This document discusses fluid and haemodynamic disorders. It covers body fluid compartments, water and electrolyte balance, acid-base balance, fluid exchange, and disturbances that can occur like edema, dehydration, and overhydration. It also discusses specific types of edema like pulmonary, renal, cardiac, cerebral, hepatic and nutritional edema. Hemodynamic disturbances covered include active hyperemia, passive hyperemia/venous congestion, and hemorrhage. Specific organ changes seen with chronic venous congestion of the lung, liver, spleen, and kidney are also summarized.

2. FLUID & HAEMODYNAMIC
DISORDERS
 Body water- Salt water
Life from ocean
Milieu interior or Internal
environment
Interstitial fluid bathing cells to
maintain morphology & function
Homeostasis : Exchange of
fluids,electrolytes,metabolites,etc
across Body fluid compartments &
membranes to maintain constant
Milieu interior

3.  Body fluid comprtments
 ECF 27%{Plasma 5% Interstitial fluid 12%others 10%}
 ICF 33%
 Mineral, fat, proteins 40%
 Composition – Water 50 – 70%
 Electrolytes:Cations + ve charge ICF:KMg ECF: Na
 Anions - ve charge ICF : Phosphates Proteins ECF
: Chloride Bicarbonate

4. WATER & ELECTROLYTE BALANCE
 Water Input : Bowel absorption,parentral 2.8 L
 output : kidney 1.5 L skin 800 ml lungs 400 ml
 Electrolytes : ICF : K PO4 ECF : Na Cl
Endothelial cell wall permeable Cell
membrane poor permeabilty
 Sodium pump maintains equilibrium by pushing
out Na , water follows

5. ACID BASE BALANCE
 Acid : Molecule /ion can give H+ ion (Donor)
 Base : “ “ “ “ can take H+ ION (Acceptor)
 Acids during normal metabolic activity -- Carbonic ( aerobic activty ) Lactic,
Sulfuric, Keto
 But Ph maintained at 7.4 +/ - 0.5 by Buffer system ( bicarbonate, Hb,
Carbonic anhydrase), Pulmonary ( CO 2 removal) and Renal mechanism (H+
ions with phosphates, NH4 ions , bicarbonate)

6. FLUID EXCHANGE
 Water /Crystalloids (electro) – free interchange
 Colloids ( plasma proteins) -- minimal
 Hydrostatic pressure -- Capillary blood pressure
32mm Hg arteriolar 12 mm Hg Venular end
 Osmotic pressure : Crystalloid - electrolytes
Colloid ( oncotic ) --plasma proteins
 Arteriolar end – fluid goes out – Hydrostatic pr
 Venular end - fluid comes in – Oncotic pr

7. DISTURBANCES IN BODY FLUIDS
 Main derangements are :
 Oedema : Free fluid in Interstitial tissue &
serous cavities
 Dehydration : pure deprivation of water
– Na retention - Hypernatremia
 Overhydration : increased ECF due to pure
water excess or water intoxication

8. OEDEMA
 Greek – swelling
 Abnormal & excessive accumulation of
free fluid in Interstitial tissue spaces &
serous cavities
 Body cavities – ascites, pleural &
pericardial effusions
 Interstitial spaces – pitting & non pitting
 Localised or generalised

9. PATHOGENESIS OF OEDEMA
 Decreased plasma oncotic pressure hypoprotenimeia –N S,
Glomerulonephritis, protein losing enteropathies, Cirrhosis
 Increased capillary hydrostatic pressure – Cardiac : CCF,
Constrictive pericarditis , Ascites, Mechanical obstn :
Thrombus,Varicosities, tumors, pregnancy
 Lympatic obstruction – Ca breast surgery, Filariasis, Tumor
pressure on thoracic duct

10. PATHOGENESIS OF OEDEMA
 Tissue factors – oncotic pressure in Interstitial
space , Tissue tension
 Incresed capillary permeability – damage to
endothelium by drugs, toxins,anoxia, infections,
anaphylaxis, inflammation, allergy
 Sodium & water retention - Na 80 %reabsorbed
due to Renal / extra renal mechanisms
Water retention due to release of ADH

