Edema | Types Causes and Symptoms👨‍⚕️

0:00 today we are going to talk about the core concepts related with the edema right now ah before I really give the lecture I would love to ask you a few questions how do you define what is edema yes please right uh she's saying that edema is accumulation of interstitial fluid interstitial fluid is normally there interstitial fluid is normally there but normally we are not edematers someone can improve on this definition yes it's really we can say you are saying that it is accumulation of abnormal fluid in interstitium still not good yes is us you can make it a better

0:59 okay he's saying that edema means accumulation of excessive fluid in interstation right this is right definition but it's not the complete because by this definition you miss a big part of Edema anyone can improve it further definition of Edema yes abnormal accumulation of fluid in the interstitium yet not yes okay anyone else excellent very good uh he is saying excess fluid in the body there is excessive fluid either inside the cells which is intracellular edema or in the interstitium and body cavities which is called extracellular edema so my dear friend at least you should know what is edema let me tell you edema is just edema is excessive fluid excess fluid in body tissues that's it what is the edema a demise excess fluid yes in body tissues that's it it may be intracellular or edema may be extra cellular

2:22 right when you say edema mean fluid in interstitium that is wrong because normally there is fluid in interstitium and if you say edema is excessive fluid in interstitium then you miss intracellular edema right so what is the edema edema simply means excessive amount of fluid present in the body tissues but let's refine it further why because its excessive fluid not in all body tissues for example if their excessive fluid in the blood if there is excessive fluid in the blood is it called edema no if there is excessive fluid in the blood that is not called edema it means that when Whenever there is excessive fluid in the vascular compartment that is not considered edema so we can further improve our definition that edema is excessive fluid in body tissues extra vascularly extra vascular ly right now let me draw a diagram to make it more clear let's suppose from your body I remove a piece of tissue right this is a piece of tissue a typical tissue from your body and naturally

3:46 the tissue is having arterial Supply right let's suppose here is your left heart all right systemic circulation and this is hypothetically we make that there is arterial Supply coming to this tissue right arterial input in the same way this tissue must have some outflow mechanism that is venous right and that will be going to which side of the heart yes please right heart very good that would be going to the right heart and of course all of you know that blood from the right heart yes

4:33 blood from the right Hearts the pulmonary what arteries go to lungs and through the microvasculature of the lungs blood is eventually being brain to the left side so pulmonary veins which have oxygenated blood right now what have what what I am showing in this diagram from the left heart blood is going to the tissues right and we have taken a sample tissue here and this is the arteriolar input and here I have shown the venous output is that right now let's see in detail in this tissue right arterial system of course arteries come they divide into arterioles and eventually they divide into Capital rays right uh there's some going draw micro circulation this is your micro circulation this one right and there is arterial input here is Venous output here are your cells

5:41 cells in the tissue right parenchymal cells and let's suppose this is representing body cavities right body cavities these are parenchymal cells in the body and this area this area this is interstitial tissue what is this interstitial tissue so we can say interstitial tissues between the parenchymal cells and the vasculature is that right this is interstitial tissue now let's divide our body weight and see what are the normal fluid compartment because when we Define edema as excessive fluid we Define edema as excess amount of fluid in body tissues but extra vascularly right when we Define like this we must know what is the normal amount of fluid in different body compartment right because when fluid is Success then it is edema but as a good doctor you must know what is the normal amount of fluid in different body compartments let's suppose here you are your beautiful picture right yes let's suppose you are adult and your weight is 72 kg right

6:58 if you are 72 kg how much water will be there in your body yes five liter water I think I will die immediately five liter water is too low water you know if you are 72 kg and if you have only 5 liter bottle five liter of water in total body you must be dead already uh foreign how did you calculate it excellent very good actually when we say total body weight total body weight right 72 kg is the total body weight of this person total body weight is divided into two total body water and lean body mass lean body mass and total body water if we remove that for example if this diagram is representing all the body weight right if it is representing all the body weight then in this person this hole should represent 42 kg out of that total body weight divided into lean body

8:11 mass which is about 40 percent and total body water is about 60 percent this is very important to understand whatever our weight approximately sixty percent we are just water when we say if I say I'm falling in love with a girl actually sixty percent water of Dr najib is and plus 40 percent of lean body mass is falling in love with the girls how much water sixty percent of the water and forty percent off lean body mass so you need to remember this that all of us consist of six to about 60 percent of water about 60 percent of water is that right children have a little more percentage anyway so sixty percent of water it means if my weight is 72 kg then okay this whole system has 72 kg weight how much water 60 percent about 42 liters so if my weight is 72 kg I will have how much water 42 letters don't sell 42 kgs and if my weight is 100 kg then how much water I have 60 liters so is that clear right and out of this 42 this 42 liter is divided into very important fluid

9:32 compartments in the body right for example out of this 42 one third is in the intra cellular fluid it means one third fluid is present inside the cells these are cells so all your if my weight is 42 yes 40 72 kg total water I have is 42 out of that intracellular is two thirds and extra cellular fluid is one third extracellular is one third intracellular is two third and what is the extracellular fluid extracellular fluid mean outside the cell outside the salmon

10:20 fluid in the interstitium including body cavities and fluid in the blood your understanding so if I have 72 kg weight the 42 liter of water in my body out of that 28 liter is present inside the cells because 42 3 is 28 letters and one third is 14 letters so it means I will write it here how much I have 28 28 liters here and how much is left then 14 so 14 letters here outside the cells out of this 14 inside the plasma is about 3.5 liters 3.5 liters and outside is about 10.5 liters

