This document discusses haemodynamic disorders, thromboembolic disease, and shock. It covers topics such as edema and effusion, thrombosis, embolism, infarction, shock, hyperemia and congestion, and hemorrhage. Edema is defined as the accumulation of fluid in the interstitial tissue spaces, while effusion is the accumulation of fluid in body cavities. There are various pathophysiological categories of edema including increased hydrostatic pressure, reduced plasma osmotic pressure, lymphatic obstruction, sodium retention, and inflammation. Edema can be classified based on its pathophysiology, extent of involvement, and clinical presentation. Localized edema has causes such as acute inflammation, hypersensitivity reactions,

1. HAEMODYNAMIC DISORDERS,
THROMBOEMBOLIC DISEASE,
and SHOCK
Professor Tamanna Choudhury
HOD, Pathology
MCWH
2020/4/4 1
TOPIC 1
EDEMA & EFFUSION

2. 2020/4/4 2
References:
• Robbins & Cotran Pathologic Basis of
Disease- 9th edition
• Davidson’s Principles and Practice of
Medicine-23rd edition
• IMAGES- Above mentioned books &
internet

3. TOPICS
1. EDEMA & EFFUSION
2. THROMBOSIS
3. EMBOLISM
4. INFARCTION
5. SHOCK
6. HYPEREMIA & CONGESTION
7. HEAMORRHAGE
8. DISSEMINATED INTRAVASCULAR
COAGULATION (DIC)
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4. HAEMODYNAMIC
DISORDERS
• Haemo- related to blood
• Dynamics- concerned
with the motion of
bodies under the action
of forces.
• Haemodynamics -Is the
study of dynamics of
blood flow or the
circulation
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5. HAEMODYNAMIC
DISORDERS
• The health and well being of cells and
tissues depends not only on the circulation
of blood which delivers oxygen but also on
normal fluid balance
• Alteration of any of these results in some
disorders known as haemodynamic
disorders
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6. HAEMODYNAMIC DISORDERS,
THROMBOEMBOLIC DISEASE and
SHOCK
Disorders of haemodynamics
 Edema & Effusion
 Hyperemia & Congestion
 Shock
Disorders of abnormal bleeding and clotting
 Hemorrhage
 Thrombosis
 Embolism
 Infarction
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7. EDEMA & EFFUSION
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8. TOPICS
• Definition
• Pathophysiology
• Types and examples
• Morphology
• Clinical significance
• Renal edema
• Cardiac edema
• Hepatic edema
• Pulmonary edema
• Cerebral edema
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9. EDEMA- DEFINITION
Accumulation of fluid in the interstitial
tissue spaces
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10. Interstitial Tissue Space
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11. EFFUSION
DEFINITION
Accumulation of fluid in the body
cavities
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12. EFFUSION
• Hydrothorax (pleural effusion)
• Hydropericardium
• Hydroperitoneum (ascites)
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13. Pleural effusion
This is a right sided pleural effusion (in a baby)
The fluid is clear, pale yellow in appearance (serous
effusion)
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14. Pleural effusions
Bilateral pleural effusions.
