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EDEMA Basic Course of Diagnosis Xiaoqi XU Renal Divison, Renji Hospital, Shanghai Second Med.Univ. Definition A clinical apparent increase in the interstitial fluid volume. Distribution: local general Special form: ascites hydrothorax Pathogenesis Total body water(TBW): 2/3 body weight intracellular 2/3 TBW Interstitial 3/4 extracellular 1/3 starling force intravascular 1/4 Starling force depends on : hydrostatic pressure(静水压) colloid oncotic pressure（胶体渗透压） Pathogenesis Disturbed starling forces(reduced effective circulating volume,edema formation) systemic venous pressure increase right-sided heart failure,constrictive pericarditis local venous pressure increase left-sided heart failure,vena cava obstruction, portal vein obstruction reduced oncotic pressure nephrotic syndrome,decreased albumin synthesis combined disorders cirrhosis Primary hormone excess (increased effective circulating volume) primary aldosteronism Cushing ‘s syndrome SIADH Primary renal sodium retention (increased effective circulating volume) renal failure SIADH: syndrome of inappropriate antidiuretic hormone production Capillary damage inflammation due to the bacteria infection,allergic reaction,immune reaction Lymphatic obstruction Clinical causes of edema General edema: Congestive Heart Failure Nephrotic Syndrome and Other Hypoalbuminemic States Cirrhosis Drug-Induced Idiopathic Edema Localized edema: Obstruction of venous (and lymphatic) drainage of a limb Table 37-2. Principal Causes of Generalized Edema: History, Physical Examination, and Laboratory Findings Organ System Cardiac Hepatic Renal History Physical Examination Dyspnea with exertion prominent-often associated with orthopnea-or paroxysmal nocturnal dyspnea Elevated jugular venous pressure, ventricular (S3) gallop; occasionally with displaced or dyskinetic apical pulse; peripheral cyanosis, cool extremities, small pulse pressure when severe Frequently associated with Dyspnea infrequent, ascites; jugular venous except if associated with pressure normal or low; BP significant degree of lower than in renal or ascites; most often a cardiac disease; jaundice, history of ethanol abuse palmar erythema, Dupuytren's contracture, spider angiomata, male gynecomastia; asterixis and other signs of encephalopathy chronic: decreased appetite, BP may be elevated; metallic or fishy taste, altered hypertensive or diabetic sleep pattern, difficulty retinopathy in selected concentrating, restless legs cases; nitrogenous fetor; or myoclonus: dyspnea can periorbital edema may be present, but generally less predominate; pericardial prominent than in heart friction rub in advanced failure cases with uremia NOTE: S3, third heart sound.SOURCE: From GM Chertow, GE Thibault, Approach to the patient with edema, in L Goldman, E Braunwald (eds): Primary Cardiology. Philadelphia, Saunders, 1998. Laboratory Findings Elevated BUN/Cr ratio common; elevated uric acid; serum Na diminished; liver enzymes occasionally elevated with reductions in Alb, hepatic congestion Cho, transferrin, fibrinogen liver enzymes elevated, tendency toward hypokalemia, respiratory alkalosis; macrocytosis from folate deficiency hypoalbuminemia; elevation of serum creatinine and urea hyperkalemia, metabolic acidosis, hyperphosphatemia, hypocalcemia, anemia (usually normocytic) Malnutrition: weight loss occurs from lower extremities • diet grossly deficient in protein over a long period • Protein-losing enteropathy • Severe burn Idiopathic edema: exclusive in ♀,periodic episodes of edema(unrelated to MC) Miscellaneous:located pretibial region,periorbital region •hypothyroidism(myxedema) •Drug-induced edema Exogenous hyperadremocortism Estrogen vasodilators Localized edema: •Local inflammation •Thrombosis •Thrombophlebitis •filariasis Accompanied symtoms With hepatomegaly With gross proteinuria With dyspnea Related with menstrual cycle Approach to the Patient Localized or generalized? Hydrothorax or ascites? Sites accompanied symptom