Edema
Differential Overview
❑ Congestive heart failure
❑ Venous insufficiency
❑ Hypoalbuminemia
❑ Drugs
❑ Cirrhosis
❑ Deep vein thrombosis
❑ Inferior vena cava obstruction
❑ Lymphatic obstruction
❑ Glomerular injury
❑ Idiopathic edema
❑ Myxedema
❑ Lipedema
❑ Toxemia
❑ Cyclical edema
❑ Refeeding
❑ Filariasis
❑ Milroy
Diagnostic Approach
The degree of edema is influenced by membrane permeability, hydrostatic pressure, and/or oncotic pressure. Edema implies an increase in interstitial volume of several liters. Low protein fluids (hypoalbuminemia, cardiac, and venous edema) pit easily and recover quickly on release. High protein fluids (cellulitis, lymphedema) resist pitting and recover slowly.
The distribution of the edema combined with an estimation of the jugular venous pressure (JVP) can help differentiate heart failure, cirrhosis, renal sodium retention and nephrotic syndrome. Anasarca suggests cardiac, renal, or hepatic disease. Splenomegaly is found more often in patients with cirrhosis than those with congestive heart failure.
Clinical Findings
Congestive heart failure The edema is pitting and responds readily to changes in position. The mechanism involves excessive fluid and sodium retention, decreased right ventricular pump function, and increased central venous pressure. Usually, other signs of right-sided heart failure are present, such as jugular venous distension and hepatojugular reflux.
Venous insufficiency The edema is asymmetric, and accompanied by varicosities and brownish venous stasis changes in the skin. There may be a clinical history of deep vein thrombophlebitis. Swelling will be worse after prolonged dependency of the leg, and there may be a sensation of heaviness in the leg. JVP is normal.
Hypoalbuminemia The edema pits and is often accompanied by morning periorbital edema and ascites. With the albumin less than 2.5 gm/dL, there will be decreased oncotic pressure, and the kidneys will compensate by retaining sodium. Underlying causes include malnutrition, nephrotic syndrome (dipstick proteinuria will be present), cirrhosis, and protein-losing enteropathy.
Drugs Antihypertensives such as calcium channel blockers (especially amlodipine), methyldopa, or minoxidil can produce edema through fluid retention and/or negative inotropy. Anabolic steroids, NSAIDs, and TZDs are also common causes of edema.
Cirrhosis Suspect cirrhosis when there are collateral venous channels visible on the abdominal surface, ascites, jaundice, and spider angiomata. Edema in cirrhosis is caused by a combination of hypoalbuminemia, blockage of hepatic venous outflow, and activation of the renin-angiotensin-aldosterone axis with sodium and volume retention. There is increased capillary pressure below the hepatic vein and normal or reduced cardiopulmonary blood volume, so there are no rales or elevation of JVP.
Deep vein thrombosis Edema is unilateral or at least asymmetric and relatively acute in onset. Calf pain or tenderness, and palpable cords are variably present, so a high index of suspicion must be maintained.
Inferior vena cava obstruction Lower extremity swelling is massive. Veins on the abdominal wall are dilated, and flow below the umbilicus is reversed so that the veins fill from below when stripped.
Lymphatic obstruction The edema is brawny and nonpitting and has overlying hypertrophic skin changes. Palpable lymphadenopathy or splenomegaly and signs of a primary cancer should be sought. This obstruction occurs with
primary retroperitoneal tumors or tumors that have metastasized to the retroperitoneal lymph nodes (prostate cancer in men, lymphoma in women).
Glomerular injury Nephrotic-range proteinuria (recognized by foamy urine) is present, with concurrent hematuria and hypertension.
Idiopathic edema It presents as periodic nonmenstrual edema with abdominal distension. The patient may seem volume-depleted with low JVP.
Myxedema There is brawny nonpitting edema in the legs, and periorbital edema. Usually the patient has signs of profound hypothyroidism, such as lethargy and coarse hair and facial features.
Lipedema There is disproportionate fat accumulation in the legs and buttocks. This pseudoedema does not pit and spares the feet.
Toxemia Edema is an early sign in patients in their third trimester of pregnancy. Hypertension and proteinuria also occur.
Cyclical edema Occurring in women, cyclical edema is often synchronous with menstrual periodicity. Transient abdominal distension and rapid weight fluctuations are common, accompanied by headache, fatigue, or anxiety.
Refeeding Edema is a consequence of sudden introduction of food in a patient with protein–calorie malnutrition.
Filariasis Suspect in persons with geographic exposure risk and massive nonpitting lymphedema.
Milroy A benign form of edema in young adults, Milroy is characterized by swelling that is sharply demarcated at a joint (e.g., sparing the toes).
Book Source Details
- Book Title: Field Guide to Bedside Diagnosis
- Author(s): David S. Smith
- Year of Publication: 2007
- Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2007 Lippincott Williams & Wilkins.
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Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2008 Williams & Wilkins.
More About Causes of Groin swelling
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More About This Book:
Title: Field Guide to Bedside Diagnosis
Authors: David S. Smith
Publisher: Lippincott Williams & Wilkins
Copyright: 2007
ISBN: 0-78178-165-5
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