Congestion
S.No. Contents
1. Definition
2. Introduction
3. Types of Venous Congestion
4. Etiology
5. Pathogenesis
6. Sign and Symptoms
7. Effects and complications
8. Diagnosis
9. Treatment
10. Prevention
11. Complications and associated conditions
12. Summary
13. Reference
Congestion (Passive Hyperemia)
Definition
The dilatation of veins and capillaries due to impaired venous drainage results in passive hyperemia or venous congestion, commonly referred to as Passive Hyperemia.
Introduction:
Congestion is the passive process resulting from decreased outflow of venous blood, as occurs in congestive heart failure ( Passive hyperemia is when blood can’t properly exit an organ, so it builds up in the blood vessels. This type of hyperemia is also known as congestion. Congestion is a pathological term referring to reduced blood flow out from tissues, which may be localized or systemic.
Congestion may be Acute or Chronic, the latter being more common and is called Chronic Venous Congestion (CVC). The affected tissue or organ is bluish in colour due to accumulation of venous blood (cyanosis). Obstruction to the venous outflow may be local or systemic.
Types of Venous Congestion
Accordingly, venous congestion is of 2 types:
Local venous congestion
Systemic (General) venous congestion
1. Local venous congestion
Local venous congestion results from obstruction to the venous outflow from an organ or part of the body e.g. portal venous obstruction in cirrhosis of the liver, outside pressure on the vessel wall as occurs in tight bandage, plasters, tumours, pregnancy, hernia etc, or intraluminal occlusion by thrombosis.
2. Systemic (General) venous congestion
Systemic (General) venous congestion Is engorgement of veins e.g. in left-sided and right-sided heart failure and diseases of the lungs which interfere with pulmonary blood flow like pulmonary fibrosis, emphysema etc. Usually the fluid accumulates upstream to the specific chamber of the heart which is initially affected. For example,
• In left-sided heart failure (such as due to mechanical overload in aortic stenosis, or due to weakened left ventricular wall as in myocardial infarction) pulmonary congestion (or CVC lungs).
• Whereas in right-sided heart failure (such as due to pulmonary stenosis or pulmonary hypertension) systemic venous congestion (i.e. CVC of systemic organs).
Etiology
Congestion has many causes, which may be localized or systemic. These include;
• Localized:
o Extrinsic compression of a vein
o Stenosis of a vein
o Vasoconstriction
o Vasculitis
• Systemic:
o Congestive cardiac failure
o Renal failure
o Hepatic failure
• Mitral stenosis, a type of heart disease
• A Blockage in a blood vessel
• A kink in a vein
• Pneumonia
• Thrombosis
Medication for Congestion causes may include:
• Beta-blockers to lower blood pressure
• Digoxin to strengthen the heartbeat
• Blood thinners
Another cause of passive hyperemia is the inability of the heart to pump blood efficiently, causing a buildup of too much blood in areas leading to the heart.
In right-sided heart failure, the blood backs up into the liver. In left-sided heart failure, the blood backs up into the lungs.
Heart failure or ventricular failure; The left and right ventricles are the two main pumping chambers of the heart. The right ventricle pumps blood to the lungs, and the left ventricle pumps oxygen-rich blood to the body. When the heart can’t beat well enough to push blood through the body, blood begins to back up. This backup causes swelling, or congestion, in organs like the liver, lungs, spleen, and kidneys.
Right-sided heart failure
• If the problem is on the right side of the heart, it can cause congestion in the liver, spleen, kidney, or leg. This can lead to what is known as “nutmeg liver” due to the mottled pattern that appears on the liver. Over time, this can cause cirrhosis, which is scarring caused by long-term liver damage and can ultimately lead to liver failure and death.
Left-sided heart failure
• The lungs are more likely to be affected if there is a problem with the left side of the heart. The lungs will appear dark red and there may be excess fluid in the lungs. Heart failure in one side can eventually lead to failure in the opposite side as well.
