hey guys it's medicosusperfxnetis where medicine makes perfect sense continuing our playlist called labs in the last video we talked about the nitrouretic peptides such as a and p b and p and c p today it's time for a topic that used to drive me crazy the serum society's albumin gradient or s-a-a-g put differently what is the cause of your assighties with that said now let's get started this is my labs playlist on youtube and today's video is video number 21. you will never understand the serum aside is albumin gradient without a robust background in physiology so let's go your total body water makes about sixty percent of your total body weight two-thirds of this water is in your intracellular fluid inside your cells one third is in the extra surface which means outside the cell this extracellular fluid is present in plasma interstitial space and transcellular which includes the three p's your cerosal cavities the pleura pericardium and peritoneum never ever forget this so the fluid in your perigeum is part of the ecf but humidicus hobo the fluid inside my red blood cells say it again red blood cells yeah these are cells so the fluid inside of them is still intracellular fluid however the fluid in the plasma is extra serve fluid the fluid is in the interstitium is exerted fluid the fluid in your peritoneal cavity is extracellular fluid most of the proteins are intracellular few proteins are extracellular of those extracellular proteins most of them are in the plasma that's why you call them plasma proteins the hero of this is the albumin so what the flip is edema edema is accumulation of fluid in the interstitial space another way of saying the same thing is when your fluid leaves your capillaries and goes to your interstitial space and now you will be swollen like an older beast this swelling is called edema the fluid that leaves the capillaries and goes to the interstitial space aka the fluid of edema could be an exudate or a transdate what causes the exudate increased capillary permeability basically inflammation what causes a transudate increased capillary hydrostatic pressure which is the pressure that pushes fluid from the capillary to the outside or decreased capillary oncotic pressure which is the pressure that pulls the fluid towards the inside so you either increase this one or decrease this one in either case fluid will leave your capillaries and goes to your interstitial space hashtag edema what causes increased capillary hydrostatic pressure basically too much fluid volume in the capillary but what causes decreased capillary oncotic pressure loss of albumin because albumin pulls towards the capillary when you lack albumin the fluid is going to leak to the outside which is edema so now i have acute inflammation and fluid is leaving my capillaries and going to the outside is this edema absolutely exudate or transdate exudate is it due to increased capillary permeability or increased hydrostatic pressure or decrease on current pressure it's due to increased capillary permeability can it have pus absolutely is it pitting no it's not what is oozing from the kepler to the outside water and proteins and as you know proteins do not pit you cannot make a dent in a protein and that was the first story second story is your patient with congestive heart failure what happened your heart has failed your heart has failed your heart cannot pump blood or your heart cannot receive blood either way fluid is gonna pile up and accumulate before the heart so if this is the right side of the heart and the right side of the heart is toast it has failed now fluid is gonna pile up here in the ivc and the tributaries of the ivc including the liver will this lead to swelling absolutely this is edema exudate or translate transdate you know why because this is increased capillary hydrostatic pressure back up pressure back of pressure back up pressure it's going to pile up here called cardiac cirrhosis it's going to pile up in your abdominal cavity called ascites third story or stories here we have patients with low proteins in the blood or low albumin why is this maybe i'm not eating enough proteins quash your core maybe i'm not making proteins liver disease or liver failure or maybe i'm eating i'm making but i'm losing protein like crazy who's losing your protein blame the gut or blame the kidney when you blame the gut it could be malabsorption syndrome a problem in your intestines or a protein losing gastropathy aka minutes real disease a problem in your stomach blame the kidney protein losing nephropathy akan frotic syndrome in all of these cases your plasma proteins is low serum albumin is low do you get edema absolutely exhaust or translate transudate is it due to increased hydrostatic or decreased oncotic decrease on chronic pressure because you lost the source of the oncotic pressure hashtag albumin for more info about exudate versus strange day check out this video about the plural effusion it's in my pulmonology playlist are you ready for some questions let's go please answer exudate or translate left-sided heart failure causing pulmonary edema what do you think the answer is this is a transdate next quash your core causing edema is this a transdate or exudate the answer is trench date