11:12 approximately of course the degree of hydration changes percent to person and time to time but approximately now we come back so what we have decided that extra solar fluid is divided into interstitial fluid which is here and what is this intravascular fluid normally how much blood you have how much blood you have five letters you are answering this thing you are saying five letter five letters the amount of blood in a person but we have fluid outside the blood secondly in the blood even five liter is not the whole fluid there are cells too we are talking about let's suppose this is vascular system these are red blood cells now which is the fluid inside the red blood cell that is intravascular not only intravascular that is intra cellular to in the blood vessels you have five liter of the blood but in the blood there are cells right and there are red blood cells the white blood cells and there are platelets all of them have fluid inside but that fluid is considered part of the

12:19 intra cellular compartment that is considered part of the intra cellular compartment so plasma which is left that is considered extra cellular so plasma is about three and a half liter out of five liter blood one and a half liter you can see is your cells cells my friend you are having five letter blood right out of that blood approximately one and a half liter is yourself and whatever fluid is present inside the cells that is considered intra cellular fluid is that right but other than cells blood has plasma so five liter of the blood one half liter is cells and three and a half liter is plasma that three and a half liter plasma is considered part of the extracellular fluid that is considered part of the extracellular fluid that is why extracellular fluid I write three and a half liter here and remaining within the interstitium and very little into body cavities right so into three some approximately 10.5 liters right so this is the normal distribution of

13:31 fluid why I am teaching you normal distribution because in edema there is abnormal abnormal distribution or excessive accumulation of fluid in extracellular or intracellular is component right now let me repeat if I'm having 72 kg weight right lean body masses 40 percent and total body water is 60 out of that sixty percent total body right okay let me put it that we are having this is total body mass right forty percent we remove what was that laneward now what is the remaining 60 is water

14:17 now out of that water intracellular will be two thirds and extracellular will be one third is that right so intracellular out of 42 will be 28 liters and extra solo will be 14 letters right and this extracellular fluid further divided into interstitial fluid and plasma is it clear any question up to this now why we were studying let's suppose interstitial fluid in total body rather than 10.5 liter it become 20 later then it is generalized edema or in a specific tissue in a local area interstitial fluid is excessive now before we go into further detail let's go to the very basic right and we have talked about that again I will repeat that edema is excessive fluid in the body tissues extra vascularly right so this is the definition of edema and edema can be divided into now two types of Edema intracellular edema intracellular edema which is this edema if there is over excessive accumulation of fluid inside the cells that is considered intra cellular edema and if

15:42 there is excessive accumulation of fluid outside the cells what is that extra cellular edema extracellular edema and here it is intracellular edema right so today onward when you talk about edema please clear that are you talking about intracellular edema or extra cellular edema but in medical literature and during medical discussions generally generally speaking when we say edema usually we mean excessive fluid in interstitial area right so if excessive fluid is here what is

16:27 this what type of Edema extra cellular edema or in general discussions non-specifically speaking we call it just edema we just call it edema right excessive fluid intracellular edema excessive fluid here and in body cavities and in body cavity both are called extracellular edema amiclet now what are these body cavities Excel solar edema is either in the interstitium enter station here or it is in serous body cavities serous body cavities are yes pericardium when there is excessive fluid in pericardium we call it just a minute when there is excessive fluid in the pericardium we call it we call it pericardial effusion OK we can call it pericardial effusion very good or we can call it hydropericardium very good Hydro Perry cardium when there is excessive fluid in the pericardium what we call it

17:44 hydropericardium or we call it as you said pericardial effusion someone said pericardial tamponade someone said it who was that raise your hand raise your both hands you are absolutely wrong what is cardiac tamponade it means you do not have the concept of cardiac tamponade listen let me tell you if there is normal fluid here then we say this is normal pericardial fluid of course but when there is excessive fluid we call there is cardiac pericardial effusion and now listen carefully and if due to excessive fluid if due to accumulation of excessive fluid cardiac filling is significantly compromised then that is called cardiac tamponade you understand it whenever you have extra fluid here in the pericardium that is not cardiac tamponade having more fluid here

18:49 is just pericardial effusion but when a fusion is able to compress the heart and does not allow the Heart during dastly to fill and compromise compromises cardiac function then we say there is cardiac tamponade so please yes now in acute case if there is cardiac pericardial Fusion if it rapidly develop a smaller fume can produce tamponade but if pericardial effusion is developing very gradually very slowly over the months and years then too much fluid can accumulate in pericardium and still it doesn't compress hard so we say there is Big pericardial effusion there is no cardiac tamponade am I clear so next time in your life before you speak about tamponade remember tamponade is only there when a fusion is able to compromise cardiac function right now let's move forward so hydropericardium what else pleural cavity may have extra fluid normally there is fluid if floral cavity has extra fluid we call it we can call it plural efficient we can also call it Hydro

20:09 thorax in the same way if there is excess fluid excess fluid in the peritoneal cavity we can call it peritoneal effusion Which is less commonly used term more commonly we can say Hydro Hydro peritoneum but very commonly we use the word very good cities excellent who said site is first very good so when the scientists become symptomatic house how large and Society sciatic fluid should be to detect it clinically just a minute just a minute First Let Me Clear My question when there is normally peritoneal cavity in abdomen do does have a little fluid okay if there is excessive fluid there we call it Hydro peritoneum or we call it a site is very good my question is that if a person is having ascites it start developing maybe in the very beginning a slight increase in fluid cannot be detected clinically how much fluid extra fluid or how much total amount of fluid should be present in my peritoneal cavity to be detected by a stute clinician a sharp doctor yes

