EDEMAEDEMA

Prepared byPrepared by

Dr. Mizanur Rahman ChowdhuryDr. Mizanur Rahman Chowdhury

EdemaEdema

DefinitionDefinition Excessive accumulation of Excessive accumulation of abnormal amount of fluid into abnormal amount of fluid into the interstitial space and or the interstitial space and or body cavities.body cavities.

Normal homeostasisNormal homeostasisFactor tending to drive the fluid out of the Factor tending to drive the fluid out of the

blood vessels:blood vessels:• Hydrostatic pressure with in the Hydrostatic pressure with in the vesselsvessels

• The colloidal osmotic pressure of The colloidal osmotic pressure of interstitial spacesinterstitial spaces

Factor tending to drive the fluid with in the Factor tending to drive the fluid with in the blood vessels:blood vessels:

• Tissue tensionTissue tension• The colloidal osmotic pressure of The colloidal osmotic pressure of interstitial spacesinterstitial spaces

Classification of edemaClassification of edemaOnOn the basis of involvementthe basis of involvement

Localized edemaLocalized edemaGeneralized edemaGeneralized edema

On the basis of inflammationOn the basis of inflammationInflammatory/Exudative edemaInflammatory/Exudative edemaNon inflammatory/Transudative edemaNon inflammatory/Transudative edema

Clinical ClassificationClinical ClassificationPitting edemaPitting edemaNon pitting edemaNon pitting edema

Pathophysiological Categories of Pathophysiological Categories of edemaedemaIncrease hydrostatic pressureIncrease hydrostatic pressure• Impaired venous returnImpaired venous return

Congestive cardiac failureCongestive cardiac failure

Constrictive pericarditConstrictive pericardit

Liver cirrhosisLiver cirrhosis

• Venous pressure or obstructionVenous pressure or obstruction

ThrombosisThrombosis

External pressureExternal pressure

• Arteriolar dilationArteriolar dilation

HeatHeat

Neurohumoral dysregulationNeurohumoral dysregulation

Pathophysiological Categories of Pathophysiological Categories of edemaedemaDecrease plasma colloidal osmotic Decrease plasma colloidal osmotic

pressurepressure

Nephrotic syndromeNephrotic syndromeLiver cirrhosisLiver cirrhosisMalnutritionMalnutritionProtein loosing Protein loosing gastroenteropathygastroenteropathy

Pathophysiological Categories of Pathophysiological Categories of edema edema

Lymphatic obstructionLymphatic obstructionoInflammatoryInflammatoryoNeoplastic Neoplastic oPost surgicalPost surgicaloPost irradiationPost irradiation

Pathophysiological Categories of Pathophysiological Categories of edemaedema

Sodium retentionSodium retention Excessive salt intake with renal Excessive salt intake with renal

insufficiencyinsufficiency Increase tubular reabsorption of Increase tubular reabsorption of

sodiumsodium Renal hypoperfusionRenal hypoperfusion Increase renal angiotensin Increase renal angiotensin

aldosterone secretionaldosterone secretion

Pathophysiological Pathophysiological Categories of edemaCategories of edema

InflammatoryInflammatory• Acute inflammationAcute inflammation• Chronic inflammationChronic inflammation• AngiogenesisAngiogenesis

Localised oedemaLocalised oedema

Inflammatory edema:Inflammatory edema: Exudate are formed due to increase vascular Exudate are formed due to increase vascular

permeability proteinpermeability protein

Edema due to venous obstructionEdema due to venous obstruction: : In venous obstruction there is rise of hydrostatic In venous obstruction there is rise of hydrostatic

pressure, this lead formation of exudates.pressure, this lead formation of exudates.

