Differential diagnosis for EDEMA

1. EDEMA DD
Dr Aisha Razzaq

2. Definition
• Accumulation of excessive fluid in the subcutaneous tissue.
• When edema results from lymphatic stasis, the term lymphoedema is used.
• Expansion of the interstitial fluid volume
• Weight gain precedes overt edema
• Massive and generalized edema is called anasarca
• Pitting and non-pitting edema

6. Edema

7. Anatomy & Pathophysiology
• Starling’s law:
• Extra-vascular and intra-vascular hydrostatic pressures;
• Differences in oncotic pressures within the interstitial
space and plasma;
• The permeability of the blood vessel wall.

8. Reduced Plasma Oncotic Pressure
• Increase protein loss OR decrease protein synthesis

9. 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
• Responsible for inflammatory edema
• Non-pitting, localized redness and tenderness

10. Clinical Causes of Edema
• Systemic edema
• Congestive heart failure
• Cirrhosis
• Nephrotic syndrome/other
hypoalbuminemia
• Drug-induced
• Idiopathic
• Localized edema
• •Venous obstruction
• •Lymphatic obstruction

11. Getting start with history
• 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?

12. Interview framework
• Assess for alarm symptoms
• Ask about symptoms of heart failure
• Ask about alcohol abuse or risk factor for liver disease
• Ask about risk factor for venous stasis and vascular injury
• Take a dietary history
• Determine the temporal pattern and duration of symptoms,
accompanying symptoms or precipitating factors.

13. Identify the alarm symptoms
• Serious diagnosis:
• CHF
• Anaphylaxis
• Liver failure
• DVT leading to pulmonary embolism

14. Alarm symptoms Consider
New medication
Exposure to chemicals
Anaphylaxis
Chest discomfort, SOB, orthopnea,
paroxysmal nocturnal dyspnea
Valve insufficiency
Cardiac ischemia
Loss of consciousness
Feeling to pass out, while walking(pre-syncope)
Outflow tract obstruction
(aortic stenosis)
Pulmonary embolus
Alcohol abuse
Use of injection drugs
Use of illicit drugs
Abdominal swelling
Liver failure
Smoking
History of blood clot
Use of oral contraceptives
Sedentary position for prolong position(long travel,
bedridden)
Pulmonary embolism

15. History questions subdivision
• Related to increased capillary permeability
• Related to raised intravascular pressure
• Related to venous /lymphatic obstruction
• Related to decreased oncotic pressure.

16. Increased permeability

17. Focused questions: Increase
permeability
Affects all tissue beds equally, edema of arms, legs
and face suggests increased permeability
• What medication u use? How long u using it?
• Histamine
• Do you use over the counter medications?
• Are u taking any ACE inhibitors or calcium channel blockers?
• Bradykinin
• Do u feel tired, or have dry skin, course hair or intolerance to
cold?
• ..inc.vascular permeability and excess of ADH.

19. Increased intravascular pressure

20. Increased intravascular pressure
• 1.Volume overload…..or….
• 2. obstruction of venous blood return to heart
• Because pressure is greatest in the lower extremities
due to gravity, edema always begins in lower extremity
and ascend superiorly to the site of obstruction.
• Typically begins in left leg then bilateral ???

21. Questions for inc IV pressure
• Decrease urinary output?
• Type of food ?
• Is patient receiving IV medications?
• What IV fluid is the patient receiving?
• Do u work outdoor or in hot climate?
• Are u taking steroids?
• Do u have marked weakness or stretch marks on abdomen?

22. Alarm symptoms` a
Decrease urinary output? Cardiac, renal, hepatic failure
Type of food ? Excessive salt contained in the food?
Is patient receiving IV medications? Anion drugs…that must be taken with cation
component to increase its
solubility(ticarcillin)
What IV fluid is the patient receiving? Recommended sodium intake/day is less
than 3gm, one liter of normal saline contain
0.9% sodium or 9gm
Do u work outdoor or in hot climate? loss of fluid due to sweating…stimulates
aldosterone…minor lower extremity edema.
Are u taking steroids? Many steroids stimulate aldosterone
receptor…increase sodium and water
retention.
Do u have marked weakness or stretch marks
on abdomen?
Cushing syndrome: excess cortisol stimulates
aldosterone receptor, causing sodium and
water retention.