21:32 no you are not understanding my question 2.5 liter absolutely wrong if some doctor can guess that I have developed 2.5 liter of water and only then he can guess he is a very pathetic clinical method that is listen if you are able to detect the societies when I have developed 2.5 liter of fluid in my abdomen that is not a great physician a very sharp physician should have so good clinical methods that he should be able to detect even a small amount of fluid in the abdomen free fluid how small can be usually detected by a good doctor I'm not talking about doctor with yes yes half letter a good doctor should be able to detect presence of ascites when it is about half letter and if someone only detect a site is when there is two and a half liter water oh that's a very sad and bad situation for that doctor okay and for patient too anyway so we were talking about extrasolar edema mean edema fluid excessive fluid in interstitial area and and or serous body cavities

22:56 I'm saying serious body cavities not everybody can they have a nasal cavity it doesn't have edema there I just got nasal secretions there are other cavities I will not commence there right so what I'm talking about serous body cavities especially pericardial cavity return cavity and pleural cavity right so this is a basic concept of edema right but here I would love to mention one more thing that as we mentioned a fluid is more here intracellular edema fluid is more here excessive fluid here and here extracellular edema but if there is flu excessive fluid here what is that if we take a tissue let's suppose you take a small tissue here and there is excessive amount of blood present in micro circulation excessive amount of blood or fluid present in micro circulation of course we know we do not call it edema we don't call it edema what do we call it yes anyone raise your hand all of you know it but you don't know you know it yes

24:03 hyperbolemia is a simple term yes you can call it simply hyperbolemia but the hyperbolemia is usually used when all body has total blood volume more than normal what I'm talking about is specific tissue if there is a small amount of tissue right and due to some reason uh in this tissue amount of blood in micro circulation is more than normal right okay talk about my finger in in my finger due to some reason total amount of blood is more than the normal of don't call it edema because edema will be called if there is excessive fluid either intracellularly in the finger or excessive fluid in the interstitium of the finger then it is edema but if there is excessive fluid in the vascular compartment of the fin of the finger we will call it very good we'll call it high premium or congestion we'll call it very no we can call it hyperemia hyperemia or congestion now a good doctor will tell me what is the difference in hybrid listen if I have excessive amount of

25:09 fluid or blood in my circulatory compartment of this finger one finger or some small tissue we say either tissue is hyperemic or tissue is can just having circulation which is congested what is the real difference between hyperemia and congestion she is very shy she doesn't want to reveal her knowledge yes but she's shy otherwise she knows hyperemia is that excessive amount of blood is because more blood is entering here because more blood is entering here is that right if there is arterial or dilation here an excessive amount of blood is entering here and total amount of blood here is more because of more arrival of blood into tissue we say tissue is hyperamic and if you look a little reddish we call it there is erythema what we call it there is erythema classically this is seen in

26:14 inflammation but why to go for inflammation do a little exercise and to show us more blood but don't tell that my tissue develop edema you say that is a there's increased blood flow in the tissue and we can call what is there hyperemia right but if there is due to some reason blood flow out of the tissue is reduced if there is some obstruction to the outflow or due to any reason outflow for example if there's a thrombosier and outflow of the blood is reduced then excessive fluid is accumulated here this situation is called congestion so again if there is excessive fluid present in intracellular compartment intracellular edema if there is excessive fluid in interstitium and body cavities or body cavities this is called extracellular edema but generally speaking in medical literature and generally in discussions medical community call edema if not specified only for extracellular edema but please don't say that excess fluid in body tissues is

27:25 edema because blood is also body tissue right but if blood if there's excessive fluid here it is either High premium when there is more inflow of the blood or it is congestion if there is decreased outflow of the blood any question up to this oh my God you are the thinking of our God things he's asking what is vascular and gorged meant right so many things coming in my mind but I will stay simple engagement is that when blood vessels dilate and more blood coming to tissue and venous outflow from a particular organ is reduced just imagine an organ it's up to your wild imagination and more blood is coming in due to arteriologation and less blood is going out due to venous compression we say there is engorgement of the tissue is that right and in this case hyperemia is there as well as congestion is there we can use the word engorgement a very dangerous word am I right so anyway let's come back to edema any question up to this yes

28:37 no no no no no he's saying that hyperemia can occur only in arteries no I'm talking about this accumulation of fluid is in the micro circulation which may be arterial and capillaries of meta capillaries or whatever types of is and venules and veins excessive blood here is simply excessive blood thank God doctor didn't put any name or maybe he is trying to put a name here that we say micro circulation is engorged if microcirculation here is in God then this engorgement is due to excessive fluid input then it will be in government engorgement and hyperemia right but if engagement is due to decreased fluid going out excessive flu blood here then we say there is congestion right classically when we say a specific tissues on God and there is usually there is arteriologation so hyperemia is occurring and venous compression so the degree of congestion there too right so in government both components can be there right but let's go back to edema okay before I really go into very

29:46 big detail of extra cellular edema right I will mention few words about intracellular edema which is also called cellular swelling right so few words about intracellular edema and then we go into detail of extracellular Edema which is called just edema also intra yes cellular edema now when we talk about intracellular edema it means there is excessive fluid in the intracellular compartment it means healthar swollen is that right in what condition it can happen why excessive fluid will enter into cells what could be the reason anyone from the last row no from the last row anyone okay you are saying hyper or small Clarity where extra cellularly or intracellular intracellularly very good that inside the cell if inside the cell is hyperosmolar if there is more solute in the cells actually let me tell you he is right if Whenever there are more solute in the cells or the left solutes outside the cells water will shift to the intracellular compartment

31:03 right now what could be the reasons of why the cells become hyper or smaller okay you are saying that intracellular edema may be due to increased osmolarity of intracellular fluid why this fluid become hyper or smaller raise your hand just to remind everyone has two hands yes okay he's trying to impress me he has read something which he doesn't remember clearly but he has read something let me explain what he is trying to say let me explain what he is trying to say all of you know that every cell has special type of pump which is called sodium potassium 80 pays the sodium potassium pump sodium potassium pump is all the time taking three ions of sodium three ions of sodium outside and always actively pushing two ions of potassium

