edema (swelling, tumefaction, tumescence)

Introduction

An increase in the amount of interstitial fluid which is determined by filtration in the arterial capillary bed & resorption in the venous capillary bed.

Etiology

• Factors favoring development of edema
  • hydrostatic pressure gradient from capillaries to interstitial fluid
  • oncotic pressure gradient from plasma to interstitial tissue
  • increased permeability of capillary walls
  • obstruction to lymphatic flow
• systemic edema
  • heart failure (hydrostatic)
  • renal failure
    • nephrotic syndrome (oncotic)
    • glomerulonephritis
  • liver failure (oncotic)
    • hepatic cirrhosis
    • hepatic vein thrombosis (Budd-Chiari syndrome)
    • portal vein thrombosis
  • metabolic dysfunction (oncotic)
  • protein deficiency (oncotic)
  • endocrine dysfunction
    • Cushing's syndrome
    • hypothyroidism
  • idiopathic cyclic edema (women)
  • lipedema: symmetric nonpitting fat deposition in buttocks & legs, no edema in feet, occurs in women
  • increased capillary permeability: angioneurotic edema
  • pharmacologic agents
    • NSAIDs
    • Ca+2 channel blockers
      • especially amlodipine, felodipine, nifedipine
    • hydralazine
    • clonidine
    • minoxidil
    • carbenicillin, amantadine
    • androgens (testosterone), estrogens, progestins
    • glucocorticoids
    • aromatase inhibitors, tamoxifen
    • alpha-blockers, beta blockers, hydralazine, diazoxide
    • phenothiazines, thioridazine, lithium
    • reserpine, guanethidine, MAO inhibitors
    • gabapentin, pregabalin
    • thiazolidinediones (pioglitazone)
    • insulin
    • dopamine agonists
      • bromocriptine, pramipexole, ropinirole

History

• duration, localized vs generalized, associated pain or redness, dyspnea, history of heart failure, liver disease, renal disease, thyroid disease, pregnancy, estrogens, steroids, vasodilators, exacerbation by menses or position, malnutrition

Clinical manifestations

• distribution
  • bilateral: generally of systemic origin
  • unilateral: generally of regional origin
  • calf or thigh only without feet or ankles
    • muscle trauma
    • aneurysm
    • hematoma
    • sarcoma
  • sparing of feet (lipedema)
• overlying skin
  • erythema
    • cellulitis
    • phlebitis
    • lymphangitis
  • reddish-blue - DVT
  • cyanotic & bilateral - CHF
  • ecchymosis - muscle trauma
• pitting edema
  • systemic etiology
  • interstitial fibrosis with chronic edema may prolong pitting
• onset
  • acute: hours to days
    • cellulitis
    • deep vein thrombosis
    • compartment syndrome
    • muscle trauma
  • chronic
    • systemic process
    • medications
    • chronic venous insufficiency
    • lymphedema
• pain
  • painless
    • systemic process
    • lymphedema
  • painful
    • cellulitis
    • muscle trauma
    • ruptured Baker's cyst
    • compartment syndrome
    • deep vein thrombosis
• fever & chills
  • cellulitis
  • lymphangitis
  • venous thrombosis
• symptoms associated with CHF
  • dyspnea
  • orthopnea
  • paroxysmal nocturnal dyspnea
• symptoms of urinary tract disease
  • recent Streptococcal sore throat
  • recurrent cystitis
  • hypertension
• sign of chronic liver disease
  • hepatitis
  • alcoholism
  • axillary hair loss
  • palmar erythema
  • icterus
  • spider telangiectasias
  • gynecomastia
  • hepatomegaly
  • splenomegaly
  • caput medusa
  • ascites

Laboratory

• serum chemistries
  • serum electrolytes
  • liver function tests
  • renal function tests
• thyroid function tests (free T4, serum TSH, TSI, serum T3)
• urinalysis

Radiology

• chest X-ray
• echocardiogram as indicated
• ultrasound to rule out DVT as indicated

Management

• general
  • diuretics
  • salt restriction < 2 g Na+/day
  • fluid restriction < 1.5 L fluid/day
  • elastic compression stockings
  • digoxin
  • vasodilators
• specific treatment depending upon cause

More general terms

• sign/symptom

More specific terms

• anasarca
• angioneurotic edema; angioedema; atrophedema; Bannister's disease; Milton's disease; Quincke's disease; periodic or Quincke's edema; giant urticaria or hives; urticaria gigans, gigantea, or tuberosa.
• blepharedema; eyelid edema
• bronchial edema (bronchoedema)
• cerebral edema
• chemosis
• dependent edema
• genital edema
• myoedema
• non-pitting edema
• periorbital edema
• peripheral edema
• pitting edema
• pulmonary edema (pulmonary congestion, PE)
• refractory edema
• scrotal edema
• unilateral upper extremity edema