Edema due to lymphatic obstruction:Edema due to lymphatic obstruction: Excessive lymphatic obstruction can produce an Excessive lymphatic obstruction can produce an

oedema of high protein content but not as that oedema of high protein content but not as that of exudateof exudate

Hypersensitivity edemaHypersensitivity edema

Generalized edemaGeneralized edema

Cardiac edemaCardiac edemaRenal edemaRenal edemaHepatic edemaHepatic edemaFamine edemaFamine edemaOthers Others

Cardiac edemaCardiac edema

Most common cause is right sided Most common cause is right sided congestive cardiac failurecongestive cardiac failure

Transudative edemaTransudative edemaDependant peripheral edemaDependant peripheral edemaDistribution is influenced by gravity i.e.Distribution is influenced by gravity i.e.

When patient is ambulant: ankle When patient is ambulant: ankle edemaedema

When patient is recumbent: sacral When patient is recumbent: sacral edemaedema

Edema pits on pressureEdema pits on pressure

Pathogenesis of Cardiac Pathogenesis of Cardiac oedema oedema

Heart failureHeart failure

Increase central venous pressureIncrease central venous pressure

Increase capillary pressureIncrease capillary pressure

Increase transudation Increase transudation

OedemaOedema

Pathogenesis of Cardiac oedemaPathogenesis of Cardiac oedema

Heart failure Heart failure

Decrease cardiac output Decrease cardiac output

Decrease effective arterial blood volumeDecrease effective arterial blood volume

Renal vasoconstrictionRenal vasoconstriction

Decrease GFRDecrease GFR

Increase tubular reabsorption sodium and waterIncrease tubular reabsorption sodium and water

Increase plasma volumeIncrease plasma volume

Increase transudationIncrease transudation

OedemaOedema

Pathogenesis of Cardiac oedemaPathogenesis of Cardiac oedema

Heart failureHeart failure

Decrease cardiac outputDecrease cardiac output

Decrease effective arterial blood volume Decrease effective arterial blood volume

Increase renin secretion Increase renin secretion

Increase aldosterone Increase aldosterone

Increase renal reabsorption of sodium Increase renal reabsorption of sodium

Increase renal retention of sodium and waterIncrease renal retention of sodium and water

Increase plasma volume Increase plasma volume

Increase transudation Increase transudation

oedemaoedema

Pathogenesis of Cardiac oedemaPathogenesis of Cardiac oedema

Heart failureHeart failure

Decrease cardiac outputDecrease cardiac output

Decrease effective arterial blood volumeDecrease effective arterial blood volume

Increase ADH secrationIncrease ADH secration

Increase renal retention waterIncrease renal retention water

Increase renal retention of sodium and waterIncrease renal retention of sodium and water

Increase plasma volumeIncrease plasma volume

Increase transudationIncrease transudation

edemaedema

Renal edemaRenal edema

Cause of renal edemaCause of renal edema Acute Acute glomerulonephritisglomerulonephritis

Nephrotic syndromeNephrotic syndrome

Pathogenesis of Renal Pathogenesis of Renal oedemaoedema

Acute glomerulonephritis:Acute glomerulonephritis: Salt and water retention by the Salt and water retention by the

damaged kidney.damaged kidney.There may be additional factor of There may be additional factor of

heart failure.heart failure.Nephritic edema affect the face Nephritic edema affect the face

and eyelids predominantly; ankle and eyelids predominantly; ankle and genitalia also often affected.and genitalia also often affected.

Pathogenesis of Renal edemaPathogenesis of Renal edema

Nephrotic syndromeNephrotic syndrome::

Heavy proteinuria Heavy proteinuria

Decrease plasma colloidalDecrease plasma colloidal

osmotic pressureosmotic pressure

Generalized oedema.Generalized oedema.

Pathogenesis of Renal Pathogenesis of Renal oedemaoedema

Nephrotic syndromeNephrotic syndrome: : Salt and water retention occour in nephrotic Salt and water retention occour in nephrotic

syndromesyndrome

Increase blood volumeIncrease blood volume

Increase hydrostatic pressure Increase hydrostatic pressure

Generalized oedemaGeneralized oedema

Pathogenesis of Renal edemaPathogenesis of Renal edema

In some cases of nephrotic syndrome blood volume In some cases of nephrotic syndrome blood volume decrease decrease

Activate renin angiotensin aldosterone mechanismActivate renin angiotensin aldosterone mechanism

Sodium and water retention by the kidneySodium and water retention by the kidney

blood volume increaseblood volume increase

Increase hydrostatic pressureIncrease hydrostatic pressure

Generalized edema.Generalized edema.