32:06 inside it is taking two potassium in and it is taken three sodiums out is that right this is sodium potassium pump which is always pumping the sodium out of the cells and taking the potassium in is that right now due to some reason if this pump is not working well due to some reason if this pump is not working well then it is not bringing two potassium in but it is keeping the three sodium in and gradually sodium will accumulate in the cell and then cell will become hyperosmotic and pull the extra cellular water in pull the extracellular water in so whenever sodium potassium pumps which are present in every cell sodium potassium pumps are present on every cell more accurately they should be called sodium potassium ET phases what we call sodium potassium 80 Pages because this pump has special enzyme which break down the ATP uses the energy of ATP to operate and do its function right we call it sodium potassium 80 phases if due to any reason sodium potassium 80 pages are not working

33:21 then sodium is no more expelled from the cells the sodium which is retained in the cell that pulls the water with it and cell become swollen and intracellular edema develop but can you tell me a condition in which sodium potassium 80 pages will not be working any pathological disease condition s conditions in which sodium potassium body phases are not working is right but he should explain more elaborately simple as that I mentioned so just a minute now my turn sodium potassium metal phase is using ATP ATP is the energy in the cell if cells become hypoxic it's very simple if any tissue becomes ischemic if any tissue become ischemic the less blood flow going there less oxygen going there less glucose than other nutrients going there if the tissue is ischemic or cell is ischemic

34:20 cancel make without oxygen without glucose or other nutrients can it make ATP no if it cannot make energy how it will operate the pump and if this pump is not working how it will throw the sodium out sodium love to go in it is like I must say I will not say what kind of iron what kind of behavior but it loves to go in right so we have to push it out all the time out of the cell why you are smiling very naughty smile on your face all boys very bad okay sodium is just sodium ion okay so it loves to go in and we keep on pushing it out but whenever the tissue is the skimmick or hypoxic less oxygen energy producing Pathways collapse ATP deficiency develop sodium potassium 80 phases are not working sodium start accumulating in the cells and sodium will pull the water with it and cell will swollen up is that right these are like unhappy cells like making unhappy phase is that clear so these are swollen cells no energy if you don't have money how is your face

35:25 a big one in the same way when cells don't have ATP no energy they also make a big face right so hypoxia ischemia can make the cells admit a swollen this is one of the feature of cell injury then due to any other toxin if mitochondria are damaged still ATP is not produced because ATP is mainly produced through the help of mitochondria and if mitochondrial Machinery fail the ATP is not produced sodium potassium battery phases are not working again cells will undergo swelling right then any type of injury direct to the membrane remember outside the cells there is a lot of let me make a cell here a typical Cellar normally normally sell them more potassium or sodium think and then answer yes yes

36:21 normally myself have more sodium or more potassium wow that's very good cells are just bags of potassium they have a lot of potassium that is why when Crush injury is there when there is Crash injury a lot of cell rupture and potassium come out in the blood and hyperkalemia develops right but anyway come back cells are the bags of potassium and cells love to keep the sodium outside cells love to keep the sodium outside extracellularly sodium bind a lot of water with it so sodium cannot enter into cell through the simple cell membranes sodium can only enter in the cells so special transport mechanisms or channels right but whatever sodium enter into cell we must get it out we must get it out now so outside there is higher concentration of sodium and inside there is high concentration of potassium and also there's one more iron which has extracellularly in high concentration outside as compared to the inside very important okay color right but more

37:34 important than chloride calcium calcium it's very important so extracellular environment is rich in sodium and calcium and many other things of course but right now it's relevant that extracellular environment is rich in sodium and calcium intracellular environment is rich in potassium and other things now a cell normally cell membrane is not freely permeable to these sodium and calcium normally cell membranes are not freely permeable to sodium and calcium so normally sodium are trying to go in but they are repelled in the same way calcium loves to go in but it is not allowed only under special physiological functions sodium and calcium go in like sodium goes in during action potentials depolarization or calcium go in when there is some security functions but remember normally extracellular fluid is rich in sodium and calcium intercellular fluid is rich in potassium and if there is membrane damage due to any reason

38:39 whatever the reason if cell membranes are damaged in any way what will go in sodium and calcium and the sodium and calcium when when it will go in not only in toxic concentration it will hurt the intracellular Machinery but it will do one more thing it will drag the water with it and cell will start swelling so intracellular edema it may be due to impairment of sodium potassium 80 pages which fail to keep the sodium out and sodium starter being retained inside or intracellular edema may occur when generally cell membranes are damaged whatever the mechanism whatever the cause whatever etiology right then one more condition let's suppose in the cell sodium potassium 80 phases are working fine sodium potassium atps are working fine and generally cell membrane is also okay cell membrane is also ok right in this cell but due to some reason outside the cell hyponatremia develops

39:49 what is the difference of sodium concentration in the blood in the plasma and interstitial fluid some very good doctor can answer everyone cannot my question is what is the sodium concentration difference between the blood concentration of sodium and interstitial concentration of sodium here I've told you intracellular fluid very poor in sodium extracellular fluid very rich in sodium but now I'm asking a tricky question that sodium concentration difference in Blood and interstitution fluid yes ma'am uh not a normal person healthy person you think interstitial fluid is more yes ma'am you also agree with her but remember medical facts are not decided by democracy the 10 people are wrong then right become wrong Yes Man G iven same why you think it should be the same in the vasflow compartment and here because capillaries are freely permeable to sodium he is right oh my God you don't know this sodium chloride and many ions concentration in the plasma and interstitial fluid is same

