Transcript EDEMA
EDEMA Leyi Gu Renal Division, Renji Hospital DEFINITION • Expansion of the interstitial （间质）fluid volume. • Weight gain precedes overt edema • Massive and generalized edema is called anasarca（全身性水肿） • Pitting (压凹性) and non-pitting (非压凹性) edema Schroth BE, JAAPA 2005 11 Edema Pitting edema Non-pitting edema Anatomy and pathophysilolgy • 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%); Anatomy and pathophysilolgy Starling’s law: • Extravascular and intravascular hydrostatic pressurs; • Differences in oncotic pressures within the interstitial space and plasma; • The permeability of the blood vessel wall. • Vascular system Hydrostatic pressure （流体静水压） Colloid oncotic pressure （胶体渗透压） Interstitial space Hydrostatic pressure (tissue tension) Colloid oncotic pressure Reduced Plasma Osmotic Pressure Albumin is the serum protein MOST responsible for the maintenance of colloid osmotic pressure A decrease in osmotic pressure can result from increased protein loss or decreased protein synthesis 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 Immune • Responsible for inflammatory edema • Nonpitting localized redness and tenderness Clinical Causes of Edema Systemic edema Localized edema • Congestive heart failure • Cirrhosis • Nephrotic syndrome/other hypoalbuminemia • Drug-induced • Idiopathic • Venous/lymphatic obstruction Systemic Edema Congestive heart failure Congestive heart failure • Left-sided heart failure: shortness of breath with exertion and when lying down at night (orthophea,端坐呼吸)－－ 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 liver cirrhosis congenital hypoalbuminemia • 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 drugs Antihypertensive agents Direct arterial/arteriolar vasodilators Calcium channel antagonists a-Adrenergic antagonists Steroid hormones Glucocorticoids Anabolic steroids Estrogens Cyclosporine Growth hormone Immunotherapies Interleukin 2 OKT3 monoclonal antibody Progestines Localized edema • Inflammation • Venous/lymphatic obstruction • Chronic lymphangitis • Resection of regional lymph nodes • Filariasis (丝虫病) Diagnosis • Of particular importance is excluding major organ system dysfunction, especially cardiac, liver, and renal dysfunction. • 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? • Pay special attention to the patient’s medications; • Also, obtain a thorough dietary history, paying careful attention to the patient’s dietary sodium intake, total daily fluid intake; Physical examination & Diagnostic testing • In addition to the standard physical examination, chart the patient’s weight and note general appearance, paying special attention to the edema with respect to location, symmetry, pitting or nonpitting appearance, tenderness, and associated skin changes. Assess the severity of edema with a method such as the four-point scale (+1, slight, to +4, very marked) ; • Including a chemistry panel and urinalysis to evaluate renal and liver function and albumin levels to assess nutritional status. Consider measuring the thyrotropin level to rule out hypothyroidism. In cases where screening for a cardiac etiology is required, an ECG and chest radiograph may be helpful in assessing cardiac function. Differential diagnosis • Heart failure • Renal diseases • Cirrhosis • Nutritional origin • Idiopathic • Others Differential diagnosis Heart Failure • Edema initially occurs at lower part of the body (lower extremities) • symmetric location • The presence of heart diseases cardiac enlargement gallop rhythm dyspnea basilar rales venous distention hepatomegaly • Noninvasive tests may be helpful echocardiography radionuclide angiography Differential diagnosis Renal diseases • Mainly due to hypoabluminemia and salt/water retention • Associated with hematuria, proteinuria, hypertention and impaired renal functional • Characteriastic of edema of renal origin: puffiness of the face prominent in the periorbital areas Differential diagnosis Cardiac/Renal disease Renal Location onset from the face, periobital areas Progression progress quickly Identity soft and mobile Other signs proteinuria hypertension impaired renal functional test Cardiac onset from the lower part of the body progress slowly relatively solid, less mobile signs of heart failure: cardiac enlargement venous distention hepatomegaly Differential diagnosis Liver diseases (cirrhosis) • Clinical evidence of hepatic disease jaundice spider angiomas ascites • Ascites refractory to the treatment • Edema may also occur in other parts of the body due to: •Hypoalbuminemia •increased intraabdominal pressure •impede venous return from the lower extremities Differential diagnosis Idiopathic edema • Exclusive in women • periodic episodes • accompanied by abdominal distention Differential diagnosis Other Causes of Edema • Hypothyroidism (myxedema, 粘液水肿) periorbital puffiness nonpitting • Exogenous hyperadrenoncortism • Pregnancy • Estrogens • angioneurotic Approach to the patient Heart Liver Kidney Generalized or Venous obstruction Lymphatic obstruction Localized Thanks for your attention