approach to edema,causes,mechanisms of edema,management of edema

1. APPROACH TO EDEMA
Dr.G.VENKATA RAMANA
MBBS DNB FAMILY MEDICINE

2. DEFINITION
• Edema represents an excess of interstitial
fluid that has become evident clinically
• Anasarca refers to gross, generalized
edema
• Ascites refer to accumulation of excess
fluid in the peritoneal cavity
• Hydrothorax refer to accumulation of
excess fluid in the pleural cavity

3. HOW TO RECOGNIZE EDEMA?
• Persistence of an indentation of the skin after
pressure known as “pitting” edema
• In its more subtle form, edema may be detected
by noting that after the stethoscope is removed
from the chest wall, the rim of the bell leaves an
indentation on the skin of the chest for a few
minutes.
• When the ring on a finger fits more snugly than in
the past
• When a patient complains of difficulty putting on
shoes, particularly in the evening.
• Puffiness of the face, in the periorbital areas

4. GRADING OF EDEMA

5. • Fast edema
• This indicates edema occurring in
conditions causing hypoalbuminaemia
• The oedema pits on pressure application
but disappears within 40 seconds of its
application
• Slow edema
• This indicates edema occurring in
conditions causing congestion (CCF)
• The edema pits on pressure application
but lasts for more than 1 minute

9. MAJOR CAUSES OF EDEMA BY PRIMARY
MECHANISM
• (1) An increase in intracapillary hydrostatic
pressure
• (2) Reductions in the oncotic pressure in
the plasma
• (3) Damage to the capillary endothelial barrier
• (4) Inadequate lymphatic drainage
• (5) Increases in the oncotic pressure in the
interstitial space

10. Increased capillary hydraulic pressure
• Increased plasma volume due to renal sodium retention
1. Heart failure, including cor pulmonale
2. Primary renal sodium retention
• Renal disease, including the nephrotic syndrome
• Drugs: Nonsteroidal antiinflammatory drugs (NSAIDs),
glucocorticoids, fludrocortisone, thiazolidinediones
(glitazones), insulins, estrogens, progestins, androgens,
testosterone, aromatase inhibitors, tamoxifen; and by multiple
mechanisms: vasodilators (hydralazine, minoxidil, diazoxide)
and calcium channel blockers (particularly dihydropyridines
[ie, amlodipine, nifedipine])
• Refeeding edema
• Early hepatic cirrhosis
3. Pregnancy and premenstrual edema
4. Idiopathic edema, when diuretic induced
5. Sodium or fluid overload: Parenteral antibiotics or other
drugs with large,amounts of sodium, sodium bicarbonate, or
excessive or overly rapid fluid replacement

11. Increased capillary hydraulic pressure
• Venous obstruction or insufficiency
• Cirrhosis or hepatic venous obstruction
• Acute pulmonary edema
• Local venous obstruction
1.Venous thrombosis
2. Venous stenosis
• Chronic venous insufficiency – Post-thrombotic
syndrome
• Arteriolar vasodilation
• Drugs: Frequent – Vasodilators (hydralazine, minoxidil,
diazoxide), dihydropyridine calcium channel blockers;
less frequent – alpha1 blockers, sympatholytics (ie,
methyldopa), nondihydropyridine calcium channel
blockers
• Idiopathic edema

12. Hypoalbuminemia
• Protein loss
• Nephrotic syndrome
• Protein-losing enteropathy
• Reduced albumin synthesis
• Liver disease
• Malnutrition

13. Increased capillary permeability
• Idiopathic edema
• Burns
• Trauma
• Inflammation or sepsis
• Allergic reactions, including certain forms
of angioedema
• Acute respiratory distress syndrome
• Diabetes mellitus
• Interleukin 2 therapy
• Malignant ascites

14. • Lymphatic obstruction or increased
interstitial oncotic pressure
• Lymph node dissection
• Nodal enlargement due to malignancy
• Hypothyroidism
• Malignant ascites
• Other drugs (uncertain mechanism)
• Anticonvulsant: Gabapentin, pregabalin
• Antineoplastic: Docetaxel, cisplatin
• Antiparkinson: Pramipexole, ropinirole

21. EDEMA IN CARDIAC DISEASE

23. • The presence of cardiac disease is manifested
by
• Cardiac enlargement and/or ventricular
hypertrophy
• Clinical evidence of cardiac failure, such as
dyspnea, basilar rales, venous distention, and
hepatomegaly
• Noninvasive tests such as electrocardiography,
echocardiography, and measurements of BNP
(or N-terminal proBNP [NT-proBNP]) are helpful
in establishing the diagnosis of heart disease
• The edema of heart failure typically occurs in the
dependent portions of the body

50. APPROACH TO EDEMA