41:05 because sodium is freely permeable here here it cannot freely go sodium is like men it can be on the road or it can be on the side of the road but men are not allowed to enter in every house you understand and you know why and if they have entered in under special circumstances a sodium Channel open like Windows when someone call at midnight or every day time when doorbell and special Channel sodium goes in right but if sodium goes inappropriately who throws it out sodium potassium 80 phase it comes it is kicked out is that right but sodium concentration in the cell extra in extrasal of fluid everywhere is same in the blood and interstitial fluid is same you are understanding am I clear okay but here now I was saying due to any reason if you develop hyponatremia hyponatremia mean in the blood sodium level is less it means it's pertaining to blood so when I say the person has hyponatremia what does it mean sodium concentration

42:15 in the blood is less what is the normal concentration of sodium in the blood yes only this man ah yeah he's smiling but not telling normal concentration of sodium in the blood oh no no I know you know the ions too much you are in love of electrolytes electrophilic boy 142 watt machine guns equivalent per liter okay all of you are right that when we say normal amount of sodium in the blood is 142 ml equivalent per liter but please be a good doctor tell me the range don't tell me your phone 42 the way you are telling me that normal sodium is 142 it means if I have 41 or 43 it is abnormal it is not abnormal so what is the range oh my God you I don't know you are very consistent to be wrong today sodium is sodium is 135 to 145 Milli equivalent yes

43:14 equivalents per liter or millimole per liter so why it's so important to know that lower limit is 135 upper limit is 145 because when sodium becomes less than 135 we say that patient is going to hyponatremia because hyponatremia is basically defined as amount of sodium a concentration of sodium in the blood less than 135 Milli equivalent per literally mole per liter right even though clinical problems start appearing at lower level of sodium but what I'm saying whatever sodium level is here the same level is here let's suppose someone has severe hyponatremia rapidly developing severe hypo nutrimia sodium level drop very rapidly in the blood of course they will also drop here and sodium become less sodium love to hold water if sodium is very less here inside the cell normally normally

44:18 total osmolarity inside the cell and outside the cell normally it is equal or different equal equal normally it is equal so what happens even though there are different type of ions here and there are other different type of ions here but two in total extracellular osmolarity and intracellular osmolality in physiological condition is and most of the tissue is equal but if from outside we remove the sodium so it become a hyponatremic situation right and it become hyper hyposmolar loss molality what will happen to the cells they will absorb water because cells will be hyperspolar as compared to interstitium and blood again I will repeat it if I develop rapidly hyponatremia whatever the mechanism if myosodium level in the blood is going down of course it will also go down in interstitium interstitial fluid is surrounding all the cells so all the cells have around them less than normal sodium so around the cell there's hypoosmolality and when the

45:24 hyposmolarity of course then normal similarity of the cell will be more than the surrounding fluid and it will pull the water in and cells will again swell so cellular edema cellular edema can be due to three mechanisms I told you number one I just told you now cellular edema can be due to low sodium hypo natremia or cellular swelling may be due to cell membrane damage cell membrane damage when cell membrane is damaged right sodium and calcium will jump in and water will follow and then I told you those conditions in which sodium potassium 80 phases are impaired where sodium potassium 80 pages are impaired it may be hypoxia or is chemical or whatever right so these are the conditions in which there can be intracellular adhima now we forget about the intracellular edema now we come to the real edema which most of the doctors talk about that is extra cellular edema because when in your Wards or generally when you speak with each other you say

46:40 patient as edema usually it is meant extracellular edema because if patient has intracellular edema we always mention there is intracellular edema right so now our lecture will go towards what are the causes and mechanism of extracellular Edema why excessive fluid accumulate an interstitution and or body cavities let's have a break and then we'll continue with this discussion right in previous lecture we were talking about edema right and we defined edema as how the edema was defined yes please edema was defined as excessive fluid in body tissues excessive fluid in the body tissue and then we divided edema in two types of Edema intracellular edema and extra solar edema and we discussed intracellular admires in excessive fluid inside the cells where cells are swollen especially after atps pump failure or hypoxia ischemia cell membrane injury right and then we were talking about extra cellular edema and there we discussed Excelsior edema is actually excessive amount of fluid

47:54 present in interstitium and or body serous cavities right now today we'll go into detail that of the specially extracellular edema we will talk about extracellular edema now onward in this series of lectures when I use the word edema you you should pre-assume that I am talking about extra smaller edema right so let's go for that as let's suppose here is your arterial system here was your left heart right and you know left heart is pumping in the body it's left heart not anything else right with the aorta

48:39 and let's suppose here is an arterial system coming out this is representing let me make a piece of tissue here let's suppose this is a piece of tissue and this is the arterial input into this tissue right you know our artery is divided into arterials and then met arterial then eventually into capillary Network and here is the venous output from that specific tissue which we have put it over here and here is your guess micro circulation I'm going to make micro circulation here in between the arterial end and the when ascent

49:34 okay so in this specific tissue this is arterial end of the micro circulation and here is the venous end of the micro circulation and here is your micro circulation and let's suppose here are your parenchymal cells right these are parenchymal cells and these are of course what are these cells endo thelial cells right along with the basement membrane and the capillaries and venules and the blood which is draining from the tissues eventually going to Major veins which will eventually drain into right heart right they will drain into right heart which will itself eventually drain into lungs right and now this is pulmonary dishes tell me pulmonary artery and here is the pulmonary veins and in between them there is pulmonary micro circulation right you shouldn't go out of the lung now as we were discussing yesterday that when we talk about interstitial edema this is the area which is interstitium is basically area which is outside the circulation and also outside the

