EDEMA, GENERALIZED

EDEMA, GENERALIZED: Excerpt from Algorithmic Diagnosis of Symptoms and Signs

Ask the following questions:

1. Does the edema pit on pressure? Edema that pits on pressure is more likely to be due to heart, liver, or kidney disease. Edema that does not pit on pressure is more likely due to myxedema or lymphedema.
2. Is there hepatomegaly? If there is hepatomegaly, one should consider liver disease such as cirrhosis or cardiac disease.
3. Is there ascites? If there is ascites along with hepatomegaly, cirrhosis of the liver is the most likely cause of the edema. However, one should not forget constrictive pericarditis. If there is no ascites along with the hepatomegaly, then congestive heart failure should be considered.
4. Is there jugular vein distention? Jugular vein distention certainly would be most suggestive of congestive heart failure, but other causes of jugular vein distention include superior vena cava syndrome due to a mediastinal mass such as carcinoma of the lung and constrictive pericarditis. Right heart failure secondary to pulmonary emphysema and fibrosis can also cause jugular vein distention.
5. Is there an abnormal urinary sediment? If there is an abnormal urinary sediment, consider nephritis, whether it might be due to chronic glomerulonephritis or whether it is secondary to diabetes mellitus or a collagen disease.
6. Is the patient taking any drugs that could cause the edema? Among the drugs that should be considered are corticosteroids, progesterone, estrogen, anti-inflammatory drugs such as naproxen (Naprosyn®) and ibuprofen (Motrin®), antihypertensive drugs such as methyldopa (Aldomet®) and clonidine hydrochloride, calcium channel blockers, beta-adrenergic blockers, and antidepressants.

DIAGNOSTIC WORKUP

A CBC should be done to rule out significant anemia that may be the cause of the edema. If there is anemia, we need to determine its source. Liver function tests are done to rule out liver disease, and serum protein electrophoresis and tests for BUN and creatinine should be done to exclude renal disease. The urinalysis is very important both for the routine studies and also to examine the urinary sediment for diseases such as chronic glomerulonephritis and collagen disease. If there is significant loss of protein in the urine, one should be considering nephrosis. An EKG, chest x-ray, and venous pressure and circulation time will be extremely helpful in diagnosing congestive heart failure, but pulmonary function tests can be done as the vital capacity is significantly reduced in this disease. When there is a strong suspicion of congestive heart failure, echocardiography or radionuclide-gated blood pool scintigraphy should be done to determine the left ventricular ejection fraction (LVEF). A value of less than 45% is considered abnormal. A thyroid profile should be done to diagnose myxedema. A CT scan of the chest will help diagnose constrictive pericarditis. Occasionally, the edema is due to an abdominal tumor. A CT scan of the abdomen and pelvis will be helpful in those cases. Contrast lymphangiography may be necessary to diagnose lymphedema.

Book Source Details

• Book Title: Algorithmic Diagnosis of Symptoms and Signs
• Author(s): R. Douglas Collins
• Year of Publication: 2003
• Copyright Details: Algorithmic Diagnosis of Symptoms and Signs, Copyright © 2003 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: Algorithmic Diagnosis of Symptoms and Signs Authors: R. Douglas Collins Publisher: Lippincott Williams & Wilkins Copyright: 2003 ISBN: 0-7817-3805-9

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