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edema (swelling, tumefaction, tumescence)

An increase in the amount of interstitial fluid which is determined by filtration in the arterial capillary bed & resorption in the venous capillary bed. Etiology: 1) Factors favoring development of edema - hydrostatic pressure gradient from capillaries to interstitial fluid - oncotic pressure gradient from plasma to interstitial tissue - increased permeability of capillary walls - obstruction to lymphatic flow 2) systemic edema a) heart failure (hydrostatic) b) renal failure - nephrotic syndrome (oncotic) - glomerulonephritis c) liver failure (oncotic) - hepatic cirrhosis - hepatic vein thrombosis (Budd-Chiari syndrome) - portal vein thrombosis d) metabolic dysfunction (oncotic) e) protein deficiency (oncotic) f) endocrine dysfunction - Cushing's syndrome - hypothyroidism g) idiopathic cyclic edema (women) h) lipedema: symmetric nonpitting fat deposition in buttocks & legs, no edema in feet, occurs in women i) increased capillary permeability: angioneurotic edema j) pharmacologic agents [3] - NSAIDs - Ca+2 channel blockers - especially amlodipine, felodipine, nifedipine - hydralazine - clonidine - minoxidil - carbenicillin, amantadine - androgens (testosterone), estrogens, progestins - glucocorticoids - aromatase inhibitors, tamoxifen - alpha-blockers, beta blockers, hydralazine, diazoxide - phenothiazines, thioridazine, lithium - reserpine, guanethidine, MAO inhibitors - gabapentin, pregabalin - thiazolidinediones (pioglitazone) - insulin - dopamine agonists - bromocriptine, pramipexole, ropinirole History: - duration, localized vs generalized, associated pain or redness, dyspnea, history of heart failure, liver disease, renal disease, thyroid disease, pregnancy, estrogens, steroids, vasodilators, exacerbation by menses or position, malnutrition Clinical manifestations: 1) distribution a) bilateral: generally of systemic origin b) unilateral: generally of regional origin c) calf or thigh only without feet or ankles - muscle trauma - aneurysm - hematoma - sarcoma d) sparing of feet (lipedema) 2) overlying skin a) erythema - cellulitis - phlebitis - lymphangitis b) reddish-blue - DVT c) cyanotic & bilateral - CHF d) ecchymosis - muscle trauma 3) pitting edema - systemic etiology - interstitial fibrosis with chronic edema may prolong pitting 4) onset a) acute: hours to days - cellulitis - deep vein thrombosis - compartment syndrome - muscle trauma b) chronic - systemic process - medications - chronic venous insufficiency - lymphedema 5) pain a) painless - systemic process - lymphedema b) painful - cellulitis - muscle trauma - ruptured Baker's cyst - compartment syndrome - deep vein thrombosis 6) fever & chills - cellulitis - lymphangitis - venous thrombosis 7) symptoms associated with CHF - dyspnea - orthopnea - paroxysmal nocturnal dyspnea 8) symptoms of urinary tract disease - recent Streptococcal sore throat - recurrent cystitis - hypertension 9) sign of chronic liver disease - hepatitis - alcoholism - axillary hair loss - palmar erythema - icterus - spider telangiectasias - gynecomastia - hepatomegaly - splenomegaly - caput medusa - ascites Laboratory: 1) serum chemistries a) serum electrolytes b) liver function tests c) renal function tests 2) thyroid function tests (free T4, serum TSH, TSI, serum T3) 3) urinalysis Radiology: 1) chest X-ray 2) echocardiogram as indicated 3) ultrasound to rule out DVT as indicated Management: 1) general - diuretics - salt restriction < 2 g Na+/day - fluid restriction < 1.5 L fluid/day - elastic compression stockings - digoxin - vasodilators 2) specific treatment depending upon cause

Specific

anasarca angioneurotic edema; angioedema; atrophedema; Bannister's disease; Milton's disease; Quincke's disease; periodic or Quincke's edema; giant urticaria or hives; urticaria gigans, gigantea, or tuberosa. blepharedema; eyelid edema bronchial edema (bronchoedema) cerebral edema chemosis dependent edema genital edema myoedema non-pitting edema periorbital edema peripheral edema pitting edema pulmonary edema (pulmonary congestion, PE) refractory edema scrotal edema unilateral upper extremity edema

General

sign/symptom

References

  1. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 207-9
  2. Chan & Winkle, Diagnostic History & Physical Examination, Current Clinical Strategies Publishing. Laguna Hills, 1996
  3. Prescriber's Letter 18(9): 2011 Drugs That Commonly Cause Peripheral Edema Detail-Document#: 270918 (subscription needed) http://www.prescribersletter.com
  4. Trayes KP, Studdiford JS, Pickle S, Tully AS. Edema: diagnosis and management. Am Fam Physician. 2013 Jul 15;88(2):102-10. Review. PMID: 23939641 Free Article
  5. Rashid RM, Barros BS (images) Hidden Heart Disease: 19 Dermatologic Clues You Should Know. Medscape. June 13, 2017. http://reference.medscape.com/slideshow/hidden-heart-disease-6004452