EDEMA

DEFINITION
Expansion of the interstitial fluid
volume.
Weight gain precedes overt edema
Massive and generalized edema is called
anasarca
Pitting () and non-pitting ()
edema

Schroth BE, JAAPA 2005 11
Edema
Pitting edema Non-pitting edema
Anatomy and pathophysilolgy
1/3 of total body water is extracellular
space, and 2/3 is intracellular space;
Extracellular space is composed of the
intravascular plasma volume (25%) and
the extravascular interstitial spaces (75%);
Starlings law:
Extravascular and intravascular hydrostatic pressurs;
Differences in oncotic pressures within the interstitial
space and plasma;
The permeability of the blood vessel wall.

Anatomy and pathophysilolgy
Vascular system Interstitial space
Hydrostatic pressure
Hydrostatic pressure
Colloid oncotic pressure (tissue tension)
Colloid oncotic pressure
Reduced Plasma Osmotic Pressure
Albumin is the serum protein MOST
responsible for the maintenance of colloid
osmotic pressure

A decrease in osmotic pressure can result
from increased protein loss or decreased
protein synthesis


Capillary Damage
Damage to the capillary endothelium
Increase its permeability and permits the transfer of protein
into interstitial compartment
Injury agents
Drugs Viral/bacterial agents
Thermal/mechanical trauma Immune
Responsible for inflammatory edema
Nonpitting localized redness and tenderness
Clinical Causes of Edema
Systemic edema

Congestive heart failure
Cirrhosis
Nephrotic syndrome/other
hypoalbuminemia
Drug-induced
Idiopathic
Localized edema

Venous/lymphatic
obstruction
Systemic Edema
Congestive heart failure
Congestive heart failure
Left-sided heart failure: shortness of breath with exertion
and when lying down at night (orthophea,)
pulmonary edema

Right-sided heart failure: swelling in the legs and feet
peripheral edema

The physician examining a patient who has congestive
heart failure with fluid retention looks for certain signs: pitting
edema; rales in the lungs, a gallop rhythm and distended
neck veins.

Systemic Edema
Nephrotic Syndrome/Hypoalbuminemic states
The primary alteration: decreased colloid
oncotic pressure
protein loss in the urine severe nutritional deficiency
protein loss enteropathy congenital hypoalbuminemia
liver cirrhosis
Promotes fluid move into the interstitium
Causes hypovolemia
salt/water retention activation RAA axis etc
Idiopathic Edema
Diurnal alterations in weight occurring with
orthostatic retention of sodium and water
Increase in capillary permeability
fluctuate in severity
aggravated by hot weather
Reduction in plasma volume in this condition with
secondary activation of the RAA system
Drug-induced edema
Nonsteroidal anti-inflammatory drugs
Antihypertensive agents
Direct arterial/arteriolar vasodilators
Calcium channel antagonists a-Adrenergic antagonists
Steroid hormones
Glucocorticoids Anabolic steroids Estrogens Progestines
Cyclosporine
Growth hormone
Immunotherapies
Interleukin 2 OKT3 monoclonal antibody
Localized edema
Inflammation
Venous/lymphatic obstruction
Chronic lymphangitis
Resection of regional lymph nodes
Filariasis ()
Diagnosis
Of particular importance is excluding major organ system
dysfunction, especially cardiac, liver, and renal dysfunction.
Ask questions such as the following:
Do the rings on your fingers get tight?
Have you had to let your belt out?
Have your clothes or shoes gotten too tight?
Pay special attention to the patients medications;
Also, obtain a thorough dietary history, paying careful
attention to the patients dietary sodium intake, total daily
fluid intake;

Physical examination & Diagnostic testing
In addition to the standard physical examination, chart the
patients weight and note general appearance, paying
special attention to the edema with respect to location,
symmetry, pitting or nonpitting appearance, tenderness, and
associated skin changes. Assess the severity of edema with
a method such as the four-point scale (+1, slight, to +4, very
marked) ;
Including a chemistry panel and urinalysis to evaluate renal
and liver function and albumin levels to assess nutritional
status. Consider measuring the thyrotropin level to rule out
hypothyroidism. In cases where screening for a cardiac
etiology is required, an ECG and chest radiograph may be
helpful in assessing cardiac function.

Differential diagnosis
Heart failure
Renal diseases
Cirrhosis
Nutritional origin
Idiopathic
Others
Differential diagnosis
Heart Failure
Edema initially occurs at lower part of
the body (lower extremities)
symmetric location
The presence of heart diseases
cardiac enlargement gallop rhythm dyspnea
basilar rales venous distention hepatomegaly
Noninvasive tests may be helpful
echocardiography radionuclide angiography
Differential diagnosis
Renal diseases
Mainly due to hypoabluminemia and
salt/water retention
Associated with hematuria, proteinuria,
hypertention and impaired renal functional
Characteriastic of edema of renal origin:
puffiness of the face
prominent in the periorbital areas
Differential diagnosis
Cardiac/Renal disease
Renal Cardiac
Location onset from the face, onset from the lower
periobital areas part of the body
Progression progress quickly progress slowly
Identity soft and mobile relatively solid, less
mobile
Other signs proteinuria signs of heart failure:
hypertension cardiac enlargement
impaired renal venous distention
functional test hepatomegaly

Differential diagnosis
Liver diseases (cirrhosis)
Clinical evidence of hepatic disease
jaundice spider angiomas ascites
Ascites refractory to the treatment
Edema may also occur in other parts of the
body due to:
Hypoalbuminemia
increased intraabdominal pressure
impede venous return from the lower extremities
Differential diagnosis
Idiopathic edema
Exclusive in women

periodic episodes

accompanied by abdominal distention
Differential diagnosis
Other Causes of Edema
Hypothyroidism (myxedema, )
periorbital puffiness nonpitting
Exogenous hyperadrenoncortism
Pregnancy
Estrogens
angioneurotic

Approach to the
patient

Generalized
Localized
or
Heart
Liver
Kidney

Venous obstruction
Lymphatic obstruction

Thanks for your attention