Haemodynamic disorders

• Hyperhydratio (water excess)

• Dehydratio
• Oedema
• Hyperaemia and congestion
• Haemorrhage
60 minutes
 Water excess
• Conn’s syndrome: aldosterone producing adenoma →
hyperaldosteronism → excessive reabsorption of sodium
and water. Fluid excess mostly in circulation:
hypervolemia → hypertension.
• SIAD: Syndrome of Inappropriate (high) ADH secretion:
↑ fluid retention → ↓ renin-angiotensin activity →
sodium and water loss. End result: euvolemia and
marked hyponatremia.
• Iatrogenic water overload: excessive parenteral infusion
in patients with impaired renal function.
• Extensive edema: see later.
 Dehydration
Causes:
• Excessive water loss
• Inadequate water intake
• Combination of both
Water loss can be due to
• Vomiting and diarrhoea
• Extensive burns
• Excessive sweating
• Diabetes insipidus (failure of proper ADH secretion)
• ↑ diuresis, e.g. osmotic loss accompanying glycosuria
in DM
Inadequate water intake is common in drought and
famine areas.
 Clinical signs of dehydration

• Dry mouth
• Inelastic skin
• Sunken eyes( in extreme cases)
• ↑ hematocrit → ↑ blood viscosity → sluggish
circulation → ↓ function of many organs
 Oedema
Accumulation of protein-poor fluid in the
interstitial spaces and the body cavities.
Main ingredient: water, specific gravity <1012

Localized Generalized
• Involves one organ • Involves the entire
or part of the body body, (in subcutis:
• Clinically important anasarca)
examples: • Clinical sign: pitting
Brain oedema oedema (depression in
Lung oedema the skin by pressing on
Hydrothorax Serous it with a finger)
Ascites effusion
 Types of oedema
• Venous
Yield protein-
poor • Hypoalbuminaemic
transssudates • Lymphatic
• Na retention-associated
• Inflammatory Yields
protein-rich
(detailed later) exsudates
Physiology
Hydrostatic blood pressure forces water out of
capillaries at the arterial end, but the plasma oncotic pressure
attributable to albumin sucks it back into capillary beds at the
venous end.
A small amount of water drains from the tissues
through lymphatic channels.
 Venous oedema
• Increased hydrostatic pressure due to impaired
venous return forces fluid out the capillaries that
exceeds that of plasma oncotic pressure and so
water remains in the tissues.
• Localisation follows gravity
 Venous oedema
• Sudden onset of (acute) left-sided heart failure
(reduced systolic output accompanied by
inadequate emptying of the chamber) leads
to the elevation of hydrostatic pressure in
lung capillaries ⇒lung oedema
Lung oedema: the lungs 2 to 3 times exceed their
normal weight; sectioning reveals a frothy, blood-tinged,
foamy mixture of air, oedema fluid, and RBCs
Pulmonary oedema in acute left-HF
 Venous oedema
• Chronic right-sided heart failure (reduced
systolic output accompanied by inadequate
emptying of the chamber) leads to the elevation
of hydrostatic pressure in capillaries of the
systemic circulation, and in turn, systemic
oedema and serous effusions:
- hydrothorax,
- hydropericardium
- ascites
Hydrothorax in right-sided HF
 Venous oedema
Cirrhosis of liver causes increased hydrostatic
pressure in the portal venous circulation (portal
hypertension) ⇒ ascites
 Venous oedema
Oedema of just one calf: due to thrombotic
obstruction of popliteal veins
 Hypoalbuminaemic oedema
Low albumin concentration reduces the plasma
oncotic pressure so that the water cannot be sucked
back into the capillary bed at the venous end.

Causes of hypoalbuminaemia:
• Inadequate intake, as in protein-deficient diet
(kwashiorkor)
• Decreased synthesis in the liver, as seen in end-
stage liver disease
• Increased loss in the urine (e.g., nephrotic sy) or
stool (e.g., protein-losing enteropathy)
 Lymphatic oedema
Lymphatic obstruction prevents drainage of water
from the tissues. Typically, this is a localized form
of oedema involving certain parts of the body.

• Elephantiasis - obstruction of inguinal lymph

nodes by filaria worms (filariasis) ⇒ chronic
oedema of lower extremities and external
genitalia.

• Oedema of the arm following surgical dissection

of axillary lymph nodes involved by breast cancer.
 Breast cancer. Severe lymphoedema of the arm following
mastectomy, surgical dissection of the axillary lymph nodes
and irradiation of the axillary region
 Sodium retention-associated oedema
Primary sodium retention, with obligatorily
associated water retention, causes both increased
hydrostatic pressure (owing to hypervolaemia) and
reduced osmotic pressure.

Sodium retention occurs in renal disease, e.g.,

glomerulonephritis, acute tubular necrosis
 Hyperaemia and congestion
Both indicate increased volume of blood in a
particular tissue.

Active hyperaemia results from increased blood

inflow because of arteriolar dilatation
• Skeletal muscle during exercise
• Sites of inflammation
• Facial skin during blushing

The affected tissue is redder than usual because of

the engorgement happens with oxygenated blood.
 Congestion (passive hyperaemia)
Results from impaired venous outflow from a
tissue.
• Systemic, as in cardiac failure
• Local, resulting from an isolated venous
obstruction

The tissue has a blue-red color (cyanosis) because

stagnation of blood in the capillaries leads to
accumulation of deoxygenated haemoglobin.
 Congestion
• Congestion of capillary beds is closely related to
the development of venous oedema, so that
congestion and oedema usually run together.

