Subcutaneous tissue Flashcards
Osmolality
is of prime importance in maintaining homeostatic balance b/w ICF + ECF
- IS THE MEASULE OF SOLUTE CONCENTRATION AND IS DEFINED AS THE NUMBER OF THE OSMOLES OF SOLUTE PER KILOGRAM OF WATER ( osm/L)
Osmolarity
- is the measure of osmoles of solute per liter of solution (osm/L)
Electrolytes
ionized substances which contribute most to the total solute concentration / ( osmolality ) of body fluids
From Vascular space -> Extracellular space
- Hydrostatic pressure from vascular system
2. Coloid oncotic pressure of interstitium
To vascular compartment
- Coloid - oncotic pressure ( plasma protein )
2. Hydrostatic pressure - Interstitial
Edema
Palpable swelling produced by expansion of the interstitial fluid volume
- accumulation of fluid in intercellular spaces ( Interstitium )
- clinical evident only after accumulation of a few liters
- preceded by increased G with 4-5 kg ( PreEdema not evident at clinical exam -> loop diuretic decreases G )
From capillary arteriolar end to the interstitium
Return from interstitialto vascular space through :
- venous capillary end
- lymphatics
Edema
Mechanisms
- ↑ venous pressure
- ↓ plasma oncotic pressure
- ↑ capillary permeability
- obstruction venous and lymphatic vessel
- hydro-saline retention at kidney level
Increased water and salt capital of the body
MECHANISMS: Imbalance between forces
EDEMA
- Obstruction of venous system → ↑ Capillary press. → edema
- 🡫 coloid oncotic pressure - in hypoalbuminemia
- capillary endothelium dysfunction- ↑ capillary permeability
- injury by chemical agents , bacterial, thermal, mechanical
- protein transfer to interstitium
Edema Lymphatic drainage
- Safety supplementary mechanism
- It takes on the albumin filtered through the capillary wall and the excess of the transudated fluid
- Reduces lymphatic flow
- Essential role in the production of lymphedema
EDEMA
CLINICAL ASPECT
- Swelling- Increased volume of a region
- Disappearance of anatomical reliefs
- Pitting edema (usually pressed on a bony plane)
occur in areas with lax connective tissue where
interstitial pressure is small (retromaleolar, face,
eyelid)
EDEMA: General Characteristics
- Initial stage (Preliminary stage)
- Shiny & tight edematous skin - The resorption stage
- Fine longitudinal folds (“wrinkly” skin)
- Stretch marks (thigh and abdomen)
Chronic Stage
- Thickening / rigidity of the tegument (hyperplasia of
subcutaneous cellular tissue ←↑ interstitial press over longtime)
- Lichenoid appearance (fibroblastic proliferation)
- Harsh to the touch
- Marked peeling
- Pit difficult to evoke→ pitting only after prolonged compression
- Dystrophic skin (cracks, wet ulcerations)
EDEMA: General Characteristics
COLOUR
Red: inflammatory and allergic edema
White: renal edema
Cyanotic (ocher dermatitis):cardiac & venous edema
LOCAL TEMPERATURE
Increased: inflammatory edema
Normal: renal edema
Reduced: cardiac edema
CONSISTENCY
Elastic, let the pit easily → renal & carential edema
Hard ~ non pitting→ inflammatory & venous edema
PAIN
Painless = most edema of general cause
Painful = inflammatory edema
Renal edema
🡫 coloid osmotic pressure
↑ capillary permeability
Hepatic edema
🡫 coloid osmotic pressure - due to hypoalbuginemia
CARDIAC EDEMA
↑ venous pressure (venous congestion)
CARENTIAL EDEMA
↓ oncotic pressurei by hypoproteinemia
ANASARCA
Generalized edema - Fluid effusion in body cavities associated Biology: TRANSUDATE - Serocitrine - Low proteine level
ANASARCA- characteristics
- Generalized (not from the beginning)
- Start at lower limb (retromaleolar, anterior tibial)
- Infero intern area of thigh, just above the knee
- Abdominal wall (orange peel appaerance)
- Lumbosacral area
- Anterior thorax
- Posterior thoracx
- Uppr limbs (infero-intern & posterior, above the
elbow) - Face (eyelid edema)
PREGNANCY EDEMA
Moderate edema - White - Soft - Pitting Easy - Lower limb usually - In late pregnancy - Pregnancy nephropaty – Eclampsia - Particular aspect : > Week 20 > Generalized Edema > HTN > Proteinuria
CATAMENIAL EDEMA
Moderate Edema at lower limbs
In women in the second half of the menstrual cycle
Trigger hormonal
MIXEDEMA
In severe hypothyroidism
Pitting
+ thickened skin
IATROGENE
DRUG INDUCED
- corticosteroids
- estrogens
- BP lowering drugs (dihidropiridine, α blockers)
IDIOPATIC EDEMA –
Milroy Syndrome
Ussualy at the calves level
Womens > 30 y old
Chronic Edema with unknown etiology
INFLAMATORY EDEMA
- Localized edema (tumor)
- Unilateral usualy
- Warm (calor)
- Painful (dolor)
- Redness of the skin (rubor)
- One of the signs of inflammation
Characterize: erysipelas, lymphangitis,
arthritis, abscess, cellulite, osteomyelitis,
phlebitis,..
