EdemaDiagnosis and Management

AAFP,July 15, 2013 ,volume 88, number 2presented by Dr. Anne Zbaracki

Edema• Accumulation of fluid in interstitial space due

to capillary filtration exceeding lymph drainage

Edema• Capillary hydrostatic pressure and oncotic

pressure is regulated by fluid between interstitial and intravascular spaces

• Disruption in local or systemic conditions

Assessment

• History– Timing- acute, chronic– Position– Unilateral, bilateral– Medications– Systemic diseases

Assessment

• PE • Focus on medial malleoulus, bony tibia, dorsum

– Pitting– Tenderness– Skin changes-temperature, color, texture

Assessment

Kaposi-Stemmer sign, in lymphedema

Assessment

• PE– Systemic causes• Heart failure-jvd, crackles• Renal-proteinuria, oligouria• Hepatic-jaundice, ascities, asterixis• Thyroid- exopthalmus, tremor, wt loss

Local

• Cellulitis• Chronic venous insufficiency• Compartment syndrome• Complex regional pain syndrome type I• DVT• Iliac vein obstruction• Lipedema• Lymphedema primary or secondary• May-Thurner syndrome

Systemic

• Allergic reaction, urticaria, angioedema• Cardiac disease• Hepatic disease• Renal disease• Malnutrition/malabsorption• Obstructive sleep apnea• Pregnancy, premenstrual

Cellulitis

• Increased capillary permeability

Chronic Venous insufficiency

• Increased capillary permeability from local venous hypertension

• treatment- compression, horse chest nut seed extract, skin care

Compartment Syndrome

• Increased capillary permeability from local venous hypertension

Complex regional pain syndrome type I

• Neurogenically mediated increased capillary permeability

Treatment- systemic steriods, topical dimethyl sulfoxide, PT, tricyclic, ca++ blockers

Deep venous thrombosis

• Increased capillary permeability

Lipedema

• Accumulation of fluid in adipose tissue

• Treatment- none

Lymphedema

• Lymphatic obstruction

May-Thurner syndromecompression of left iliac vein by right iliac artery

• Increased capillary permeability from local venous hypertension from compression

Allergic reaction

• Increased capillary permeability• Medications

– Antidepressants- monoamine oxidase inhibitors, trazodone– Antihypertensives- b-blockers, calcium channel blockers, clonidine,

hydralazine, methyldopa, minoxidil– Antivirals-acyclovir– Chemo- cyclophosphamide, cyclosporine, cytosine arabinoside,

mithramycin– Hormones- androgen, corticosteriods, estrogen, progesterone,

testoterone– Nsaids- celecoxib,ibuprofen– Diuretic- volume depletion and reflex renin angiotensin stimulation

Cardiac disease

• Increased capillary permeability from systemic venous hypertension, increased plasma volume

Hepatic disease

• Increased capillary permeability from systemic venous hypertension, decreased plasma oncotic pressure from reduced protein synthesis

Renal disease

• Increased plasma volume, decreased plasma oncotic pressure from protein loss

Malnutriton/ Malabsorption

• Decreased plasma oncotic pressure from reduced protein synthesis

Obstructive sleep apnea

• Increased capillary hydrostatic pressure from Pulmonary hypertension

Pregnancy

• Increased plasma volume

Diagnostic studies

• Labs-bnp, creatinine, urinalysis, lft’s, albumin, d-dimer

• Ankle-brachial index• Ultrasonography- venous, compression w or

w/o dopplar, duplex• Lymphoscintigraphy- radionuclide• MRI- w venography• Echo-pulmonary arterial pressures