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EDEMA
PWM Olly Indrajani2012
Edema
= Increased fluid in the interstitial tissue spaces
Anasarca: Generalized edema + profound subcutaneous swelling
Anatomy and pathophysiology
• 1/3 of total body water is extracellular space, and 2/3 is intracellular space;
• Extracellular space is composed of the intravascular plasma volume (25%) and the extravascular interstitial spaces (75%)
Starling’s law:• Extravascular and intravascular hydrostatic pressures;• Differences in oncotic pressures within the interstitial
space and plasma;• The permeability of the blood vessel wall.• Hydrostatic Pressure (capillary - tissue) - Oncotic
pressure (capillary - tissue) = net fluid movement out of capillary into interstitium.
Anatomy and pathophysiology
Pathophysiology
1. Increased Hydrostatic PressureMost common cause - Congestive heart failure,
others - DVT
2. Decreased oncotic or osmotic PressureNephrotic syndrome, Cirrhosis
3. Sodium retentionRenal failure, Renin- Angiotensin – Aldosterone
4. InflammationAcute or chronic,
Edema - Pathogenesis
Type of edema exudate in inflammatory and transudate in non inflamatory.
conditionsMorphology Mostly involve - Subcutaneous tissues - Lung, Brain
Subcutaneous – can be pitting (Cardiac or renal disorders) or non – pitting ( Thyroid disorders)Pitting edema can be- independent parts (at ankles in ambulatory and
Back or sacrum in bedridden patients- cardiac disorders)
- nondependent area ( periorbital in renal disorders)Lung or Pulmonary edema – Most common in Left Heart failure, lungs are wet and heavy, pink frothy fluid in alveoliCerebral edema – localized ( Abscess, Neoplasms) / - Generalized ( Encephalitis), narrowed sulci and distended gyri, fatal if edema develops rapidly (due to cerebellar or Tonsillar
Edema
Pitting edemaPitting edema Non-pitting edemaNon-pitting edema
Clinical Causes of Edema
Systemic edema
• Congestive heart failure• Cirrhosis • Nephrotic syndrome/other hypoalbuminemia• Drug-induced • Idiopathic
Localized edema
• Venous/lymphatic Obstruction (lymphedema)
• myxedema
Systemic EdemaCongestive heart failure
Congestive heart failure
• Left-sided heart failure: shortness of breath with exertion and when lying down at night (orthophea)-- pulmonary edema
• Right-sided heart failure: swelling in the legs and feet--peripheral edema
•The physician examining a patient who has congestive heart failure with fluid retention looks for certain signs: pitting edema; rales in the lungs, a gallop rhythm and distended neck veins.
Systemic Edema
Nephrotic Syndrome /Hypoalbuminemic states
• The primary alteration: decreased colloid oncotic pressure protein loss in the urine severe nutritional deficiency protein loss enteropathy congenital hypoalbuminemia liver cirrhosis
• Promotes fluid move into the interstitium• Causes hypovolemia salt/water retention activation RAA axis etc
Idiopathic Edema
• Diurnal alterations in weight occurring with orthostatic retention of sodium and water• Increase in capillary permeability fluctuate in severity aggravated by hot weather• Reduction in plasma volume in this condition with secondary activation of the RAA system
Drug-induced edema
Nonsteroidal anti-inflammatory drugsAntihypertensive agents Direct arterial/arteriolar vasodilators Calcium channel antagonists α-Adrenergic antagonists
Steroid hormones Glucocorticoids Anabolic steroids
Estrogens Progestines
CyclosporineGrowth hormoneImmunotherapies Interleukin 2 OKT3 monoclonal antibody
Localized edema
• Inflammation• Venous/lymphatic obstruction• Chronic lymphangitis• Resection of regional lymph nodes• Filariasis
Clinical significance
In Almost disorders causing edema, excess sodium re-absorption ( via Renin Angiotensin-Aldosterone pathway) is key factor
Treatment salt intake, Diuretics (↑sodium Excretion), Aldosterone antagonists