Basic Mechanism of Disease

Case Report: Edema

Scenario II

Seorang wanita 50 tahun masuk UGD RS Wahidin Sudirohusodo karena sesak napaf sejak 2 hari yang
lalu dan bertambah berat. Kedua kaki pasien bengkak dan terasa berat kalau berjalan sejak 3 bulan lalu.
Pasien tidak pernah mengeluh demam.

Identifying the problems
1. Sesak napas sejak 2 hari yang lalu dan bertambah berat
2. Kedua kaki pasien bengkak sejak 3 bulan lalu
3. Tidak pernah demam

Analyzing the problem
Obvious observation from patient: Bilateral edema

What is edema?

General definition: Edema is swelling in the body parts due to accumulation of excess fluid in the tissue.
Edema most commonly occurs in the feet and legs, where it is referred to as peripheral edema. The
swelling is the result of the accumulation of excess fluid under the skin in the spaces within the tissues.
All tissues of the body are made up of cells and connective tissues that hold the cells together. This
connective tissue around the cells and blood vessels is known as the interstitial space. Most of the
body's fluids that are found outside of the cells are normally stored in two spaces; the blood vessels (as
the "liquid" or serum portion of your blood) and the interstitial spaces (not within the cells). In various
diseases, excess fluid can accumulate in either one or both of these compartments.
Before we proceed further into explaining the case, it is crucial that we explain the physiology of fluid
return mechanism regulated by the lymphatic system.

Firstly, we need to know the components involved in this mechanism. We all know that the hydrostatic
pressure in the capillaries tends to force fluid and its dissolved substance out of the capillary pores into
the interstitial spaces. Conversely, osmotic pressure caused by the plasma protein (also known as the
oncotic pressure) tends to cause fluid movement by osmosis from the interstitial spaces into the blood.
This osmotic pressure exerted by the plasma protein normally prevents significant fluid loss from the
blood into the interstitial space. This also happens due to the present of albumin in the capillary, a
protein that functions to draw water inside the blood.

Also important is the lymphatic system, which returns to the circulation the small amount of excess
protein and fluid that leak from the blood into the interstitial spaces.

A brief summary:

1. The capillary pressure: tends to force fluid outward through the capillary membrane.
2. The interstitial fluid: tends to push fluid inside or outside the capillary membrane (depends on
the environment pressure)
3. The oncotic pressure: tends to cause osmosis of fluid inward through the capillary membrane

Physiology
Generation of interstitial fluid is regulated by the forces of the Starling equation. The hydrostatic
pressure at the arteriole end is higher compared to the hydrostatic pressure at the venule end. This is
due to the length of the capillary that increases as it reaches the venule. Heres an example of the
mechanism: The hydrostatic pressure, HPc at the arteriole end is 35mmHg. As the blood moves along
the capillary towards the venule end, the hydrostatic pressure decreases and become 18mmHg. In the
blood capillary, plasma proteins are present and function as a sponge to the blood vessel that withdraws
water inside the capillary. Normally, albumin is the most abundant plasma protein that can be found
inside the capillary. Since the concentration of albumin between the arteriole end and the venule end is
the same, the oncotic pressure at the arteriole and the venule would be the same too, which is
25mmHg. As it forms a hypotonic surrounding between the blood capillary and the extracellular fluid,
water molecules will diffuse in the capillary via osmosis.
Now, the net pressure between both ends is different.
At the arteriole, the net pressure is 35mmHg 25mmHg = 10mmHg.
It creates a positive net pressure, so the fluid will be forced out of the blood capillary into the
extracellular space. At the venule end, the net pressure is 18mmHg 25mmHg = -7mmHg.
Because it creates a negative pressure, so the water outside the capillary would enter the capillary via
osmosis to balance it.
The differences between the net pressure: 10mmHg 7mmHg = 3mmHg. This pressure contributes to
the excess fluid that would be regulated by the lymphatic system.
Pathologically, if there is an increased in the amount of excess fluid accumulated in the extracellular
fluid, this would lead on to edema (swelling).


Causes of edema



Discussion of case

1. No fever detected because there is no bacterial or viral infections. Hence, fever cannot be
related to the swelling of the feet. If there is inflammation due to infections, microorganism that
normally block the lymphatic system is Filaria nematodes (Wucheria bancrofti), which are
microscopic, threadlike worms.

2. Blockage of the lymphatic system Lymphedema
When lymph vessel function is greatly impaired due to blockage or loss of the lymph vessels,
edema can become especially severe because plasma proteins that leak into the interstitial have
no other way to be removed. The rise in protein concentration raises the colloid osmotic
pressure of the interstitial fluid which draws even more fluid out of the capillaries. Lymphedema
can also occur in certain types of cancer or after surgery in which lymph vessel are removed or
obstructed. For example, large numbers of lymph vessels are removed during mastectomy,
impairing removal of fluid from the breast and arm areas and causing edema and swelling of the
tissue spaces.

