Medicine presentation on edema

1. APPROACH TO EDEMA
Muhammad Abdullah

2. OBJECTIVES
• DEFINITION
• UNDERSTANDING THE PHYSIOLOGY
• CAUSES ( GEN VS LOC )
• HISTORY TAKING, EXAMINATION, INVESTIGATION
• TREATMENT

3. DEFINITION
• Edema/Swelling is an accumulation of excess
interstitial fluid in the body tissue.
• The fluid between the interstitial and
intravascular spaces is regulated by the capillary
hydrostatic pressure gradient and the oncotic
pressure gradient across the capillary.
• The accumulation of fluid occurs when local or
systemic conditions disrupt this
equilibrium leading to increased capillary
hydrostatic pressure, increased plasma volume,
decreased plasma oncotic pressure
(hypoalbuminemia), increased capillary
permeability, or lymphatic obstruction.

4. ETIOLOGY OF EDEMA
• Increase in intravascular pressure
• Increase in capillary vessel wall permeability
• Decrease in the intravascular oncotic pressure
• Lymphatic obstruction

5. TYPES 0F EDEMA
• PITTING : EXCESS FLUID BUILDS UP IN
THE BODY TISSUE THEREBY CAUSING
SWELLING, WHEN PRESSURE IS
APPLIED TO THE SWOLLEN AREA A “PIT”
FORMS ( LEGS, FEETS , ANKLES)
RELATED TO HEART, LIVER OR RENAL
PATHOLOGIES
• NON PITTING : ACCUMLATION OF
EXCESS FLUID IN SOFT TISSUES
CAUSING SWELLING. PATHOLOGIES
RELATED TO THYROID AND LYPMHATIC
OBSTRUCTION

7. Most used grading system for peripheral edema is the pitting edema scale,
which ranges from 0 to 4+ and is based on the depth and duration of the
indentation (pit) that remains after applying pressure to the skin over an
edematous area. The scale is as follows:
• 0: No pitting edema
• 1+: Mild pitting edema, indentation disappears rapidly (2-4 mm)
• 2+: Moderate pitting edema, indentation disappears in 10-15 seconds (4-6
mm)
• 3+: Deep pitting edema, indentation disappears in 30-60 seconds (6-8 mm)
• 4+: Very deep pitting edema, indentation lasts longer than 2 minutes (>8
mm)
Grading peripheral edema

9. HISTORY
1. SITE and Distribution
• Unilateral pedal edema: Local DVT, Compartment syndrome , filariasis
• Bilateral Pedal Edema : Systemic causes like congestive heart failure, CKD ,
CLD
2. Duration of illness:
• Acute (<72 hours): Cellulitis, DVT , Compartment syndrome
• Chronic (>72 hours): Systemic disease, Lymphedema
3. Association with pain
• Painful: DVT and Cellulitis
• Painless: Systemic diseases , Lymphedema,
Hypoproteinemia states
4. Hx of Systemic illness
• Cardiac , Renal , Liver PATHOLOGIES
• Hx of Hypothyroidism
5. ASK ABOUT DRUG
INTAKE
6.TRAUMA AND RADIATION
• Cellulitis and Compartment
syndrome

10. PHYSICAL EXAMINATION

11. CONTD.
• Changes in skin temperature, color, and texture provide clues to the
cause of edema. For example, acute DVT and cellulitis may produce
increased warmth over the affected area. Because of the deposition of
hemosiderin, chronic venous insufficiency is often associated with skin
that has a brawny, reddish hue and commonly involves the medial
malleolus.
CELLULITIS Myxedema
CVI

12. DIAGNOSTIC STUDIES
• Laboratory Tests
Most patients over age 50 with edema have venous insufficiency, but if the etiology is
unclear, a short list of laboratory tests will help rule out systemic disease:
• complete blood count
• Urinalysis (Proteinuria)
• LFTs
• Serum TSH
• D-dimer
• Albumin
A serum albumin below 3.2 g/dL often leads to edema and can be caused by:
• liver disease
• nephrotic syndrome
• protein-losing enteropathy

13. MANAGEMENT

14. MANAGEMENT OF EDEMA
• CHRONIC VENOUS INSUFFICIENCY
• Mechanical therapies, including leg elevation and compression stockings.
Local skin and wound care of venous ulcers is essential in preventing
secondary cellulitis and dermatitis. Treatment includes daily hydration with
emollients and short courses of topical steroid creams for severely inflamed
skin.
• LYMPHEDEMA
• The mainstay of lymphedema treatment involves complex decongestive
physiotherapy, which is composed of manual lymphatic massage and
multilayer bandages.
• REFRACTORY CASES : SURGICALLY PROCEDURES LIKE DEBULKING
AND BYPASS

15. MANAGEMENT OF EDEMA
• DEEP VENOUS THROMBOSIS
• Acute thrombotic events are treated with
anticoagulation therapy (low-molecular-weight
heparin or warfarin to prevent progression of a
clot or the development In addition to
anticoagulation, compression stockings should
be used after a DVT to prevent post-thrombotic
syndrome.

16. • MEDICATION-INDUCED EDEMA
• In patients with suspected medication-induced edema, the offending medication
should be discontinued if possible. In patients taking calcium channel blockers to
treat hypertension, use of an angiotensin-converting enzyme inhibitor may be more
beneficial than angiotensin receptor blocker therapy in reducing calcium channel
blocker–induced peripheral edema.
Chronic Kidney Disease
• Fluid and Salt restriction ( Loop Diuretics ) like furosemide can be given to reduce the
edema
Congestive Heart Failure
Salt restriction and Loop Diuretics can be given ( Furosemide), Ventricular
remodeling drugs like beta blockers and ACE inhibitors can also be given