1. Edema, Hyperemia, and Hemorrhage Flashcards
Non-cellular components of blood: – \_\_\_\_ – Salts – \_\_\_\_ – Clotting elements
Cell/tissue health depends on blood circulation:
• ____ of oxygen and nutrients
• removal of ____
• Vascular disturbances: – Disorders of hemodynamics: • Edema • Disorders of perfusion – \_\_\_\_ (active) – \_\_\_\_ • Shock
– Hemostasis
• ____
• Thromboembolic disease
– Infarction
water
proteins
delivery
waste
hyperemia
congestion
hemorrhage
Edema • Normal distribution of body water: – \_\_\_\_ body weight is water – \_\_\_\_ is intracellular – Most remaining water is interstitial – 5% of body water is in blood as \_\_\_\_
• Edema: an accumulation of ____ fluid within tissues
– Transudate
– Exudate
• Extravascular fluid can also collect in body cavities:
– Pleural: ____
– Peritoneum: ____
• ____: severe generalized edema of subcutaneous tissues and accumulation of fluid into cavities
• \_\_\_\_ -that is between the cells within tissue but not in the blood vessels and not in the cells. • This extravascular fluid can pretty much accumulate in anywhere in the body. If the vascular disturbance is such that these fluids are going to collect, they typically collect in areas of least \_\_\_\_ such as ankles and feet, sometimes in the abdomen • They can accumulate not just within the tissue but in cavities and when they are in cavities they go by specific names • Anasarca is a term for generalized edema. ○ When a patient are suffering from Anasarca, they have widespread edema throughout the \_\_\_\_ tissue as well as various cavities in the body and they will develop swelling around the \_\_\_\_ and fingers. ○ If they are bed bound they will develop sores where parts of the body come in contact with the bed such as the \_\_\_\_ ‣ This is due to the \_\_\_\_ of the edema and the trauma or irritation. The same thing can happen to the heels
60%
2/3
plasma
interstitial
hydrothorax
hydroperitoneum (ascites)
anasarca
interstitial resistance subcutaneous ankles buttocks
pressure
Fluid and low molecular solute movement between vascular and interstitial spaces
• Governed by 2 opposing forces:
– Vascular ____ pressure
– ____ pressure due to plasma proteins
- Normal conditions:
- Small net ____ into interstitial space
- drained by lymphatics
- Pro-edema conditions:
- Result of increased movement of water into the interstitium
- If water movement exceeds lymphatic drainage, fluid accumulates in ____ space with establishment of new equilibrium
- Plasma proteins and most fluid retained within vasculature as blood passes through capillaries
- normally, net movement of water and electrolytes limited
- balance often disturbed (promote edema) by:
- altered ____ function
- increase ____
- decreased ____ protein promote edema
- Drives fluid out on arterial side, and is driven back in on the venous side
- Very small percentage remains in tissue and is drained via the lymphatics
hydrostatic
osmotic
outflow
extravascular
endothelial
HP
plasma
Classification of Edema
• Based on ____
• ____
– Localized vs generalized
• ____ of accumulation
– Transudate vs exudate
• Pathologic – \_\_\_\_ – Pulmonary edema – \_\_\_\_ of liver – Renal disease
mechanism distribution content CHF cirrhosis
Mechanism responsible for edema: 1. Increased hydrostatic pressure - Due to impaired \_\_\_\_ return>transudate – Heart failure: » Left sided: CHF: \_\_\_\_ edema » Right-sided: \_\_\_\_ edema – \_\_\_\_ failure – Liver cirrhosis (Ascites—\_\_\_\_) – Local edema: due to local venous obstruction or compression (e.g. \_\_\_\_) Due to arteriolar \_\_\_\_ – Heat – Neurohumoral dysregulation
2.