3. Decreased amount of plasma protein
A reduction in the concentration of plasma proteins because of either failure to produce normal
amounts of proteins or leakage of proteins from the plasma causes the oncotic pressure to
decrease. So, the amount of fluid being forced out of the capillary increases and causes edema.
However, this type of edema is usually generalized as it involves the capillary networks in the
body. It can happen anywhere, not only affecting the feet. Therefore, it cannot be related to the
case.
Causes
of
Edema
increased
hydrostatic
pressure
decreased
amount of
plasma
protein
increased
capillary
permeability
blockage of
the
lymphatic
return
4. Increased capillary permeability
Capillary permeability is increased due to excessive kidney retention and salt. In kidney diseases
that compromised urinary excretion of salt and water, large amounts of sodium chloride and
water are added to the extracellular fluid. Most of this salt and water leaks from the blood into
the interstitial spaces. However, this will only cause extracellular edema and hypertension
because of the increase in blood volume. Also, the edema that arise this cause only cause
localized edema and it is not confirmed to be bilateral or unilateral. Hence, it cannot relate to
the case.

5. Increased hydrostatic pressure
As we can see, she suffered dyspnea (shortness in breathing) and pretty much leads to edema at
the both feet. One of the most serious and most common forms of edema is heart failure. In
heart failure, the heart fails to pump blood normally from the vain to the artery; this raises
venous pressure and capillary pressure, causing increased capillary filtration. In addition, the
arterial pressure tends to fall, causing decreased excretion of salt and water by the kidney,
which increases blood volume and raises capillary hydrostatic pressure. This could be the best
cause to relate to the abnormalities of the patient from the case.


Pathophysiology of left heart failure

Underlying disease of left heart failure are largely due to pulmonary congestion and valvular stenosis.
Impaired pump function will increases venous pressure because inadequate pumping allows blood to
back up and pool in the venous system. Then, the cardiac fibers in the heart will dilate in response to
increased venous pressure, allowing more blood to enter the heart. More blood is filled into the heart
and increases cardiac filling. The cardiac muscles fibers will stretch, increasing the force of contraction.
At this state, the heart is said to undergo heart-shunting. Slowly, the pump will be congested as to the
increasing workload of high pressure. Since the left part of the heart is greatly weakened, the blood will
be accumulated in the lungs, increasing the pulmonary capillary pressure and causing pulmonary
edema.

Pathophysiology of right heart failure

Right-sided heart failure normally causes systemic and portal venous congestion. When the left side of
the heart is impaired, the blood that enters the right side of the heart cannot be normally transported
back into the lungs due to the high blood retention in the lungs. The valves on the right heart will be
weakened due to the pressure exerted the accumulating blood. Hence, blood will be forced back into
the other parts of the body and accumulate down at the feet. That is how peripheral edema occurs.

Conclusion

Heart failure occurs when the heart is unable to pump blood at a rate that meets the metabolic
requirement of the peripheral tissues; inadequate cardiac output is usually accompanied by increased
congestion of the relevant venous circulation














The body's organs have interstitial spaces where fluid can accumulate. An accumulation of fluid in the
interstitial air spaces (alveoli) in the lungs occurs in a disorder called pulmonary edema. In addition,
excess fluid sometimes collects in what is called the third space, which includes cavities in the abdomen
(abdominal or peritoneal cavity - called "ascites") or in the chest (lung or pleural cavity - called "pleural
effusion"). Anasarca refers to the severe, widespread accumulation of fluid in the all of the tissues and
cavities of the body at the same time.
What is pitting edema and how does it differ from non-pitting edema?
Pitting edema can be demonstrated by applying pressure to the swollen area by depressing the skin with
a finger. If the pressing causes an indentation that persists for some time after the release of the
pressure, the edema is referred to as pitting edema. Any form of pressure, such as from the elastic in
socks, can induce pitting with this type of edema.
In non-pitting edema, which usually affects the legs or arms, pressure that is applied to the skin does not
result in a persistent indentation. Non-pitting edema can occur in certain disorders of the lymphatic
system such as lymphedema, which is a disturbance of the lymphatic circulation that may occur after a
mastectomy, lymph node surgery, or congenitally. Another cause of non-pitting edema of the legs is
called pretibial myxedema, which is a swelling over the shin that occurs in some patients
withhyperthyroidism. Non-pitting edema of the legs is difficult to treat. Diuretic medications are
generally not effective, although elevation of the legs periodically during the day and compressive
devices may reduce the swelling.
The focus of the rest of this article is on pitting edema, as it is by far the most common form of edema.