The fluid appears reddish, because there has been
hemorrhage into the effusion
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15. ASCITES
• It is clinically detectable
when at least 500 mL
have accumulated
CAUSES:
• Malignant disease
• Cardiac failure
• Hepatic cirrhosis
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16. Body fluid compartments
• 60% of body weight is water
(in a healthy adult)
• 2/3rd (40%) is INTRACELLULAR
• 15% is INTERSTITIAL
• Only 5% is INTRA-VASCULAR
(plasma)
Three major fluid compartments
 Intravascular
 Interstitial and
 Intracellular
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17. MECHANISM OF NORMAL
CONTROL IN SYSTEMIC
CIRCULATION
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18. Starling’s Hypothesis
• states that the fluid movement across
the capillary wall is dependent on the
balance between
• the hydrostatic pressure gradient and
• the oncotic pressure gradient across
the capillary
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19. Fluid balance across capillary
wall
Hydrostatic Pressure
Osmotic pressure 25-28 mm
32 mm
12 mm
Arterial End Venular End
Lymphatic Drainage
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20. Factors affecting fluid balance
across capillary wall
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21. Factors affecting fluid balance
across capillary wall
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INTERSTITIAL SPACES

22. PATHOPHYSIOLOGIC
CATEGORIES OF EDEMA
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23. PATHOPHYSIOLOGIC
CATEGORIES OF EDEMA
I. Increased Hydrostatic
Pressure
II. Reduced Plasma
Osmotic Pressure
(Hypoproteinemia)
III. Lymphatic Obstruction
IV. Sodium Retention
V. Inflammation
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24. PATHOPHYSIOLOGIC CATEGORIES OF
EDEMA
I. Increased Hydrostatic Pressure
A. Impaired venous return
i. Congestive heart failure
ii. Constrictive pericarditis
iii. Ascites (liver cirrhosis)
iv. Venous obstruction or compression
a. Thrombosis
b. External pressure (e.g., mass)
c. Lower extremity inactivity with
prolonged dependency
B. Arteriolar dilation
i. Heat
ii. Neurohumoral dysregulation
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25. PATHOPHYSIOLOGIC CATEGORIES OF
EDEMA
II. Reduced Plasma Osmotic Pressure
(Hypoproteinemia)
A. Protein-losing glomerulopathies
(nephrotic syndrome)
B. Liver cirrhosis (ascites)
C. Malnutrition
D. Protein -losing gastroenteropathy
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26. PATHOPHYSIOLOGIC CATEGORIES OF
EDEMA
III. Lymphatic Obstruction
A.Inflammatory
B.Neoplastic
C.Postsurgical
D.Post irradiation
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27. PATHOPHYSIOLOGIC CATEGORIES
OF EDEMA
IV. Sodium Retention
A. Excessive salt intake with
renal insufficiency
B. Increased tubular reabsorption of
sodium
i. Renal Hypoperfusion
ii. Increased secretion of
renin- angiotensin- aldosterone
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28. PATHOPHYSIOLOGIC CATEGORIES OF
EDEMA
V.Inflammation
A. Acute inflammation
B. Chronic inflammation
C. Angiogenesis
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29. TYPES OF EDEMA
I. Pathophysiology
II. Extent of involvement
III. Clinical basis
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30. TYPES OF EDEMA
I. On the basis of pathophysiology
 INFLAMMATORY - Due to increased vascular
permeability (exudate)
 NON-INFLAMMATORY - Due to alterations in
haemodynamic forces across the capillary wall
(transudate)
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31. TYPES OF EDEMA
II. On the basis of extent of involvement
 LOCAL – pulmonary, cerebral, effusions
 GENERALISED- anasarca
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32. TYPES OF EDEMA
III. On clinical basis
 PITTING
 NON PITTING
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33. Comparison of an exudate with a transudate
EXUDATE TRANSUDATE
Total protein
content
High, as in
plasma>3g/dl
Low, <3 g/dl
Distribution of
protein
As in plasma Nearly all albumin
Fibrinogen Present, as it clots
spontaneously
Not present.
No tendency to
coagulate
Specific gravity High
(over 1.018)
Low
(about 1.012)
Inflammatory cells Plentiful;
(poly,lympho)
Few present;
nearly all
mesothelial cell
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34. Pitting edema of the leg
A. In a patient with congestive heart failure, severe
edema of the leg is demonstrated by applying pressure
with a finger.
B. The resulting “pitting” reflects the inelasticity of
the fluid-filled tissue.
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35. Non pitting edema
(Pretibial myxedema)
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36. MORPHOLOGY OF
EDEMA
• Edema is most easily
recognized grossly
• Microscopically,
clearing and
separation of the
extracellular matrix
elements.