51:05 parenchymal functional cells right when we say that there is an interstitial edema it means a demise in this area right and as we Define that there is excessive fluid in the interstitution when there's edema but normally there is some fluid in the interstitium in a man with 72 kg weight usually how much interstitial fluid is there yesterday we discussed that is around 10 to 11 letters right but if interstitial fluid become excessive in all over the body or in a localized area we say there is edema now what is the function of interstitial edema or sorry what is the function of the interstitution and what is the relationship of interstitial fluid with the plasma fluid or blood fluid that is first thing to understand because let's suppose we say that there should be 10 liter fluid present in this area but do you think this fluid is static or dynamic is it always there or it keep on changing yes ma'am just keep on changing what normally happen that all the time okay I am dividing this

52:29 micro circulation and venous side of the micro circulation now what normally happens all over your body from arterial side of the micro circulation fluid is coming out constantly fluid is coming out and this fluid is bringing the oxygen and in glucose and other nutrients and this fluid is serving these cells that's why they are so happy oxygen is coming glucose is coming amino acids are coming and many other things and then this fluid goes back from this area right it's coming serving these cells right washing these cells providing them the nutrients and removing their waste product and then this fluid let's suppose come here comes here and then goes back right all your capillaries in all your tissues a small amount of fluid is coming out serving the cells and removing the waste product and going back this is what is a normal mechanism right Plus sometimes usually a very small amount of protein leak out not much

53:43 a very small amount of protein also leak out which cannot be pulled back here that small amount of protein along with some small amount of fluid is drained by an other pathway and that is called lymphatics it means that most of the fluid about 80 to 90 fluid which comes out from arterial side of micro circulation adds to interstitium and constantly being sucked back into innocent of the micro circulation and about 10 to 15 percent fluid along with proteins these are proteins it is being drained into lymphatics it is being drained into lymphatics but remember all lymph fluid eventually drains back into yes venous system you know all the lymph of the body eventually drain through the thoracic duct system into subclavian internal jugular Venus system so in a way hypo we can say that in a typical tissue the fluid input is by arterial site and fluid output is mainly by the venous side and also there is an accessory pathway an additional pathway for fluid

55:06 draining through the lymphatics but both of these eventually go back to the winner system is that clear now how the edema will fall how the edema can be made how this fluid suddenly become too much it's very easy to understand I don't know why they teach in medical Sciences it's so easy it's very simple either too much fluid is coming from here some if more than normal fluid is too much fluid come here and then edema will occur or this refused to take the fluid back it is not sucking the fluid back again fluid will accumulate or lymphatic system is not working again fluid will accumulate these are three basic mechanisms even though for edema there are more mechanisms too but let me tell you three basic mechanisms we will get other four basic mechanisms first of all when fluid is trying to come out it has to pass through what is this capillary capillary membrane which is semi-permeable membrane a fluid has to come out it has to pass through

56:13 capillary membrane now how much fluid will be coming here how much fluid will be coming here it depends on multiple factors including the capillary membrane features if capillary membrane is damaged too much fluid will come if this membrane is damaged from inside too much fluid will come so we can say that in a general concept why edema should be their interstitial edema very simple either more fluid is coming to this tissue or less fluid is draining on the venous end of the micro circulation or less fluid draining into in fact they are so simple or there is increased permeability of micro circulation right so how many things I mentioned either more fluid coming out through micro circulation number one mechanism number two or there is decreased reabsorption of fluid number

57:15 two mechanism number three or there is decreased lymphatic drainage number three mechanism or overall in the body salt and water is too much I will explain the mechanism later if body retains excessive salt and water not only excessive fluid will be here it will also come here so that will also add to the edema and eventually if permeability of this membrane is increased pathologically then excessive fluid will also leak out any question up to this everyone is clear so now first of all I will talk about why in some disease condition fluid is excessively coming out but before really we go into that condition we will talk about normal physiological mechanisms I will tell you how in a normal healthy person and a healthy tissue how this fluid movement out and back is regulated what are the factors which push the fluid out and what are the factors which reabsorb the fluid because when those factors are Disturbed edema will occur you are understanding

58:30 now what are the factors normally first of all when heart is pumping left ventricle it is pushing the blood into whole body circulation with pressure the pressure which is generated by pumping of the heart that pressure is called hydrostatic pressure normally you call it blood pressure right and of course as blood is moving forward and it divides into different arterial tree and arterioles and smaller hydrostatic pressure will keep on dropping is that right from here the blood is pumped with pressure heart is pumping the blood in the tissues with pressure but as it is moving forward pressure will drop is that right but in a typical tissue in a classical tissue for example we are taking this example the hydrostatic pressure is let's suppose 35 millimeter of Mercury so I will just write it here this is hydrostatic pressure what is this in the normal tissue this hypothetical tissue which I am showing here it has pressure of 35 millimeter of mercury now

59:39 if fluid is under pressure here and heart is pushing Under Pressure it will love to go out it will love to go out so it means outward pressures is how much 35 millimeter of mercury it is trying to push the fluid on both directions outside but there is something which holds the fluid in normally hydrostatic pressure is trying to push the fluid outward but there is something which is not Pusher you can say hydrostatic pressure in the vascular system right hydrostatic pressure is little here but hydrostatic pressure here and osmotic pressure here I will ignore in this discussion because there are minor factors major factor here which are mentioning hydrostatic pressure inside the micro circulation on the arterial side of the

1:00:40 vessels now to 35 millimeter mercury and with this 35 millimeter mercury it is trying to push the fluid outward but there is something which is not Pusher this pressure we can say is Pusher it is pushing the fluid outward Whenever there is a pusher there must be a sucker or at least holder why you laugh at sucker I'm not talking about that sucker which is coming to your mind sucker means suck the fluid back okay so what we are talking about there's a hole okay I will not use the word holder uh sucker I will use the word holder plasma proteins you know plasma proteins in this plasma there are certain proteins which are globulins and albumins and fibrinogen but classically albumin that plasma protein has a power to retain the fluid plasma protein is the power to hold the fluid they hold the water hydrostatic pressure is trying to get the water out and osmotic pressure osmotic pressure which is exerted by the plant presence of