Reduced plasma OP (hypoproteinemia; albuminemia)>____ (gen’l edema)
• Malnutrition
• Renal disease (nephrotic syndrome)-protein loss due to leaky ____ capillaries
• Liver cirrhosis—reduced ____ synthesis
[Albuminemia>reduced intravascular volume>renal ____>____ hyperaldosteronism>Na and water retention>edema]
venous pulmonary generalized renal portal hypertension DVT dilation
transudate
glomerular
protein
hypoperfusion
secondary
Mechanisms responsible for edema
• Left-side failure - HP is in the lung • Right-side failure - edema forming in areas of least resistance (generalized) • Renal failure [notes] • Liver cirrhosis ○ Scarring due to \_\_\_\_ inflammation, blood doesn't perforate, and there is a build up of fluid within the portal system - portal hypertension § Portal system and hepatic artery § Increase of fluid within the \_\_\_\_ • Decrease in blood flow as a result of heart failure - sensed by the \_\_\_\_ ○ Angiotensin-aldosterone system • Not only increase HP causing edema, but decreased BF sensed by kidneys, decreased GFR > activates RAA system > regulates \_\_\_\_ levels, H2O levels and blood volume - backup system to regulate BP ○ If a patient was normotensive, but there was a decrease in blood flow, this system once activated will make a patient \_\_\_\_ ○ If the patient was hypotensive, this system would work to restore \_\_\_\_ blood pressure. ○ Anyway this system then becomes a series of "push and pull" where decreased hydrostatic pressure is due to the decreased \_\_\_\_ return. This would then be exasperated by the activation of RAAS • Can develop DVT - \_\_\_\_ (circulating is an embolus) ○ When these DVTs develop, it will blood flow in an artery. And thats going to cause an increase in hydrostatic pressure on the upstream side of that blockage and that can cause edema. But unlike these forms of edema, this will cause \_\_\_\_ forms of edema. • in the lower right cartoons, you can see that the leg is edematous and and you can see it in real life here. • It's not bilateral, in this case it is localized • Due to arteriolar dilation: ○ There are other examples of edema being caused involving increased hydrostatic pressure that are due to arteriole dilation when you are exposed to \_\_\_\_. That will result in dilation of blood vessels and that will cause an increase in hydrostatic pressure in the capillaries just \_\_\_\_ that bc theres too much blood rushing in. ○ Then there are situations that involve \_\_\_\_ dysregulation. When they become disregulated they can lead to an increase in hydrostatic pressure.
chronic
portal hypertension
kidneys
Na+
hypertensive
normal
venous
attached
localized
heat
below
neurohormonal
Mechanisms responsible for edema
• The second mechanism I want to cover is anything that reduces plasma osmotic pressure. Leading to ____. Most often in involves albuminemia and a transudate that would be ____
○ You lose the osmotic pressure, you bring the fluid back in.
○ Anything that reduces plasma protein is going to lower ____ pressure
○ One common example is ____
○ Another is anything disease in the liver that decreases protein synthesis. For example, ____ inflammation. Also nephrotic syndrome is different form renal failure bc its a disorder where the kidney becomes too ____. And just loses proteins and there is a number of causes that will be covered next year.
○ Not only is the RAAS activated when there is decreased perfusion in the kidney. That system is invoked if the liver is ____. If the liver’s function is compromised, not only is it involved in synthetic processes, its also involved in ____ processes. In order to maintain the levels of aldosterone, when it is produced it has to be destroyed and the liver destroys it. If you have a liver that is dysfunctional, over time there will be an increase in ____. Leading to an increase in sodium and water retention and again an increase in ____ pressure.
hypoproteinemia
generalized
osmotic
malnutrition
chronic dysfunctional degradative aldosterone hydrostatic
Mechanisms responsible for edema:
- Sodium and water retention:
• Primary renal disorders
– (e.g., ____)
• Secondary due to disorders that decrease renal perfusion (e.g., ____)
• Increased ____ secretion
– Leads to increased HP (expansion of intravascular fluid volume—Na+ and H20 retention) and vascular ____
• Tx: ____ restriction, diuretics, aldosterone ____
◦ increase in water is going to increase blood volume, increasing cardiac output, raising blood pressure, in this case hydrostatic pressure.
