fresh thrombus at bottom. however. Starting to scar up at top. are notorious for embolizing. and seldom embolize. arterial thrombi generally occlude the artery. As a rule. they do not occlude the lumen (since the patient would have died first. } thrombus on ruptured plaque in coronary artery. Except in the aorta. . less often at sites of other vascular disease or old surgery.Special thrombi : Mural thrombi form on the walls ("mur-") of the cardiac chambers and aorta. adhering tightly to the wall. } thrombus in the carotid artery Thrombi that form in the aorta.) Arterial thrombi usually occur over ruptured atherosclerotic plaques.
If there are valves in the vein (i. On rotations. even if it embolizes. Even thrombosis of superficial (varicose) veins can be painful. Vegetations are thrombi that occur on cardiac valves. the valve impressions will be visible on the surface of the thrombus.) You'll also learn about scans. Venous thrombi ("phlebothrombosis". in patients with cancer of the pancreas. but often cause pain and edema ("inflammation" -. Trousseau's sign (or "Trousseau's other sign") is widespread (or "migratory") venous thrombosis. "bland".it isn't). Milk leg ("phlegmasia alba dolens") is an old name for venous thrombosis in later pregnancy or after delivery. They may be loaded with bacteria ("bacterial endocarditis").e.squeezing the calf or dorsiflexing the foot to elicit tenderness in these patients. (Beware: These maneuvers can dislodge the thrombus. or sterile ("marantic". heparin therapy. Doppler ultrasonography. etc. also the thrombi of acute rheumatic fever). "verrucous". Deep leg vein thrombi are usually asymptomatic. it's a leg vein). .. you'll learn "Homan's sign" -. venous thrombi are likely to be symptomatic. Even without embolization. the term "thrombophlebitis" is often misapplied) almost always occlude the vein.
. they are simultaneously attacked by plasmin (to break them up) and invaded by fibroblasts and angioblasts (to make them into scar. Thrombi may fragment or break free. . as the framework on which fibrinous clot continues to form. and may ultimately obstruct the blood flow. Propagation of a thromboembolus into the distal arteries confirms that the patient survived at least for a time. they organize). More about this later. The clot physiologists identify "coralline thrombi". as more clot forms on their surface. i. Since thrombi are composed of fibrin. producing thromboemboli.What happens to thrombi? Thrombi in contact with flowing blood tend to propagate. little coral-shaped masses of platelets formed within the turbulent bloodstream.e. Propagation is in the direction of blood flow.
Occasionally. into vascular granulation tissue. we think the plasmin almost always loses the race. As the thrombus turns. Ultimately. very large thrombi become infected with bacteria.. an occluded vessel that once had a single large lumen ends up with many tiny lumens. or a lumen crossed by a fibrous band. over a few weeks. it recanalizes. (A good place to catch the next thrombus. producing an intractable infection that ultimately turns the thrombus into pus. and they even calcify.. When the thrombus is large. .) Mural thrombi generally take a long time to organize..
embolus means thromboembolus. Please don't point to the thromboembolus and call it "an embolism". Most emboli are dislodged or fragmented thrombi ("thromboemboli"). It will impact and lodge somewhere. * "Emboli. "Embolus" comes from the Greek for "bottle stopper". embolization is no laughing matter when it causes infarction of a major organ such as the brain ("embolic stroke")... . : Embolus Any solid. -. "Embolus" is to "embolism" as "alcohol" is to "alcoholism"... You're driving me crazy. or when a pulmonary embolus causes unexpected death. Embolism is the clinical syndrome / situation of having one or more emboli.. sung to the tune of "Honey Pie" Despite the above.. You're making my mentation hazy.. Used without qualification.Sick humor. . liquid. You're going to my head.. or gaseous thing other than liquid blood and its solutes that travels along the bloodstream.. * Named by Virchow.
so that the foramen ovale (potentially patent in 25% of individuals) opens up. .e. to occlude a systemic artery.A paradoxical embolus (* crossed embolus) is one from the systemic veins that passes through a right-to-left intracardiac shunt (i. Pulmonary emboli seldom lyse fully. Usually.. a little fibrous band remains where they have landed. A common way to develop a right-to-left shunt is to have some previous pulmonary emboli that have caused right atrial pressure to exceed left atrial pressure. a birth defect).
. paradoxical emboli.Systemic embolization is embolization down a systemic artery.. mural thrombi from myocardial infarcts 10%.. cardiomyopathies 25%.. others: aortic aneurysms.. atrial thrombi (valve disease. Most emboli that actually occlude a named artery come from the heart. fibrillation) 5%. ulcerated atherosclerotic plaques. prosthetics.. left-sided endocarditis.. Origins: 60%. "origin ..
and that abscess formation is likely . No artery is immune. Note that the emboli of bacterial endocarditis are laden with micro-organisms. Rule: In contrast to pulmonary emboli. systemic emboli almost always produce infarcts. though the majority probably go to the lower extremities.
000 deliveries. The molecular biology of the clinical syndrome is poorly understood. Respiratory difficulty and shock are followed by DIC. Most victims die even today . The pathologist finds squamous cells and other debris in the pulmonary vasculature. enters the systemic circulation.AMNIOTIC FLUID EMBOLISM ("amniotic fluid infusion") This very lethal event occurs in 1 out of 50. which is full of baby's debris. Amniotic fluid.
the usual cause of death in scuba diving is air embolization from ruptured lungs (i.e. the diver ascended rapidly without exhaling continually .AIR EMBOLISM ("gas embolism". etc. Along with drowning.): Gas in the circulation Causes of gaseous emboli Ruptured uterine veins Delivery Abortion Ruptured chest veins Chest trauma Iatrogenic (common) or homicidal (usually fails) Decompression injury The classic "caisson disease" of deep-water divers is familiar from your undergraduate biology course..