1:01:49 plasma protein especially albumin that is trying to hold the water Within circulatory compartment and osmotic pressure which is determined by the plasma protein that is usually 25 millimeter of mercury that is trying to hold the fluid and what it is doing it is trying to keep the water inward it is trying to keep the water inward now we can see that hydrodynamic forces which will eventually determine the movement of the fluid here is determined by the balance between do these two forces this is acting as a pusher and this is acting as a holder or sucker so power outward is 35 power invert is 25 so fluid will move outward or inward outward so net pressure the difference is net outward pressure is 35 minus 25 so this is the pressure with which fluid will be coming out right and this is 10 millimeter of mercury so we can say in a normal tissue on arterial end of the micro circulation with the net filter out pressure what we can say filtration pressure what is this

1:03:17 filtration pressure forces out the fluid along with its dissolved components through the semi-permeable membrane from the intravascular compartment to the interstitial compartment with the net filtration pressure of 10 millimeter of mercury I will repeat it that usually tissue to tissues to tissues these values little vary we are taking a typical tissue and a typical tissue on the arterial side of the micro circulation hydrostatic pressure is about 35 millimeter of mercury and Collide osmotic pressure is 25 millimeter of mercury okay we call Collide osmotic pressure or some books right on cortic pressure what is the difference in Collide osmotic pressure and oncotic pressure just please they are the same

1:04:14 okay just a minute collide collide osmotic pressure right this is one term versus oncortic pressure on cortic pressure what is the difference in them before you tell me any difference there is no difference they are one and the same thing ah Collide osmotic pressure Collide osmotic pressure which is determined by the plasma proteins that is also called just on cortex pressure but if there is Collide osmotic pressure due to proteins in the interstitial tissue that is not called oncotic pressure actually when colloidal molecules like plasma proteins because when fluid is going out plasma proteins cannot go out so what plasma proteins will do try to hold the water for example if husband is going to the other country if wife cannot go she will try to hold the husband don't go that is an example of collide osmotic pressure but maybe Financial pressures are there he has to go do you get it now what I'm trying to say that could Collide osmotic pressure simply mean that osmotic pressure

1:05:30 determined by the colloidal molecules but when we use the term on cortic pressure when we use the term oncortic pressure it means Collide osmotic pressure produced due to plasma proteins interstitial proteins also exert some Collide osmotic pressure but that is not called oncotic pressure am I clear so now onwards in our discussion I may use the term Collide osmotic pressure or may use the term only osmotic pressure or I may use the term oncotic pressure so it is one of the same thing in our discussion forward so we decided that on this side fluid will gradually come out slowly and will come to the tissue circuit but what really happens as some fluid has lost but intravascular fluid is moving to the venous end it is moving forward hydrostatic pressure will drop why it will drop because micro circulation as it moves from arterial and to the pill venous end it becomes white bore diameter its total cross-sectional area increases right so naturally pressures will

1:06:46 drop if there is some pipe if suddenly you expand it pressure inside will decrease so here pressure decreases and on this side this on hydrostatic pressure usually become only 15 millimeter of Mercury and but plasma protein osmotic pressure or oncotic pressure remains almost same because proteins did not leak the amount of protein which was here and amount of protein which is here is almost same so osmotic pressure Remain the same is that right but hydrostatic pressure here it was 35 and here it is 15 so it means now hydrodynamic mechanisms shift a little point actually when a some amount of fluids seep out filter out plasma protein become a little concentrated and when plasma proteins become little concentrated on cortic pressure become little more rather than 25 it may become 27 or 28 but for our discussion we will not go into that detail we just assume as fluid is moving in micro circulation on arterial and it is losing the

1:08:00 fluid is that right cells especially red blood cells and what platelets they are not coming out only leukocyte under certain circumstances they come out and plasma proteins are not mainly going out most of the plasma proteins are retained here very little plasma proteins leak out which will be taken back through lymphatic system is that clear now look at the Bella hydrodynamic forces balances here these forces are also called Starling forces right what is the balance here now 25 is the polar 25 is the puller or we can say sucker it is trying to suck the fluid and Pusher is very weak it is only 15. so what will be the net effect it will pull the fluid from here backward because net difference 25 is pulling in 15 is just like 25 men pulling a person Inward and 15 pushing it outward still this man will move inward so fluids slowly start going back right and net filtration pressure is now inward here net filtration pressure was outward so under the 10

1:09:16 millimeter of mercury diff right fluid was filtering out on our arterial side of micro circulation and here at almost 10 millimeter mercury fluid was being sucked back or reabsorbed back right but a small amount of protein which was leaking from here a very small amount of protein which leaked from here it cannot be sucked back they are larger molecules and some cellular debris or even microbe so they will be drained through this pathway this is our secret pathway lymphatic is a additional or secret Pathway to drain the protein-rich fluid is that clear this is very important that don't allow these small amount of proteins which are leaking here to stay here it should not stay here it should be taken back because if this proteins keep on coming here and they are not drained they accumulate here those proteins will increase the osmotic pressure here and they will start holding the water and produce edema now these are the normal basic mechanisms right so

1:10:25 what are the factors which determine the pre amount of fluid in interstitial tissue interstitial area number one hydrostatic pressure it determines how much fluid will go out on this side osmotic pressure or oncotic pressure which determines how it will be pulled back and then lymphatic drainage is that another way to look at it that this side of circulatory system we can say for fluid intravascular fluid it is pusher and this side of the circulation at other reabsorb ping mechanism or suckers here's The Pusher and here is the sucker right in every tissue you have a pusher and you have a sucker I hope you'll remember that there is a pushing mechanism and there is a suction mechanism not sucking mechanism right now let's suppose we disturb these mechanisms let's suppose we disturb these mechanisms and see how a remarker I will go in detail later but just I will mention the mechanisms let's suppose due to any reason hydrostatic pressure increases here due