number three severe liver disease such as cirrhosis i'm not making any albumin decrease oncotic pressure causing edema x-date or trans-date this is a transit date also cirrhosis can lead to portal hypertension which is also a trend date nephrotic syndrome causing edema a trench date military is disease causing edema triangulate male absorption syndrome causing edema also a trans date pause and review how about acute chest syndrome exudate pneumonia causing empowerment exudate tuberculosis causing empiena exudate lung abscess exudate bronchiectasis exudate primary myelofibrosis too many cells exudate pause and review how about dvt causing pulmonary problems and pleural effusion exudate asbestosis exudate lupus exudate rheumatoid arthritis exudate lung cancer exudate metastatic breast cancer exudate pause and review let's talk about cirrhosis of the liver why do i have anxieties in cases of cirrhosis there are two reasons both of which are transgenic by the way it could be you have portal hypertension too much pressure in your vessels leading to increased hydrostatic pressure that's a trench date and when you increase hydrostatic pressure what's going to happen the fluid is going to leave the vessel and go to the interstitial space moreover you have cirrhosis that's right your liver is toast that's true you cannot make albumin anymore oops the oncotic pressure is gonna drop like a rock also a transudate so why do we have ascites and cirrhosis due to increased hydrostatic pressure and decreased oncotic pressure at the same time but hemorrhoids miliary tb can cause ascites that's right cancer also can cause a scientist that's right liver abscess can cause a sinus that's true pancreatitis can cause asylum that's right cerosities can cause a sinus that's right all of these causes are an exudate that's true so how can i tell the difference then how do i know that the anxieties was caused by increased capillary permeability increase capillary pressure or decrease capillary on cardiac pressure how can i tell this is the story of the serum society's albumin gradient now it's all gonna make sense your blood is made of plasma and cells the plasma is water and proteins the proteins are albumin and some globulins let's say that medicosis has ascites so now there is albumin inside of my blood vessels called the serum abdomen and there is albumin in my acidic fluid known as ascites albumin which compartment has more albumin is it the serum compartment or the interstitial fluid compartment and the answer is the serum compartment always has more albumin so here is your serum we start with the serum aside is we end with ascites albumin i'll do in each one gradient there is a minus here so the serum aside is albumin gradient is the album in the serum minus the albumen in the ascites and since the serum albumin will always be greater than your aside his albumin the result of the gradient is always a positive number so if you come to me and say hey midakosis the patient has an saag of negative two i'll kick your gluteus maximus metaphorically speaking there is no such thing so let's say that my serum albumin is four my society's albumin is two can you get me the gradient four minus two the saag is now two let's talk about what happens in transdate and then we'll discuss the x date translate what's happening oh what's happening is that fluid is leaving your blood and going to the extra serofluid in this case it's the peritoneal cavity what is in the trench date water do you have proteins that has shut up no proteins in the change date just water so when water leaves that serum and goes outside what's gonna happen to the albumin in the acidic fluid and since you're adding water on it it's gonna get diluted and will decrease but what do you think is gonna happen to the albumin in the serum as water is leaving this album is getting more concentrated that's true serum albumin concentration will go up what do you think is going to happen to the gradient when the serum albumin goes up and the ascites albumin goes down the gradient is going to widen well no duh and that's why the serum albumin asides gradient is greater than 1.1 if this is a trend date if only water is leaving if no albumin is being dished out if the edema is caused by increased capillary hydrostatic pressure conversely what is an exudate an exudate is a fluid that leaves the serum and goes to outside what is the nature of the x-date fluid water plus proteins so albumin is leaving the blood and going outside what's going to happen to the concentration of albumin in my serum it's going to go down what's going to happen to the concentration of albumin in the ocitis fluid as albumin is leaving the serum and going to the acidic fluid is gonna go up therefore what's gonna happen to the gradient is gonna shrink it's gonna decrease it's gonna drop below 1.1 what's the measuring unit well it's the same measuring unit as albumin what's the normal serum albumin oh it's about four grams per deciliter use the same measuring unit doofus how's that hard so if my ascites is caused by an exudate like an inflammation like increased capillary permeability what's going to happen to the saag it's going to be below 1.1 so in a nutshell if the cause of your