Introduction

 Normal fluid homeostasis means maintaining

blood as a liquid until such time as injury
necessitates clot formation
It depends on:
maintenance of vessel wall integrity
intravascular pressure
osmolarity within certain physiologic ranges
 Review

60% lean body weight is water.

3 major fluid compartments:
Intracellular fluid (ICF):fluid within cells
(cytosol) (2/3)
Extracellular fluid (ECF):fluid outside of
cells,
A) interstitial fluid: fluid surrounding the
cells
B) plasma: fluid compartment of the blood
(5% )
 Edema

Edema: abnormal increased fluid in interstitial tissue spaces and

natural body cavities.
Fluid in cavities is designated special e.g hydrothorax,
hydropericardium, hydroperitoneum (ascites)
Anasarca is severe, generalized edema with profound
subcutaneous tissue swelling
Exudate: Increased vascular permeability leads to inflammatory
edema that is rich in proteins
Transudate: Edema due to hydrodynamic derangements that is
protein poor.
Cont….
 There is outflow of fluid from the arteriolar end of
the microcirculation into the interstitium
This is nearly balanced by inflow at venular end
Small residual amount of fluid left in the
interstitium is drained by the lymphatic vessels
 Either increased capillary pressure or diminished
colloid osmotic pressure can result in increased
interstitial fluid
Cont..
Edema could be localized or generalized
Local edema in many instances occurs
 due to vascular effects of inflammation
 Local edema of a limb results from
venous or lymphatic obstruction.
Generalized edema, affecting visceral
organs and the skin of the trunk and lower
extremities reflects a global disorder of fluid
and electrolyte metabolism
Mechanism of edema formation
Normal formation and retention of interstitial fluid
depends on filtration and reabsorption at the level of
the capillaries
 The hydrostatic pressure in the arteriolar segment of
the capillary is 32 mm Hg
 At the middle of the capillary, it is 20 mm Hg
 Hydrostatic pressure is opposed by plasma oncotic
pressure -26 mm Hg
Thus, interstitial fluid is formed at the rate of 2
mL/min and is reabsorbed by the lymphatics
Pathophysiologic Categories of Edema

INCREASED HYDROSTATIC PRESSURE

Impaired venous return
Congestive heart failure
Constrictive pericarditis
Ascites (liver cirrhosis)
Venous obstruction or compression
 Thrombosis
External pressure (e.g., mass)
 Lower extremity inactivity with prolonged dependency
 Arteriolar dilation
 Heat
 Neurohumoral dysregulation
Cont…
REDUCED PLASMA OSMOTIC
PRESSURE (HYPOPROTEINEMIA)
 Protein-losing glomerulopathies
(nephrotic syndrome)
 Liver cirrhosis (ascites)
Malnutrition
Protein-losing gastroenteropathy
Cont..
LYMPHATIC OBSTRUCTION
 Inflammatory
Neoplastic
Postsurgical
Postirradiation
SODIUM RETENTION
 Excessive salt intake with renal insufficiency
 Increased tubular reabsorption of sodium
 Renal hypoperfusion
 Increased renin-angiotensin-aldosterone secretion
Cont…
INFLAMMATION
 Acute inflammation
Chronic inflammation
Angiogenesis
Morphology
 Edema is easily recognized grossly
 Any organ or tissue can be involved
 Is mostly seen in subcutaneous tissues, brain and
lungs
 subcutaneous edema can be diffuse or more
conspicuous in regions with high hydrostatic pressures
 Finger pressure over substantially edematous
subcutaneous tissue displaces the interstitial fluid and
leaves a depression, a sign called pitting edema.
Cont…
Edema as a result of renal dysfunction can
affect all parts of the body
 It often initially manifests in tissues with
loose connective tissue matrix
 With pulmonary edema, the lungs are often
two to three times their normal weight, and
sectioning yields frothy, blood-tinged fluid
—a mixture of air, edema, and extravasated
red cells.
Brain edema
Brain edema can be localized or
generalized .
 Generalized edema, the brain is
grossly swollen with narrowed sulci;
distended gyri show evidence of
compression against the unyielding
skull
Brain edema
 Brain edema is dangerous because
the rigidity of the cranium allows
little room for expansion
It is divided into
Vasogenic
 cytotoxic
 interstitial forms.
Cont…
Vasogenic edema, the most common variety of edema, is
excess fluid in the extracellular space of the brain. It
results distortion of blood brain barrier
 Disorders associated with cerebral vasogenic edema
include
 trauma
Neoplasms
 encephalitis
 abscesses
 infarcts
 hemorrhage, and toxic brain injury (e.g., lead poisoning).
Cont..
Cytotoxic edema is equivalent to
hydropic cell swelling (i.e.,
accumulation of intracellular water)
 It is usually a response to cell injury,
such as that produced by ischemia
 Cytotoxic cerebral edema
preferentially affects the gray matter.
Cont…
Interstitial edema is a
consequence of hydrocephalus,
in which fluid accumulates in
the cerebral ventricles and
periventricular white matter.
Morphology
At autopsy, an edematous brain is soft and
heavy.
 Gyri are flattened and sulci narrowed.
 Severe cerebral edema leads to herniation of
the cerebral tonsils, with lethal
consequences.
Because of alterations in brain function,
patients with cerebral edema suffer vomiting,
disorientation, and convulsions.
Clinical Consequences.

The consequences of edema range from

merely annoying to rapidly fatal.
Subcutaneous tissue edema indicates
potential underlying cardiac or renal disease
Can impair wound healing or when
significant affects clearance of infection .
Cont..
Pulmonary edema is common
seen in
 left ventricular failure
Renal failure
 Acute respiratory distress syndrome
 Pulmonary inflammation or
infection.
 Hyperemia & Congestion

Increased blood volume in particular tissue

Hyperemia: active process, arteriolar dilatation,
dilatation engorgement of vessels with engorgement
of vessels with oxygenated blood

 Congestion: Passive process, impaired tissue

outflow, venous obstruction, cyanotic (bluish)
appearance with accumulation of deoxygenated
blood
 Congestion

Occurs commonly with edema due to

increased fluid transudation
Stasis of poorly oxygenated blood can lead to
hypoxia
Capillary rupture may occur at sites of chronic
congestion leading to hemorrhage
Liver with chronic passive congestion and
hemorrhagic necrosis.
Central areas are red and
slightly depressed
compared with the
surrounding
tan viable parenchyma,
forming a “nutmeg
liver” pattern (so-called
because it resembles the
cut surface of a nutmeg)
Centrilobular necrosis with degenerating
hepatocytes and hemorrhage.
 Hemorrhage

Defines as extravasation of blood due to vessel rupture

May manifest in a variety of patterns depending on size, extent,
location of bleeding
May be external or within tissue (hematoma)
May be insignificant (bruise)
May be fatal – massive hematoma
Minute 1 – 2 mm diameter into skin (petechial) associated with
locally increased intravascular pressure, low platelet count,
defective platelet function or clotting defects
Cont..
 > 3mm called purpura associated with same
disorders as petechiae, may be due to trauma, vascular
inflammation or increased vascular fragility

 Larger (> 1 – 2 cm) subcutaneous hematomas called

ecchymoses usually seen after trauma
Erythrocytes get degraded phagocytosed by
macrophages, hemoglobin (red-blue) converted to
bilirubin (blue-green) and event
Determining the Age of a Bruise by
its Color

Color of Bruise Age of Bruise

Red (Swollen, tender) 0- 2 days
Bluish -red, red purple purple 2-55 days days
Green 5-7 days
Yellow 7-10 days
Brown 10-14 days
No further bruising 2-4 wks