1:11:36 to any reason hydrostatic pressure increases here if there is increased hydrostatic pressure in the micro circulation what will happen just imagine just imagine due to in one person there is sphere arterial or dilation arteries dilate and too much fluid enter here this pressure will be 35 or it will go up it will go up or it is normal but this venous outflow is reduced due to any mechanism which we close this or due to any reason blood cannot go back to venous system easily right if for example there is a thrombus here if blood cannot go out easily and some of it is not going out what will happen to hydrostatic pressures here increase so if due to any reason if there is increased hydrostatic pressure in micro circulation let's see what happen let's suppose hydrostatic pressure has addition of 20 what millimeter of mercury here and of course 20 millimeter of mercury here now rather than 35 how much is it 50 okay don't do that much let's put it only 10.

1:12:57 we increase the pressure of 10 here and we increase the pressure of 10 here now it is how much 45 and it is still 25 so pressure outward filtration out pressure will decrease or increase it will become double and it will become 20 millimeter of mercury when hydrostatic pressure increases here either due to arteriologation or due to venous increase the resistance to the venous outflow when hydrostatic pressure increases here right the result will be yes filtration out will be more and on this side look at it if this is also rather than 15 10 is added 25 now osmotic is 25 and it is also 25 do you think it can act as a sucker can it suck no so what will happen excessive amount of fluid is coming into interstitium on the but venous side is unable to reabsorb the fluid properly so too much fluid is coming out but not going back so there is excessive fluid arriving here is that right if excessive fluid is arriving here what will happen then yes

1:14:18 before the edema develop let me tell you something very important lymphatics they increase their capacity to drain lymphatics can increase their capacity to drain the fluid so as pressure keep on increasing here filtration pressure net filtration out pressure increases net filtration out fluid increases reabsorption fluid decreases whatever extra fluid is coming it will not produce edema immediately first initial fluid that will be drained through this this will increase its power to drain but it is a limitation when fluid coming out becomes so much that lymphatics are overwhelmed when fluid coming out due to increase hydrostatic pressure becomes so much that lymphatic in spite of increasing their draining capacity they still cannot drain all additional fluid if they cannot drain all additional fluid then fluids start accumulating here and edema develops and what develops interstitial edema develop so first mechanism of interstitial edema I told you that when there is increased

1:15:33 hydrostatic pressure increased hydrostatic pressure now the second mechanism of Edema I will go into detail later what are the diseases and condition in which hydrostatic pressure goes up but right now just Basics now we imagine another person let's suppose hydrostatic pressure is normal how much it should be here 35 yes normal and if it is normal how much it should be 15 millimeter of mercury let's suppose due to some reason those reasons we'll talk later due to some reason concentration of plasma proteins drop what is the normal uh uh yes what is the normal concentration of plasma proteins anyone from this row yes yes please what is the normal concentration of plasma proteins yes

1:16:38 8.5 watt tanks tank for what we can mention plasma protein levels in two ways total plasma proteins you can say it is 6 to 6.02 8.0 uh grams per decilator or we can say six to eight grams per 100 ml deciliters 100 mm or we can say 60 to 80 grams per liter your understanding because 10 deciliter is equal to one letter so in some books because I don't want you to be confused some books mentioned it is six to eight grams per deciliter or other books mentioned 60 to 80 grams

1:17:27 per liter what but it's one and the same thing total plasma protein but out of total plasma protein as you know that there are three types there are many types of plasma proteins but three are very important number one albumin albumin number two very good globulin number three fibrinogen right and there are many others but I will not go into detail albumin normal level are how much yes albumin three point three to five point 5 or maximum 5 grams per DL or per 100 ml globulins are 1.5 to 2.5 grams per Dr fibrinogen is 0.252 point five grams per deal but right now what I want to tell you out of these proteins if you take the total proteins present here right they are usually six to eight grams per 100 ml of the plasma right is clear out of this most abundant protein is albumin it's the maximum less than albumin there is globulin and less than globulin there is fibrinogen now because the albumin is most abundant in the blood and number of molecules of

1:18:53 albumin are smaller so albumin is the main protein which determines the osmotic pressure so who is the main sucker or a holder of the water I must use holder of the water I'll be a man even though uh holding power of water here is determined mainly by the women and to some extent by the other proteins now normal person normal healthy person must have six to eight grams proteins in the blood or 60 to 80 grams per liter proteins now if someone has due to any disease condition in his blood proteins level go down if someone has a problem we'll talk later either proteins cannot be synthesized or they are lost out of the body excessively we'll discuss it later but for a while we just imagine that I'm suffering with the disease in which plasma level of proteins go dangerously down right a women become very low if albumin concentration become very low what do you think this osmotic pressure will remain same or it will become less less so let's suppose due to low

1:20:09 osmotic pressure become only 15. now hydrostatic pressure is normal but osmotic pressure of the protein they have gone down or on Plasma on cortic pressure has gone down due to hypoproteinemia low protein level or to be more specifically we can say hypo album anemia so those diseases in which in the blood albumin level goes down or the severe hypovolevinemia proteinemia then plasma proteins ability to hold the water in circulatory system is less osmotic pressure is less than what will happen now in this case even though hydrostatic pressure is 35 but it is not 25 it is 15. so filter out pressure is again double so in this patient previously we had a patient in which hydrostatic pressure here was high but also oncotic pressure was normal previously and still extra fluid was coming and less fluid was absorbing and extra which was draining full lymphatic if it couldn't be drained fully then it will accumulate and produce edema now we discuss another

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