• In long-standing congestion, the poorly

oxygenated blood causes chronic hypoxic injury
resulting parenchymal cell degeneration and even
death, and induration (replacement of dead
parencymal cells by connective tissue; collagen
deposition in extravascular spaces)
 Congestion
• Capillary rupture at the sites of chronic congestion
causes small foci of haemorrhage. The
breakdown and phagocytosis of RBCs results in
clusters of haemosiderin-laden macrophages.
 Morphology of congestion
Acute left ventricular failure ⇒ acut pulmonary
congestion
• Alveolar capillaries engorged with blood
• Alveolar septal oedema
• Intraalveolar oedema with focal haemorrhages
 Morphology of congestion
Chronic left ventricular failure ⇒ chronic
pulmonary congestion (brown induration of
lungs)
• Thickened and fibrotic septa
• Haemosiderin-laden macrophages in the alveoli
(heart failure cells)
• Intraalveolar oedema with focal haemorrhages
Brown induration of the lungs
 Morphology of congestion
Liver manifestation of acute right ventricular
failure ⇒ acute hepatic congestion
• Central veins and sinusoids are distended with
blood
• Hepatocyte degeneration around central veins
may occur
• + fatty change in periportal hepatocytes

CNS manifestation of acute right ventricular

failure ⇒ brain oedema with cerebellar
herniation
 Morphology of congestion
Liver manifestations of prolonged right
ventricular failure : Nutmeg liver
Gross: centrilobular areas are red-brown and are
accentuated against the surrounding zones of
uncongested hypoxic/fatty change-altered liver
zone
LM: centrilobular trabecular (compression)
atrophy – widened sinusoids are filled by
RBCs, accompanied by peripherolobular fatty
change
 Nutmeg liver: hypoxic/fatty hepatocytes at the
perithery of the lobules are pale, central parts are red.
 Haemorrhage
Extravasation of blood.
The source of bleeding may be
• Rupture
- Arterial or arteriolar aneurysm
- Oesophageal varix
 Haemorrhage
Extravasation of blood. The source of bleeding may
be
• Rupture
- Arterial or arteriolar aneurysm
- Oesophageal varix
• Erosion
- Artery by peptic ulcer of stomach or duodenum
- Vessels by malignant tumor (e.g., cc of cervix)
• Capillary bleeding
- Chronic congestion
- Haemorrhagic diatheses (⇑ tendency to bleed
from insignificant injury)
 Classification of haemorrhage
• Surface
- External, internal
• Enclosed within a tissue
Haematoma (3-dimensional); may be
- insignificant (bruise)
- lethal (retroperitoneal, subarachnoidal)
Suffusion (2-dimensional)
Subcutaneous suffusion due to trauma
Subarachnoidal haematoma
Iatrogenic haematoma around the carotid arteries
as complication of catheterization
Petechiae: minute, 1-2 mm haemorrhages into skin,
mucous membranes or serosal surfaces, seen in
thrombocytopenia, defective platelet function
(uraemia) or clotting factor deficits
Purpura: slightly larger (>3 mm) haemorrhages,
may be associated with similar pathologies, as
well as trauma, vasculitis, or increased vascular
fragility
Purpuras in small
vessel vasculitis

Sándor Husz, MD,

SZTE Dermatology
Ecchymoses: 1-2 cm subcutaneous haematomas
after trauma

The RBCs in these local haemorrhages are

degraded and phagocytosed by macrophages.

Color changes in haematoma:

• Haemoglobin (red-blue)
• Bilirubin (red)
• Biliverdin (blue-green)
• Haemosiderin (gold-brown)
Accumulation of blood in cavities and the
Fallopian tube
• Haemothorax
• Haemopericardium
• Haemoperitoneum (haemascos)
• Haemarthros
• Haemocephalus
• Haemosalpinx
Haemopericardium (lethal)
Myocardial rupture causing
haemopericardium
Cerebral bleeding (apoplexy) associated with
haemocephalus
Other terms in association with haemorrhage
• Haematuria: appearance of blood in the urine;
microscopic or macroscopic
• Haematemesis: vomiting of blood; sign of
oesophageal and gastric haemorrhage
• Haematochezia: bleeding through the rectum
• Melaena: Sign of upper GI tract bleeding. The
blood is digested partly by HCl. The black
pigment haematein is passed in the faeces
• Epistaxis: bleeding from the nose
• Haemoptysis: bleeding from the lungs;
literally it means spitting of blood
• Menorrhagia: heavy menstrual bleeding
• Metrorrhagia: occurs any time and is not related
to menstrual bleeding
 Clinical significance of haemorrhage

Depends on the volume and rate of blood loss.

• Rapid removal of up to 20% of the blood volume
may have little impact in healthy adults
• Greater and rapid losses result in haemorrhagic
shock
 Clinical significance of haemorrhage

• The site of bleeding is also very important

Bleeding that would be trivial in the subcutaneous
tissues may cause death if located in the brain,
because the skull is an unyielding structure.

• Intracranial bleeding ⇒ increased intracranial

pressure and herniation
 Clinical significance of haemorrhage

Recurrent external blood loss (peptic ulcer or

severe menstrual bleeding) ⇒ iron deficiency
anaemia