Deep vein thrombosis (DVT). DVT is caused by a clot in one of the deep veins — often in your lower legs. The clot can break free and get lodged in a vein in your lung, called a pulmonary embolism.
Hepatic vein thrombosis (HVT), also called Budd-Chiari syndrome. HVT is a blockage in the veins of the liver caused by a blood clot.
Pathogenesis
Two mechanisms have been proposed for the pathogenesis of venous congestion in ADHF: fluid redistribution and fluid accumulation.
• The former is a primarily vascular pathway in which increased systemic resistance leads to increased afterload. Simultaneously, this leads to reduced capacitance in large veins, increased venous return to the heart, and increased preload. This mismatch between increased load and impaired cardiac function cannot be tolerated by the failing heart, ultimately leading to clinical decompensation.
• In the latter pathway, fluid progressively accumulates in the setting of cardiorenal dysfunction, leading to increased total body volume and venous congestion. In addition, medication and dietary non-compliance may cause increased sodium and water retention. Accumulating evidence suggests that venous congestion begins to develop weeks before the overt clinical decompensation that brings patients to medical attention, suggesting that it may itself be a primary contributor to disease in Acute decompensated Heart Failure (ADHF) than merely a consequence of poor cardiac function
Sign And Symptoms
Passive hyperemia affects the tissue differently and has the following symptoms:
• dark blue or red tinge
• swollen
• cooler than usual to touch
• in chronic cases, brown in color
• redness
• warmth
Other symptoms depend on the cause of the problem.
Heart failure symptoms include:
• shortness of breath
• coughing or wheezing
• swelling in the belly, legs, ankles, or feet caused by fluid buildup
• fatigue
• loss of appetite
• nausea
• confusion
• fast heartbeat
DVT symptoms include:
• swelling and redness in the leg
• pain
• warmth
HVT symptoms include:
• pain in the upper right side of your abdomen
• swelling in your legs and ankles
• cramps in your legs and feet
• itching
Effects And Complications
The type of hyperemia a person has will determine what kind of complications may occur.
For example, acute local active hyperemia may be a sign of inflammation. Acute local passive hyperemia could be due to intestinal or uterus torsion.
Chronic local passive hyperemia could indicate that tumors or abscesses are developing in the body.
Passive hyperemia or congestion, is linked to heart problems and will affect different organs in the body depending on which part of the heart is affected.
Diagnosis
Your doctor will take your personal and medical history, along with noting your symptoms. They may also perform a physical exam and take your vital signs like your heart rate, blood pressure, oxygen levels, and temperature.
Depending on the type of congestion, your doctor may or may not perform tests. .
Congestion or Passive hyperemia can be diagnosed by other symptoms like:
• Shortness of breath
• Chest pain
• Coughing or wheezing
• Swelling in the limbs and belly
• Nausea
• Pain
• Itchiness
If these symptoms occur along with variations in your vital signs, your doctor may also order:
• Blood tests
• Ultrasounds
• Exercise stress test
• Imaging tests
Doctor will use these to check the health and structure of arteries, veins, and the heart.
Treatment
Active hyperemia is a healthy response to your body’s natural functions. While you may need to treat the underlying conditions that can cause hyperemia (injury, fever, inflammation), it's not usually anything to worry about.
The treatments for passive hyperemia are more extensive and may involve significant lifestyle changes. These can include:
• Diet changes
• Increasing exercise
• Weight loss
• Stopping smoking
Medical treatments can include:
• Blood thinners
• Beta-blockers
• Statins
• Stents
Congestion itself isn’t treated, because it’s just a sign of an underlying condition.
Causes of passive hyperemia can be treated. Doctors treat heart failure by addressing the cause of the disease, such as high blood pressure and diabetes.