23. Venous or lymphatic
obstruction

24. Venous or lymphatic obstruction
Chest pain, dyspnea, SOB Aortic stenosis
Chest pain, dug use Aortic insufficiency
Drug addiction, rheumatic fever Mitral valve , aortic valve,
pulmonary stenosis
Chemotherapy, postpartum, SOB,
Heart attack
Cardiomyopathy
Dec. LT. function, inc. pressure in
lung (SOB)and systemic
veins(edema)

25. Venous or lymphatic obstruction
• History of blood clots?
• Smoke?
• Prolong state of immobility?
• Oral contraceptives?
• Past history of cancer?
• Edema localized to left leg?
• Prominent leg veins?
• h/o cancer?
• Yellow nails?

26. Alarm symptoms Consider
Do u smoke? Cardiac temponade: collection of fluid in
pericardium and heart that prevent heart for
accomodating systemic and pulmonary
venous volume
H/O TB or lung cancer?
Face or arm swollen more than legs?
Superior vena cava syndrome
Abdominal swelling? Abdominal mass or pregnancy
History of blood clots?
Smoke?
Prolong state of immobility?
Oral contraceptives?
Past history of cancer?
DVT: Virchow’s triangle of risk factors:
venous stasis, hypercoagulability, vessel injury
Edema localized to left leg? May-thurner syndrome
Confirm by venogram
Prominent leg veins? Varicose veins
h/o cancer?
Yellow nails?
Malignancy obstructing lymph flow
Yellow nail syndome

27. Decreased oncotic pressure

28. Decrease oncotic pressure
Do u have diarrhea? Protein losing enteropathy: Inability
of bowl to absorb protein…increase
oncotic pressure in bowl causes
diarrhea
How much alcohol intake?
Viral hepatitis?
Liver disease?
Cirrhosis
inability to convert absorbed protein to
albumin
Foamy urine?
History of kidney disease?
Diabetes or hypertension?
Nephrotic syndrome: loss of protein…
foamy urine

29. Associated symptoms
• Cardiac faliure: lethargy, dyspnoea, orthopnea, PND, cough ,
ankle edema, abdominal distension from ascites
• Liver disease: jaundice, pruritis, ankle oedema, ascites,
haematemesis and confusion (encephalopathy)
• Renal disease: generalized oedema, frothy urine due to proteinuria.
• Malabsorption:
• Weight loss, diarrhoea
• Venous thrombosis:
• UL leg swelling, pain,

31. examination
• Inspection: assessment of distribution: generalized causes tend to
present with dependant oedema, with fluid accumulating in the
ankles in ambulatory and sacrum in recumbent patients.
• CVS: with cardiac faliure:
• Pulses: tachy with pulsus alternus
• BP: low due to systolic faliure
• JVP: elevated
• 3rd
heart sound
• BL course pulmonary crepts
• Hepatomegaly and ascites

32. Abdominal examination:
• Generalized muscle wasting due to malabsorption or
malignancy may be inspected.
• Clubbing, palmar erythma, Duputren’s contacture, jaundice
and gynacomastia are signs of liver disease.
• Dilated collateral veins may be due to portal HTN.
• Legs: tenderness and swelling?
• Circumference compared.
• Marked painful erythematous UL swelling may indicate DVT.

33. General analysis
General analysis
• Urinalysis: heavy proteinuria:
• FBC: WBC ↑?? Hb↓??
• U&Es: urea and creatinine
↑….???
• LFTs: Abnormal??
• Serum Albumin: ??
Special investigations
• 24hr urine collection: > 3.5g of
protein…???
• Renal biopsy: to determine the cause of
NS in adults.
• Echo: ??
• Liver biopsy: liver cirrhosis
• Doppler
• Venography
• Lymphangiography
• Pelvic US/CT:
• Fecal fat estimation: ↑ in
malabsorption.

34. A to Z of edema
THE LEAK OF VEINS
Or
VALVES