Famine edema/Nutritional Famine edema/Nutritional edema:edema:

o It is due to hypoproteinaemiaIt is due to hypoproteinaemiao sometimes oedema is extensive but sometimes oedema is extensive but

plasma protein level is normal in plasma protein level is normal in famine oedema. famine oedema.

oThe true explanation is unknown. But The true explanation is unknown. But there is an important factor is loss of there is an important factor is loss of compact tissue and replace by loose compact tissue and replace by loose connective tissue which can connective tissue which can accumulate fluid without rise of tissue accumulate fluid without rise of tissue tensiontension

Hepatic edemaHepatic edema

The main manifestation of hepatic edema is The main manifestation of hepatic edema is ascitis.ascitis.

The factor responsible for hepatic edemaThe factor responsible for hepatic edemaLymphatic obstructionLymphatic obstruction

Low plasma protein levelLow plasma protein level

Increase regional venous pressure Increase regional venous pressure due to portal hypertensiondue to portal hypertension

Failure to hepatic inactivation of Failure to hepatic inactivation of aldosteronealdosterone

Pulmonary edemaPulmonary edema

Hydrostatic balance of lung capillaries is Hydrostatic balance of lung capillaries is some what different from the systemic some what different from the systemic circulation.circulation.

Blood pressure in the pulmonary circuit is Blood pressure in the pulmonary circuit is about 15-25mm hg systolic and 6-12mm about 15-25mm hg systolic and 6-12mm Hg diastolic mean capillary pressure is Hg diastolic mean capillary pressure is 7mm Hg being highest at the base and 7mm Hg being highest at the base and lowest at the apex.lowest at the apex.

The interstitial fluid pressure is -16mm The interstitial fluid pressure is -16mm Hg. Both these forces tend to drive fluid Hg. Both these forces tend to drive fluid out of capillaries in to the interstitial out of capillaries in to the interstitial space which consist of space which consist of mucopolysacchadide. Normally the mucopolysacchadide. Normally the plasma colloidal osmotic pressure25-plasma colloidal osmotic pressure25-28mm Hg is adequate to prevent fluid 28mm Hg is adequate to prevent fluid escaping in the interstitial tissue.escaping in the interstitial tissue.

Pulmonary edemaPulmonary edemaCause of pulmonary edema:Cause of pulmonary edema:

Left heart failure ,Left Left heart failure ,Left ventricular failure ,Mitral ventricular failure ,Mitral stenosis particularly in fibrilationstenosis particularly in fibrilation

Inflammation of lung, Inflammation of lung, PneumoniaPneumonia

ARDSARDSAssociated with anaemia, Associated with anaemia, Nephrotic syndromeNephrotic syndrome

Overloading of circulationOverloading of circulationWithdrawal of pleural fluidWithdrawal of pleural fluid

Cerebral edemaCerebral edema

There are two types of There are two types of cerebral edemacerebral edema

Vesogenic edemaVesogenic edemaCytotoxic edemaCytotoxic edema

Vesogenic cerebral Vesogenic cerebral edemaedema

It occurs when the integrity of It occurs when the integrity of the normal blood brain barrier the normal blood brain barrier is disrupted and increased is disrupted and increased vascular permeability occurs vascular permeability occurs allowing fluid to escape from allowing fluid to escape from the intravascular space of the the intravascular space of the brainbrain

Cytotoxic Cerebral Cytotoxic Cerebral EdemaEdema

It It occurs when there is increaseed occurs when there is increaseed intracellular fluid secondary to intracellular fluid secondary to nneural, glial, or endothelial cell nneural, glial, or endothelial cell membrene injury in a patient with membrene injury in a patient with a generalized hypoxic/ischemic a generalized hypoxic/ischemic insult or with some intoxication.insult or with some intoxication.

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