Treatments include:
• a heart-healthy diet
• exercise
• weight loss, if you’re overweight
• medicines such as ACE inhibitors and beta-blockers to lower blood pressure, or digoxin to strengthen your heartbeat
DVT is treated with blood thinners such as heparin or warfarin (Coumadin). These drugs stop the blood clot from getting bigger, and prevent your body from making new clots. If these drugs don’t work, you might get clot-busting drugs called thrombolytics to quickly break up the clot. You can also wear compression stockings to stop the swelling in your legs from DVT.
HVT is also treated with blood thinners and clot-busting drugs. You might need medication to treat liver disease, too.
Prevention
Active hyperemia is a beneficial response to help the body obtain oxygen and nutrients.
Passive hyperemia is closely associated with heart failure. There are several lifestyle changes people can make to avoid this:
• eating a heart-healthy diet
• exercising regularly
• losing weight if overweight
Complications And Associated Conditions
Congestion itself doesn’t cause complications. Conditions that cause congestion can have complications like:
• heart valve problems
• kidney damage or failure
• heart rhythm problems
• liver damage or failure
• pulmonary embolism — a blood clot that becomes lodged in a blood vessel in the lung
Outlook And Prognosis
The outlook depends on the cause of increased blood in the blood vessels;
Heart failure is a chronic condition. Although you can’t cure it, you can manage its symptoms with medication and changes to your lifestyle. DVT can be treated, but you’ll need to watch for symptoms because it can come back in the future.
Summary
CONGESTION The dilatation of veins and capillaries due to impaired venous drainage results in passive hyperemia or venous congestion, commonly referred to as congestion.
Types: Congestion may be of 2 types:
• Acute congestion or
• Chronic congestion – this being more common and is called Chronic Venous Congestion(CVC) In CVC the affected tissue or organ is bluish in colour due to accumulation of venous blood (Cynosis)
Passive congestion:- Mechanical obstruction due to thrombosis of veins of lower legs. Vericosities Pressure by pregnant uterus.
CVC: Obstruction to the venous outflow may be local or systemic
Types: Accordingly, venous congestion may be of 2 types:
• Local venous congestion: Results from obstruction to the venous outflow from an organ or part of the body - e.g. portal venous obstruction in cirrhosis of the liver, pregnancy, hernia, thrombosis
• Systemic venous congestion: Is engorgement of systemic veins, e.g. - left-sided and right-sided heart failure - diseases of the lungs which interfere pulmonary blood flow, such as Pulmonary fibrosis Emphysema.
Etiology of Congestion: Congestion has many causes, which may be localized or systemic. These include;
Localized: Extrinsic compression of a vein, Stenosis of a vein, Vasoconstriction.
Systemic: Congestive cardiac failure, Renal failure, Hepatic failure.
Pathogenesis: Congestion is developed into two manner; The former is a primarily vascular pathway in which increased systemic resistance leads to increased afterload. In the latter pathway, fluid progressively accumulates in the setting of cardiorenal dysfunction, leading to increased total body volume and venous congestion.
Sign And Symptoms: Coughing or wheezing, swelling in the belly, legs, ankles, or feet caused by fluid buildup, fatigue, loss of appetite, nausea, confusion
Diagnosing Congestion: Your doctor will take your personal and medical history, along with noting your symptoms. They may also perform a physical exam and take your vital signs like your heart rate, blood pressure, oxygen levels, and temperature.
Reference:
1. Harsh Mohan Textbook of Pathology, 7th edition.
2. Vascular Disorders and Thrombosis.
3. Congenital Heart Defects
4. Guyton and Hall Textbook of Medical Physiology
5. Jacc; Cardiovascular Interaction.
6. Derek A. Mosier, in Pathologic Basis of Veterinary Disease (Sixth Edition), 2017.
7. Vinay Kumar, Abdul K. Abbas, Jon C. Aster. Robbins and Cotran Pathologic Basis of Disease (2014).
Author: mHñ Asif Gaho
mhasifaligaho@gmail.com, mHñ Asif