◦ Primary renal disorders: involve some sort of damage (inflammatory, immune mediated) to the kidney
◦ Secondary disorders: [reads point]. Just to remind you a primary event that would contribute to sodium and water retention would be renal failure, would contribute to edema through an increase blood volume, ____. Nephrotic syndrome would contribute to a decrease in ____. but one of the things that occurs is again is activation of ____
poststreptococcal glomerulonephritis
CHF
renin-angiotensin-aldosterone
tone
salt
antagonist
cardiac output
osmotic pressure
RAAS
Renin-angiotensin-aldosterone pathway
• Listed here are evens that can contribute to a decrease in the \_\_\_\_ filtration rate. Essentially all things that produce blood flow. • [reads #1-3] • That decrease in blood pressure is going to result in a decrease in the glomerulus filtration rate. The change in GFR is sensed by the \_\_\_\_ cells in the kidney. Don't worry about how they work but basically detect changes in the kidney due to changes in blood volume. • This results in the production of \_\_\_\_, an enzyme. • Renin will act on \_\_\_\_ (inactive precursor) secreted by the liver. Cleaving it and converting it to \_\_\_\_. • angiotensin I is acted upon \_\_\_\_ in the lungs converting it to angiotensin II • Angiotensin II affects the adrenal glands/cortex on top of the kidneys to produce \_\_\_\_ which is a hormone. • Aldosterone will act on the \_\_\_\_. [reads 12] this increases \_\_\_\_ • [reads 14] if this happen in a person thats hypotensive, it should restore it to \_\_\_\_. If they are already normotensive, it will make them \_\_\_\_. ◦ Anytime you have a patient with a kidney disorder, they will elevated blood pressure due to this system • Angiotensin II can also work on arterioles and cause \_\_\_\_. Further increasing blood pressure. • These combined events mediated by angiotensin II will directly lead to \_\_\_\_.
glomerulus
juxtoglomerular renin angiotensinogen angiotensin I ACE
aldosterone
kidneys
blood volume
normotensive
hypertensive
vascoconstriction
edema
Mechanisms responsible for edema: 4. Lymphatic obstruction> lymphedema (accumulation of lymph fluid) • Typically \_\_\_\_ obstruction • Chronic Inflammation with \_\_\_\_ • \_\_\_\_-invasive malignant tumors • Postsurgical • Post-irradiation • Infectious agents (e.g., parasitic filariasis—\_\_\_\_ >inguinal lymphatic obstruction/fibrosis)
- Inflammation>exudate
The fourth mechanism for edema is lymphatic obstruction.
• Lymphedema is a little different than edema due to a transudate or exudate. Some lymph tissue is encapsulated, others is diffuse. You can’t get an immune response without involving the lymphoid tissues.
• Anytime you obstruct lymph flow, you are going to develop lymphedema which is a little different. Not just water, its somewhere between a ____ and an ____.
• elephantiasis which is an infection where you get ____ or ____ lymphedema due to obstructed flow.
• One of the more common examples are woman who have had a ____. lymphatic flow through the arm is compromised.
• The fifth major mechanism and probably one that we spend the most amount of time on is the edema due to an \_\_\_\_ associated to inflammation. Which you know come in different flavors (yummy): purulent exudates, hemorrhagic, fibrous exudates
localized
fibrosis
neoplastic
elephantiasis
exudate
transudate
localized
regional
mastectomy
exudate
• Clinical consequences of edema:
– Annoying to rapidly fatal
– Any ____ or tissue can become edematous; most common in ____ tissues, lungs and brain (important to recognize):
• Underlying ____ disease
• Underlying ____ disease
• When significant it impairs ____ and clearance of infections
– Distribution influenced by ____ (dependent edema e.g., legs when standing)
• Its very important that you recognize edema. One of the ways is by pitting edema
○ If you press on somebody’s leg, and if they have edema it will leave a ____. It will eventually go away
○ Lymphedema is generally not ____. Pitting edema is an indication of underlying ____ or ____ disease.
• There is a term called dependent edema > more ____ than pitting edema.