11. MECHANISM OF SODIUM RETENTION
 Renal mechanism : Hypovolemia - stimulation of Baroreceptors
(carotid sinus/ aortic arch ) – Vasomotor centre in brain –
Sympathetic outflow – Renal ischemia -- decrased GFR –
decrased Sodium excretion – Sodium retention
 Extra renal mechanism : Decreased Na in tubules – Renin from
Juxta glomerular apparatus – Angotensinogen –Adrenal cortex
– Aldosterone – Incresed Na reabsorption in tubules -

12. MECHANISM OF WATER RETENTION
 ADH ( Vasopressin) – stored in post.
Pitutary
 Hypovolemia & increased Na in in plasma
– release of ADH – concentration of urine -
-- water retention
 Examples of oedema due to Na & water
retention : CCF, NS, Glomerulonephritis
and Ascites due to Cirrhosis

13. PULMONARY OEDEMA
 Local but functional impairment due to fluid in alveoli
affecting gas exchange
 Increased pulmonary hydrostatic pressure as in left heart
failure , MS, Pulmn vein obstruction, cardiac surgery.
Pressure by tumor/ inflamn.
 Increased pressure in capillaries over rides plasma oncotic
pressure -fluid in septa/ intstm- prolonged – damage to
cells – leakage of proteins & fluid into alveoli

14. PULMONARY OEDEMA
 Increased permeabilty ( Irritant oedema) ;
damage to endothelium & alveolar lining cells –
increased permeabilty --leakage of proteins &
fluid eg aspiration,inhalation of toxins , ARDS,
Shock, Uremia, Drug reactions
 Acute High Altitude oedema – sudden ascent to
> 2500 mts without acclimatisation – congestion –
haemorrages & fluid in lungs

15. PULMONARY OEDEMA
 Basal accumulation of fluid
 Gross : heavy, moist , sub crepitant
 C/S ; exudes frothy fluid
 Microscopy : pink,granular,
proteinaceous fluid in alveoli &
interstitium, congestion of capillaries.
Bright eosinophilic lines on margins –
alveolar membranes

16. PULMONARY OEDEMA

17. PULMONARY OEDEMA

18. RENAL OEDEMA
 NS : heavy proteinuria – hypoalbumeniemia - decreased
plasma oncotic pressure –decrea plasma volume – Renin/
Angiotensinogen / Aldosterone mech – Na & water retention
severe, generalised oedema
 Glomerulonephritis : Renin/ Agnts / Aldstrn Mild, Loose tissue
of face, genitilia , ankle
 Acute tubular injury :Loss of reabsorption and concentrating
abilities

19. RENAL OEDEMA

20. CARDIAC OEDEMA
 Heart failure : decreased cardiac output – hypovolemia –
renal & extra renal mechanisms, ADH secretion - Na &
water retention
 Increased Central venous press – transmitted backwards –
increased caplillary pressure
 Chronic hypoxia – damage to endothelium - increased
permeabilty
 Left failure – Pulmonary Right - Systemic

21. CARDIAC OEDEMA ( DEPENDANT OEDEMA)

22. CEREBRAL OEDEMA
 Life threatening due to space constraints
 Vasogenic : increased pressure & also capillary
permeabilty eg. Contusions,infarcts abscess,
 Cytotoxic : intracellular accumulation due to acute
hypoxia, toxic chemicals, metabolic derangements
 Interstitial : excessive fluid crossing Ependymal lining of
ventricles eg. N C Hydrocephalus

23. CEREBRAL OEDEMA
 Gross : White matter swollen, Gyri
flattened, Sulci narrowed
 C/S : Soft, gelatinous
 Microscopy : separation of tissue
elements, astrocyte swelling, widening of
perivascular spaces, halo around blood
vessels

24. CEREBRAL OEDEMA

25. HEPATIC OEDEMA
 Cirrhosis with Portal hypertension
 Portal hypertension – increased
hydrostatic pressure
 Hypoproteinemia - decreased oncotic
pressure
 Sodium & water retention
 Ascites : Fluid collection in peritoneal
cavity

26. ASCITES

27. NUTRITIONAL OEDEMA
 Protein deficiency : Kwashiokor, famine,
starvation, chronic alcoholism
 Vitamin deficiency : Vit B1 (beri beri)
 Mechanism – Hypoproteinemia
Sodium & water retention

