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
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