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37. MORPHOLOGY OF EDEMA
• Although any organ or tissue in the body
may be involved,
• Most commonly encountered in
 subcutaneous tissues
 the lungs and
 the brain
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38. MORPHOLOGY OF EDEMA
Subcutaneous
Variable distribution
• Diffuse
• Dependent :
Cardiac failure
( legs and sacral area)
• Periorbital :
Nephrotic syndrome
Dependent edema
Periorbital edema
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39.  Severe, generalized edema is
called anasarca
MORPHOLOGY OF EDEMA
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40. CLINICAL FEATURES
Merely annoying to fatal
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41. Subcutaneous edema
 In cardiac & renal failure subcutaneous
edema signals underlying disease
 May impair wound healing &
clearance of infection
CLINICAL FEATURES
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42. CLINICAL FEATURES
Pulmonary edema
• Interferes with normal ventilatory
function
• Favours bacterial infection
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43. CLINICAL FEATURES
Brain edema
• Can be rapidly fatal
• Brain substance can herniate through
foramen magnum
• Brain stem vascular supply can be
compressed
• Both the conditions can injure
medullary centre & cause death
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44. Laryngeal edema
Fatal
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45. LOCAL EDEMA
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46. Local edema- causes
• Acute Inflammation
• Hypersensitivity reaction
• Venous obstruction
• Lymphatic obstruction
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47. Acute inflammation
acute appendicitis
(local edema)
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48. Acute inflammation
acute cholecystitis
(local edema)
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49. Local edema (Cont)
Hypersensitivity edema
Vascular permeability seen in
 type I
 type III &
 type IV hypersensitivity reaction
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50. Local edema
Edema due to venous obstruction
Examples
• Venous thrombosis
• A tumour / growth compressing a vein
Increased hydrostatic pressure proximal
to the obstruction
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51. Local edema (Cont)
Edema due to lymphatic obstruction
Examples :-
(a) Filariasis
(b) Recurrent bacterial lymphangitis
(c) Lymphatic edema of arm & peau d'
orange appearance of the breast in
breast carcinoma
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52. Filariasis
 W. bancrofti parasites are
mainly transmitted by Culex
quinquefasciatus mosquitoes
and some species of
Anopheles
 Brugia parasites are mainly
transmitted by Mansonia
mosquitoes
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53. Edema secondary to lymphatic obstruction.
Massive edema of the right lower extremity
(elephantiasis) in a patient with obstruction of lymphatic
drainage.
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54. Peau d’ orange appearance in
breast carcinoma
• Peau d Orange is a
French term, which
means “skin of an
orange.”
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55. GENERALIZED EDEMA
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56. Generalized edema
CAUSES:
 Heart failure
 Renal failure
 Nephrotic syndrome
 Cirrhosis of liver
 Malnutrition
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57. Mechanism of systemic edema in heart failure, renal
failure, malnutrition, hepatic failure and nephrotic
syndrome
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58. Renin Angiotensin Aldosterone axis
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59. Nephrotic Syndrome
• Massive proteinuria (daily loss of
3.5gm or more of protein)
• Hypoalbuminaemia- plasma albumin
level less than 3gm/L
• Generalized edema
• Hyperlipidemia and lipiduria
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60. Edema in Nephrotic
Syndrome
• Nephrotic syndrome is caused by a
derangement in glomerular capillary
walls resulting in increased
permeability to plasma proteins
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61. NEPHROTIC SYNDROME-
pathogenesis
Leaky glomerular capillary wall
Heavy proteinuria
Hypoproteinaemia
Decreased colloidal
osmotic pressure
EDEMA
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62. Edema in Nephrotic
Syndrome
Direct consequence
Aggravates edema
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63. EDEMA IN CIRRHOSIS OF
LIVER
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64. EDEMA (ascites) IN LIVER CIRRHOSIS
 Increased hydrostatic pressure: elevated
pressure in the veins running through the liver
(sinusoidal hypertension)
 Percolation of hepatic lymph into the
peritoneal cavity
 Splanchnic vasodilation and hyperdynamic
circulation
 Hypoalbuminemia: a decrease in liver
function caused by scarring of the liver,
i.e., cirrhosis.
 Failure in hepatic inactivation of aldosterone
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65. Systemic, portal,
hepatic circulation
Splanchnic circulation
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66. 1. Increased hydrostatic
pressure
2. Percolation of hepatic
lymph into the peritoneal
cavity
3. Splanchnic vasodilation
and hyperdynamic
circulation
4. Hypoalbuminemia
5. Failure in hepatic
inactivation of
aldosterone
EDEMA IN CIRRHOSIS OF LIVER
1.
3.
4. 5.
2.