28. NUTRITIONAL OEDEMA

29. PITTING OEDEMA

30. NON PITTING OEDEMA
 Pre tibial Myxedema : accumulation of
mucopolysaccharides
 Lymphatic obstruction due to
inflammation & fibrosis eg. Filariasis

31. PRE TIBIAL MYXEDEMA

32. FILARIASIS

33. INTERSTITIAL OEDEMA

34. DEHYDRATION
 Loss of water but not Na - hypernatremia
 Intense thirst,oliguria,fever, mental confusion
 GIT : Cholera, diarrhoea, severe vomitting
 Renal : ARF diuretic phase, D. Insipidius, Addison’s disease, excessive use of diuretics
 Blood/plasma loss: injuries, child birth,burns
 Skin : Hyperthermia, excessive sweating
 Accmln : Intstnl obstn , sudden ascites

35. DEHYDRATION
 Organs dark & shrunken
 Haemoconcentration, raised PCV & Hb
 Increased blood urea & sodium
 Renal shutdown
 Shock

36. OVERHYDRATION
 Increased ECF volume : pure water excess
, water intoxication
 Nausea, vomitting, headache, confusion
 Convulsions, coma, death
 Excessive IV infusions : N. saline, Ringer
lactate
 Renal Na/water retention : CCF, Acute GN,
CRF, Cirrhosis, Cushing’s syndrome

37. OVERHYDRATION
 Sudden weight gain
 Reduced plasma electrolytes
 Reduced plasma proteins
 Reduced PCV

38. HEMODYNAMIC DERANGEMENTS
DISTURBANCES IN VOLUME
 Active Hyperemia
 Passive Hyperemia or Venous congestion
 Haemorrage
 Acute or Chronic

39. ACTIVE HYPEREMIA
 Active Hyperemia : increased volume due
to Arteirolar dilatation
 Sympathetic mechn, Vasoactive substn
 Redness( Erythema), Incr temperature
 Blushing, Inflammation,menopausal
flush,goitre, A-V malformations, exercise

40. BLUSHING

41. PASSIVE HYPEREMIA ( CONGESTION)
 Venous congestion due to impaired
drainage , usually chronic ( CVC)
 Local : Obstn to venous flow eg, portal
vein in cirrhosis, bandage, plaster, hernia
tumors, pregnancy, thrombus
 Systemic : Heart failure, emphysema,
Pulmonary fibrosis
 Left heart failure– pulmn Right - systemic

42. CVC LUNG
 Right heart failure , Rheumatic mitral
stenosis – high pulmn venous pressure
 Gross ; heavy, firm, dark, rusty brown
induration of lung(fibrosis & pigmentation)
 Microscopy: widened alveolar septa
(dilated capillaries & oedema), Fibrosis,
haemorrages & hemosiderin laden
macrophages ( heart failure cells)

43. CVC – BROWN INDURATION LUNG

44. CVC LUNG

45. CVC LIVER
 Right heart failure or occlusion of Inferior
Venacava
 Gross : enlarged, tender, tense capsule
 C/S : Nutmeg appearance (red & yellow
mottled)
 Microscopy : Central vein & sinusoids
congested Periphery fatty change
 Later Centrilobular necrosis – Fibrosis &
regeneration - Cardiac cirrhosis

46. CVC LIVER – NUTMEG APPEARENCE

47. CVC LIVER

48. C V C SPLEEN
 Right heart failure, Portal hypertension
 Gross : Mod enlarged, cyanotic ,tense
 C/S : grey tan
 Microscopy : Red pulp : enlarged, sinusoidal
dilatation, haemorrage, increased splenic
macrpohages, fibrosis of capsule/ trabeculae
 Gamna gandy bodies : Siderofibrotic nodules
haemorrage, fibrosis & hemosiderin/ Ca depn

49. C V C SPLEEN

50. C V C SPLEEN

51. C V C KIDNEY
 Gross : enlarged , congested medulla
 Microscopy : mild changes
glomeruli – mesangial proliferation
tubules -- cloudy swelling, fatty change