ALERGIC EDEMA
Characteristics
Colour: red
Temperature: warm
Painfull
Non-pitting !!!!
Sudden onset
Characteristic location:
- Face, eyelid, lips, tongue
Asociated symptoms
- Pruritus
- Urticaria
ALERGIC EDEMA
Forms:
Acute, Chronic, Recurrent Quincke Angioneurotic Edema - Sudden onset - Disapearance: hours, days - Without pruritus !!!!!! Associated with: - glotic edema - asphyxia - paroxysmal inspiratory dyspnoea caused by different allergens (food, medicines)
LYMPHEDEMA
- Pale
- Start asymetricaly
- Soft initially, then it becomes card boarded with lichenifications
- Unusual locations: dorsal area of the hand, feet
Mechanism:
- Blockage of lymphatic circulation through
- Malformations of the lymphatic vessels
- Tumors
- Metastases
- Postoperative: resection of the lymphatics
- After irradiation of the lymph nodes
- In filariasis - grotesque aspect “elefantiazis arabicum”
- Forms: congenital, acquired
VENOUS EDEMA
Superficial thromboflebitis
- Edema around the superficial afected vein
- Present with inflammations signs
Deep vein thrombosis
- Edema characteristics: white, painful spontaneously and with palpation, (positive Homans sign)
- Swelling of the affected area (ex. calve, thigh)
- Superficial vein network prominent
- Superimposed arterial spasm may determine cyanosis
VENOUS EDEMA
Chronic venous insuficiency
- Secondary to varicose veins or
repeated deep vein thrombosis - Unilateral or bilateral but uneven
- Especially on the lower limbs
- Accentuated in orthostatism
- Cyanotic skin, with ocher dermis
- Possibly complicated by ulcers
EDEMA in superior cava vein syndrome
swelling in the face, neck, arms, and upper chest
sometimes with a bluish-red skin color
EDEMA in superior cava vein syndrome
Mechanism
- Obstruction of superior cava vein
- ↑ venous pressure above the SCV obstruction
- Colateral circulation associated
DEPENDENT (GRAVITATIONAL) EDEMA
- Determined by prolonged gravitation effect
- Long duration trip
- In patient with critical limb arterial ischemia due to
prolonged sitting as attempt to diminish the related pain - Favored by hot season
NEUROTHROPHIC EDEMA
- Moderate edema
- It affects the paralyzed limb
- The typical appearance = “juicy hand” described by Marinescu
DEHYDRATION
Clinical condition caused by a reduction in content water of the body
CLASSIFICATION
- Cellular dehydration
- Extracellular dehydration
Cellular dehydration (1)
- Determined by ↓ volume of intracellular water, due to the loss of water through: polyuria, perspiration, respiration (in coma)
- It may accompany edema (extracellular hyperhydration) when the patient ↓ fluid intake, maintaining salt intake
- May accompany extracellular dehydration resulting in global dehydration
Cellular dehydration (2)
Clinical aspect
- Thirsts (by stimulating the hypothalamic osmometer)
- Nausea-free anorexia
- Dry tongue and mouth due to decreased parathyroid secretion
- Fever (by altering the thermoregulation)
- Neurologic phenomena (cheyne-stokes breathing, delirium, drowsiness, coma)
Biology:
Natremia > 145 mEq/l
↑ plasma osmotic Pressure
Oliguria + ↑ urinary density
Extracellular dehydration (1)
It is the consequence of the predominant losses of
sodium by the way:
- kidney (nephropathies, excess diuretics)
- digestive (vomiting, diarrhea)
- skin (profuse sweating) - drastically reducing the salt
intake
Extracellular dehydration (2)
Clinical aspect:
- The patients are not thirsty
- Persistent skin fold through the 🡫skin turgor
- Eyeball hypotony
- Colaps, hypotension, by reducing circulating volume
- Tachycardia oliguria (with high urinary density)
Biology:
- Natremia usually normal
- Hemoconcentration !!!!!!!!!
