EDEMA

Leyi Gu Renal Division, Renji Hospital

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%);

Anatomy and pathophysilolgy

Starlings law: Extravascular and intravascular hydrostatic pressurs; Differences in oncotic pressures within the interstitial space and plasma; The permeability of the blood vessel wall.
Vascular system Hydrostatic pressure Colloid oncotic pressure Interstitial space Hydrostatic 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 protein loss enteropathy liver cirrhosis severe nutritional deficiency congenital hypoalbuminemia

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
Location onset from the face, periobital areas Progression progress quickly Identity soft and mobile

Cardiac
onset from the lower part of the body progress slowly relatively solid, less mobile signs of heart failure: cardiac enlargement venous distention hepatomegaly

Other signs

proteinuria hypertension impaired renal functional test

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

Heart Liver Kidney

or
Venous obstruction Lymphatic obstruction

Localized

Thanks for your attention