Usually this is trivial. globules of fat are released into the circulation. but sometimes people get sick. the syndrome is a recognized complication of both procedures.FAT EMBOLISM After fractures of bones. Less common causes are arthroplasty and liposuction. The fat embolization syndrome occurs 1-3 days after injury with heavy fat embolization .
. Therapeutic embolization of bad body parts by clinicians may use gelatin foam ("Gelfoam"). silicones (especially a current illegal practice for cut-rate breast augmentation: or other substances.
. ("Death is a total body infarct". liver. expect an infarct whenever an arteriole shuts down. lung. extremities. the athlete's heart). * calling all infarcts "infarctions" isn't necessary) Note that all vascular occlusion need not produce an infarct. etc.INFARCTION An infarct is a localized area of necrosis due to ischemia. occlusion in an organ without collateral arteries (spleen. bowels. By contrast. kidney). especially in organs with good collateral circulation (brain..
but menstruation is due. . migraine leading to stroke. Much less common are extrinsic compression from adhesions or tumors. The mechanism of death in many suicidal hangings is venous ischemia of the brain (nasty).e. edema deep within a limb interferes with venous drainage of closed anatomic compartment. fibrous adhesions). } infarct of hand following embolus to brachial artery You'll seldom hear this. The next most common cause is spasm (Prinzmetal's angina. in part. and even tumors or extrinsic pressure (pressure neuropathies) can impinge on outflow. Venous infarcts result when veins are compressed and deoxygenated blood cannot leave the organ.TYPES OF INFARCTS Arterial infarcts usually result from thromboemboli or in-situ thrombus formation.. compartment syndromes (i. The classic examples involve the bowel (strangulated hernias. torsion of the testis. resulting in muscle necrosis). to infraction of the endometrium. ergotism or Raynaud's phenomenon leading to loss of digits).
where collateral circulation is good) are hemorrhagic from reperfusion . but typically bleeding is minimal. Red infarcts ("hemorrhagic infarcts". blood) are usual when arteries are occluded in solid organs. cloudy swelling of cells pushes blood back out. White infarcts ("anemic infarcts". or when the organ was already very congested. blood may seep in. If there are collaterals. from "an-". sounds like an oxymoron but isn't) result when veins are occluded. Infarcts of the lung and small bowel from any cause tend to be hemorrhagic. and "-eme". not. and many brain infarcts (especially the embolic ones. and the red cells lyse and disperse their hemoglobin. or when arteries are occluded in loose tissues (bowel) or with a dual blood supply.
and the organ possesses only a single blood supply. and there is no reperfusion from removal of the occlusion. KEY: If the artery (rather than the vein) is occluded. then the infarct will be white. Otherwise it will be red .
or was "septic" with infected blood).. Septic infarcts result when bacteria find the dead area.e. Bland infarcts do not become infected . the patient had an infection at the site of the infarct. or if the infarct was due to an infected embolus (from a heart valve infection or elsewhere). This is likely to happen if they were already present (i.
spleen.GROSS INFARCT Big Robbins" (and many other authorities) claim that "all infarcts tend to be wedge-shaped" (actually. infarcts. and kidney infarcts. pyramidal). or myocardial infarcts. . "Zahn infarcts" of the liver. since the hepatocytes atrophy and blood from the hepatic arteries and veins tends to engorge the widened sinusoids. variably-shaped areas of atrophy in the distribution of an occluded branch of the portal vein. are another famous autopsy finding. cerebral infarcts. This doesn't really apply for venous infarcts. The "wedge-shaped infarcts" rule works for lung. with the apex pointed at the focus of arterial occlusion. They may appear red.
HISTOLOGY INFARCT The microscopist sees coagulation necrosis (unless there is bacterial infection. or the infarct has caused necrosis of all the cells in a portion of the brain). and become plentiful over the next several days. Inflammatory cells enter the infarct by the first day. .
RT INT CAROTID THROMBUS This specimen shows one of the major arteries to the brain blocked by a thrombus ("blood clot") caused by atherosclerosis ("hardening of the arteries"). .
PULMONARY THROMBO-EMBOLISM .
THROMBUS HISTOLOGY .
Amniotic fluid may gain access to uterine veins following a tear in the placental membranes and embolize to the lungs.AMNIOTIC FLUID EMBOLISM A rare complication seen at term during or shortly after labor in pregnancy resulting in sudden death is amniotic fluid embolism. and mucin can embolize to small pulmonary arteries. Fetal squames. vernix. producing acute dyspnea with cyanosis and shock. . lanugo hair. Seen here are epithelial squames in a peripheral pulmonary artery.
there is loss of consciousness. most in white matter.FAT EMB IN BRAIN With cerebral fat embolism syndrome. Cerebral edema and herniation may follow. Overall. . but it is difficult to predict which patients will. few persons with a history of trauma will develop fat embolism. Note the multitude of petechial hemorrhages here.
This is fat embolism syndrome. . Treatment is supportive.FAT EMB BRAIN HISTOLOGY Seen here with Oil red O stain in a peripheral cerebral artery branch are globules of lipid.
Since the etiology of coagulative necrosis is usually vascular with loss of blood supply. .INFARCT SPLEEN Two large infarctions (areas of coagulative necrosis) are seen in this sectioned spleen. Thus. the infarct occurs in a vascular distribution. infarcts are often wedge-shaped with a base on the organ capsule.
BOWEL INFARCT .
THANK U .
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