Failure of the lymphatic system due, for example, to occlusion by infectious organisms (as in the disease elephantiasis)

allows the accumulation of excessive interstitial fluid. The result can be massive swelling of the involved area (Figure 12–
48). The accumulation of large amounts of interstitial fluid from whatever cause (others are described in later sections)
is termed edema.

Heart failure is a condition in which elevated venous pressure backs up into the capillaries, and the elevated hydrostatic
pressure (Pc) causes filtration to occur faster than the lymphatics can remove interstitial fluid. The resulting edema can
occur in either systemic or pulmonary capillary beds, as will be discussed in an upcoming section.

A more common experience is the swelling that occurs with injury, for example, when you sprain an ankle. Histamine,
and other chemical factors released locally in response to injury, dilate arterioles and thus elevate capillary pressure
(review Figure 12–43) and filtration. In addition, the chemicals released within injured tissue cause endothelial cells to
distort, increasing the size of intercellular clefts and allowing plasma proteins to escape from the bloodstream more
readily. This increases the protein osmotic force in the interstitial fluid (IF), adding to the tendency for filtration and
edema to occur. Finally, an abnormal decrease in plasma protein concentration also can result in edema. This condition
reduces the main absorptive force at capillaries (p), thus allowing an increase in net filtration. Plasma protein
concentration can be reduced by liver disease (decreased plasma protein production) or by kidney disease (loss of
protein in the urine). In addition, as with liver disease, protein malnutrition (kwashiorkor) compromises the manufacture
of plasma proteins. The resulting edema is particularly marked in the interstitial spaces within the abdominal cavity,
producing the swollen-belly appearance commonly observed in people with insufficient protein in their diets.

Disease states that alter the Starling forces can result in edema; e.g., heart failure, tissue injury, liver disease, kidney
disease, and protein malnutrition.

Hydrostatic edema refers to accumulation of excess interstitial fluid which results from elevated capillary hydrostatic
pressure while permeability edema results from disruption of the physical structure of the pores in the microvascular
membrane such that the barrier is less able to restrict the movement of macromolecules from the blood to interstitium.
Lymphedema represents a third form and may result from impaired lymph pump activity, an increase in lymphatic
permeability favoring protein flux from lumen to interstitial fluid, lymphatic obstruction (e.g., microfiliarisis), or surgical
removal of lymph nodes, as occurs in the treatment of breast cancer.