ascites is a trans date in other words only water is leaving the saeg will go up but if the cause of your ascites is an exudate in other words water and albumin is leaving the gradient is going to shrink easy peasy lemon squeezy medicine because medicine makes so much sense once you understand what the flip you're talking about so my patient has ascites what should i do keep calm and get the paracentesis tap that big swollen belly what did you do in case of rheumatology the patient's joint was inflamed how do you know if it's osteoarthritis rheumatoid arthritis gout arthritis septic arthritis how did you know i tapped the joint i got the fluid i sent it to the lab do the same stinking thing here get that puppy send it to the lab to order the s-a-a-g which is the difference between the serum albumin and the aside his albumin if the s-a-a-g is low it's probably an exudate if the saeg is high it's probably a trend date which one of these two situations is likely the portal hypertension well what is portal hypertension oh there's hypertension in my vessels due to cirrhosis for example and what happens when everything is clogged up oh the pressure is gonna rise so when we have increased capillary hydrostatic pressure what's that that's likely a trans date which means in this situation my saeg is high water only is leaving and the albumin in the serum will become more concentrated this will go up but the albumin in the asides will go down become more diluted and this will go down saeg will widen other causes of increased capillary hysteric pressure include the chf especially right solid heart failure what we call cardiac cirrhosis or nut meg liver as well as butt chiari syndrome caused by a clot in the hepatic veins on the other hand if the saeg is low less than 1.1 this is not a portal hypertension this is not caused by an increased capillary hazard pressure this is likely an exudate caused by increase increased capillary permeability or decreased oncotic pressure anything but an increase in the hydrostatic pressure give me examples of increased capillary permeability have inflammation infections such as tuberculosis malignancy and biliary leak give me an example of a decreased serum albumin decrease on correct pressure nephrotic syndrome quasi-core malabsorption i'm not eating it i'm not absorbing it i am peeing it out or pooping it out if it's militaries disease but homelessness sometimes cirrhosis can have low serum albumin causing a transdate which is here and that's why not all cases of cirrhosis is going to have a high saeg only 80 of cases of cirrhosis will be in this category the other 20 percent of cases are here mnemonic time if the fluid is a trench date it's probably gonna have a high saeg a transcendent gradient but be careful this has to be due to increased hydrostatic pressure and not a decrease in the oncotic pressure so if it's an exudate it's easy it's going to be a low gradient if it's a trench date ask yourself is it due to increased hydrostatic pressure aka portal hypertension if the hydrostatic pressure is high the gradient is high but if the oncotic pressure is low the gradient is low if you remember my video on the plural effusions the difference between x-date and trench date was here in the lights criteria remember the first part the effusion which is the fluid in the pleura over the serum protein ratio if it's height means it has too much protein and the protein rich fluid is called an exudate but if this ratio is low it's protein-poor fluid known as the transdate because it has water only with no proteins can we borrow the same logic and use a different method to tell the difference absolutely this method is arguably better than the gradient in other words the division is better than subtraction how do you do this easy the effusion over the serum the fluid over the serum what kind of fluid peritoneal fluid ascites okay if it's low it means it's protein poor at transit if it's high it's an x-date because if this is high it means that the fluid albumin is robust and the only way you will have too much albumin in your ascites is if your capillary is leaking albumin with the water question of the day let's match so you have two possibilities either a serum albumin a side is gradient of 0.8 or a serum aluminized grain of 1.3 and you have five cases the first patient has lymphoma do you think he will have this gradient or this gradient how about the second patient miliary tb this or this but chiari this or this cirrhosis this or this chf this or this let me know the correct answers in the comment section if you like this video you will enjoy my acid base imbalances course on my website medicosisperficionatis.com and you will like my utakoids pharmacology course if you want to learn about cyclic amps serotonin histamine treatment of peptic ulcer disease etc and for the next six students only you can get a 40 discount towards anything on my website just use promo code histamine thank you for watching please subscribe hit the bell and click on the join button you can support me here or here go to my website to download my premium courses thank you for watching as always be safe stay happy study hard this is mitochosis perfect tinnitus where medicine makes perfect sense