• Certainly if it involves inflammation, that can be striking. But if you look at generalized edema involving subcutaneous tissue, this is normal skin (top right pic). And this is (lower right) a parent suffering from generalized subcutaneous edema. Basically what you are seeing is dilated ____ and a lot of space between the collagen in this case is due to a ____.
organ cardiac renal wound healing gravity
pit
pitting
renal
cardiac
subtle
BV
transudate
Hyperemia and congestion
Hyperemia
– Increase in ____ within tissue
– An ____ process:
• ____ dilation and Increased blood inflow
– Examples:
• Inflammation
• ____ and skeletal muscle
– Tissue is ____ due to engorgement with oxygenated blood
– Histologically: presence of dilated and engorged arterioles and capillaries
Congestion
– Increase in blood volume within tissue
– ____ process
• Impaired outflow of ____ blood
– Occurs systemically and locally
• Systemic: ____ failure
• Local: isolated venous ____
– Tissue appears ____: blue-red color
• Due to RBC stasis accumulation of deoxygenated hemoglobin
– Acute congestion: increased volume and pressure leads to ____
– Chronic congestion leads to inadequate tissue perfusion and ____
• ____ due to ischemic injury
• Secondary ____
• Elevated intravascular pressure>edema, rupture of capillaries and focal ____
○ Edema in the acute congestion is due to increased \_\_\_\_ pressure bc the blood flow in is static, the blood flow out is reduced and that results in a blood pressure upstream of the venules
blood volume active arteriolar exercise redder
passive venous cardaic obstruction cyanotic edema cell death fibrosis hemorrhage
hydrostatic
Example of congestion • Passive liver congestion- centrolobular venous congestion: – May occur as a result of \_\_\_\_ heart failure – Centrolobular congestion and eventually necrosis (\_\_\_\_) with \_\_\_\_ congestion – Nutmeg liver • \_\_\_\_ pulmonary congestion
• there are two main examples of congestion: venous and pulmonary
◦ Again it is bringing blood from the venous circulation back to the heart and into the lungs. So if it is not working properly, it will decrease venous flow leading to congestion in the tissue
◦ When you have congestion of the liver due to centrolobular congestion you refer to it as ____ liver
right-sided hypoxia sinusoidal passive nutmeg
Passive congestion of the liver:
• Liver is comprised of hepatic ____ (in blue)
◦ These are the units of the liver
◦ Here is one in isolation (left bottom pic)
• ‣ In the middle of the liver is a ____ (circled)
• ‣ Surrounding the lobule are clear regions that are known as the hepatic
triad (red). They serve the ____ pyramids
• Within the triad are three vessels (bottom right)
◦ Hepatic artery- bringing ____ blood from the arterial circulation
◦ Portal venule - ____ blood rich in nutrient coming from the intestines
◦ Bile duct-transporting bile produced by the liver, stored in the gall bladder, and utilized by the intestines
• ‣ In between the hepatic rays is space referred to as \_\_\_\_ • ‣ The blood comes in through the lobule through the triad • ‣ Hepatic \_\_\_\_ blood and \_\_\_\_ blood mix and they flow from the triads, through the sinusoids, into the vein. During that process they are filtered. So blood flow is from \_\_\_\_ to \_\_\_\_
pyramids/lobules
central vein
adjacent
oxygenated
deoxygenated
sinusoids
arterial
portal
triad
central vein
Passive congestion of the liver:
• Histologic appearance:
– Central vein and sinusoids are distended with blood (____)
– Nutmeg appearance: ____ and slightly depressed due to central lobular congestion surrounded by tan areas (uncongested and sometimes ____ liver)
• In liver congestion, venous flow is disrupted ‣ You see the within the sinusoids is the accumulation of blood aka congestion. It is due to the decrease of blood flow \_\_\_\_ . • Basically what you are seeing is distention of the sinusoids due to blood, thats congestion in the \_\_\_\_ phase. • If you look at the tissue in low power (bottom right) what you see are dark areas due to congestion, alternated by tan areas which as normal areas or in some cases \_\_\_\_ liver. • This is what nutmeg looks like (bottom middle) and bc of the alternation of light and dark that is where it gets its name
centrolobular
red-brown
fatty
OUT
ACUTE
fatty