- Hyperazotemia !!!!!!
It can be associated with cellular hyperhydration by migrating water inside the cells, a state characterized by apathy, headache , vomiting ( cerebral edema )
Launois-Bensaude Syndrome: A Benign Symmetric
Lipomatosis -Madelung disease
Multiple symmetrical lipomatosis, Launois-Bensaude
syndrome, cephalothoracic lipodystrophy, Madelung
disease, Brodie’s syndrome, Buschke’s disease, “Fat neck”
Launois-Bensaude Syndrome: A Benign Symmetric
Lipomatosis -Madelung disease
Characteristics
occurs mostly in men between 30 - 60 y with known alcohol use
- more common in Mediterranean countries
-characterized by the presence of fat masses: - large size
- located symmetrically in various parts of the body (but mainly in the cervical region)
- slightly circumscribed (diffuse outline, no limiting
capsule) - soft consistency
- painless
- it develops progressively in the subcutaneous tissue
- in evolution, it often infiltrates neighboring structures
histological: normal fatty tissue , - benign disease, malignant transformation is exceptional
Progressive lipodystrophy
Barraquer–Simons syndrome
- rare form of acquired lipodystrophy
- bilateral gradual symmetrical reduction of adipose tissue that begins at the face (by the disappearance of the Bichat’s bubble) and may variably progress to the neck, upper arms trunk and abdomen
keeping intact the adipose tissue of the lower extremities associated with :
autoimmune diseases in a minority of patients (systemic lupus erythematosus, autoimmune thyroiditis and/or metabolic diseases (Diabetes) - females are more affected than males
- when it occurs in men, it occurs earlier
Insulin lipodystrophy
Abnormal reactions in subcutaneous fat to insulin - in diabetic patients
LIPOATROPHY is characterized by:
- subcutaneous nodules alternating with areas of adipose tissue atrophy
- cutaneous hypoaesthesia, possibly
- considered an adverse effect with an immune mechanism
LIPOHYPERTROPHY:
benign tumor like swelling of fatty tissue at the injection site secondary to lipogenic effect of insulin
Rothmann Makai Syndrome
- spontaneous paniculitis of children (very rare )
- A variant of lobular panniculitis presenting with numerous large subcutaneous lesions
- small, circumscribed, tender, erythematous subcutaneous nodules or plaques, most frequently occurring on the extremities and less commonly on the trunk and face
- with no severe systemic involvement
- version: lipophagic panniculitis-characterized by atrophy in lesions with skin depressions
Weber-Christian Disease
- idiopathic nodular panniculitis, which is characterized by subcutaneous nodules:
> symmetrical, size 1-2 cm, sensitive, erythema associated their disruption expresses a brown oily liquid (liquefying paniculitis)
> characterised by exacerbations and remissions within a few weeks
> it heals with depression of the overlying skin
lesions are bilaterally symmetrical and are usually seen in the lower limbs
> systemic symptoms are associated: fever, asthenia,
nausea, vomiting, weight loss, myalgias, arthralgias
Inflammatory disorders of the subcutaneous
tissue: cellulite and paniculitis
- inflammation without necrosis of the skin and subcutaneous tissue
- redness, tumor, heat, pain (rubor, tumor, calor, dolor)
- the skin entrance gate can sometimes be identified
- severe infection is suggested by the presence of:
- altered general condition, fever
- regional lymphangitis
- purplish bullous lesions circumferential disposition
Progressive hemifacial atrophy
Parry–Romberg syndrome (PRS)
- progressive shrinkage and degeneration of the tissues beneath the skin,
- usually on only one side of the face (hemifacial atrophy)
- evolves self-limiting with residual and mutilating hemifacial atrophy
- skin, subcutaneous tissue, underlying muscles, nerves, hair are affected
- rare disease
- higher prevalence in females