Ref: Davidson’s Principle & Practice of
Medicine. 23rd ed. Chapter 22
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67. PULMONARY EDEMA
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68. CLASSIFICATION OF PULMONARY
OEDEMA
• A. HEMODYNAMIC EDEMA
• B. EDEMA DUE TO MICROVASCULAR
INJURY
• C. EDEMA OF UNDETERMINED
ORIGIN
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69. CAUSES OF PULMONARY OEDEMA (Cont)
EDEMA DUE TO HAEMODYNAMIC CAUSE
Increased Hydrostatic pressure
 Left heart failure
 Volume overload
Decreased oncotic pressure
 Nephrotic syndrome
 Liver disease
Lymphatic obstruction
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70. CAUSES OF PULMONARY OEDEMA(Cont)
EDEMA DUE TO MICROVASCULAR INJURY
Infectious agents : viruses, mycoplasma,
other
Inhaled gases : oxygen, sulfur dioxide,
cyanates, smoke
Liquid aspiration : gastric contents, near-
drowning
Drugs and chemicals:
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71. CAUSES OF PULMONARY
OEDEMA(Cont)
EDEMA OF UNDETERMINED ORIGIN
High altitude
Neurogenic
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72. Grossly: Weight
Frothy, blood tinged fluid – on section
M/E : Alveolar capillaries engorged
Intra-alveolar precipitate
Alveolar microhaemorrhage
Hemosiderin laden macrophages
(heart failure cell)
Fluid is expressed
from the cut
surfaces of both
lungs
Pulmonary edema
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73. CEREBRAL EDEMA
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74. Cerebral edema- causes
 Primary or metastatic tumour
 Infarction
 Contusion
 Abscess
 Encephalitis
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75. MORPHOLOGY OF CEREBRAL EDEMA
Cerebral edema:
 Swollen
 Softer
 Gyri – Flattened
 Sulci – Narrowed
 Ventricular cavities
– compressed
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76. • Definition- edema, effusion
• Pathophysiological categories of edema
• Types of edema
• Mechanism of edema- heart failure, renal failure,
nephrotic syndrome, hepatic cause (Edema in
cirrhosis)
• Morphology of edema
• Local edema- causes & examples
• Pulmonary edema
• Cerebral edema
What we have learnt in this class
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77. Practice questions
1. Define edema.
2. What are the types of edema ? What is anasarca?
3. What are the pathophysiological categories of edema?
4. What are the causes of generalized edema?
5. What are the causes of localized edema? Give few examples of
localized edema.
6. What are the differences between exudates & transudates?
7. What is the clinical significance of edema?
8. Discuss the mechanism of edema in heart failure.
9. Discuss the mechanism of edema in nephrotic syndrome.
10. What is the mechanism of edema in liver cirrhosis?
11. What are the causes of pulmonary edema? What is heart failure
cell?
12. Mention few causes of cerebral edema.
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78. MCQ
Edema occurs due to
a) Decreased hydrostatic pressure
b) Lymphatic obstruction
c) Increased plasma colloidal osmotic
pressure
d) Sodium retention
e) inflammation
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79. MCQ
Edema occurs due to
a) Decreased hydrostatic pressure F
b) Lymphatic obstruction T
c) Increased plasma colloidal osmotic
pressure F
d) Sodium retention T
e) Inflammation T
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80. MCQ
Exudate is associated with
a) Low protein content
b) Inflammation
c) Low specific gravity
d) Increased tendency to clot
e) High cellular content
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81. MCQ
Exudate is associated with
a) Low protein content F
b) Inflammation T
c) Low specific gravity F
d) Increased tendency to clot T
e) High cellular content T
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82. MCQ
Local edema occurs in
a) Inflammation
b) Neoplasia
c) Lymphatic obstruction
d) Hypersensitivity reaction
e) Malnutrition
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83. MCQ
Local edema occurs in
a) Inflammation T
b) Neoplasia F
c) Lymphatic obstruction T
d) Hypersensitivity reaction T
e) Malnutrition F
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84. MCQ
Edema due to sodium retention occurs in
a) Congestive cardiac failure
b) Nephrotic syndrome
c) Cirrhosis of liver
d) Filariasis
e) Increased tubular reabsorption of
sodium
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85. MCQ
Edema due to sodium retention occurs in
a) Congestive cardiac failure F
b) Nephrotic syndrome F
c) Cirrhosis of liver F
d) Filariasis F
e) Increased tubular reabsorption of
sodium T
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86. MCQ
Hypoproteinemia causes edema in
a) Congestive cardiac failure
b) Liver cirrhosis
c) Nephrotic syndrome
d) Protein losing enteropathy
e) Filariasis
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87. MCQ
Hypoproteinemia causes edema in
a) Congestive cardiac failure F
b) Liver cirrhosis T
c) Nephrotic syndrome T
d) Protein losing enteropathy T
e) Filariasis F
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