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Edema: Diagnosis and Management KATHRYN P Edema: Diagnosis and Management KATHRYN P. TRAYES, MD, and JAMES S. STUDDIFORD, MD, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania SARAH PICKLE, MD, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey AMBER S. TULLY, MD, Cleveland Clinic, Cleveland, Ohio Edema is an accumulation of fluid in the interstitial space that occurs as the capillary filtration exceeds the limits of lymphatic drainage, producing noticeable clinical signs and symptoms. The rapid development of generalized pitting edema associated with systemic disease requires timely diagnosis and management. The chronic accumulation of edema in one or both lower extremities often indicates venous insufficiency, especially in the presence of dependent edema and hemosiderin deposition. Skin care is crucial in preventing skin breakdown and venous ulcers. Eczematous (stasis) dermatitis can be managed with emollients and topical steroid creams. Patients who have had deep venous thrombosis should wear compres- sion stockings to prevent postthrombotic syndrome. If clinical suspi- cion for deep venous thrombosis remains high after negative results are noted on duplex ultrasonography, further investigation may include magnetic resonance venography to rule out pelvic or thigh proximal venous thrombosis or compression. Obstructive sleep apnea may cause bilateral leg edema even in the absence of pulmonary hyperten- sion. Brawny, nonpitting skin with edema characterizes lymphedema, which can present in one or both lower extremities. Possible secondary causes of lymphedema include tumor, trauma, previous pelvic surgery, inguinal lymphadenectomy, and previous radiation therapy. Use of pneumatic compression devices or compression stockings may be help- ful in these cases. (Am Fam Physician. 2013;88(2):102-110. Copyright © 2013 American Academy of Family Physicians.) ILLUSTRATION CRAIG BY ZUCKERMAN ▲ Patient information: dema is an accumulation of fluid in a medication history and an assessment for A handout on this topic the intercellular tissue that results systemic diseases (Table 2). Acute swelling of is available at http:// familydoctor.org/ from an abnormal expansion in a limb over a period of less than 72 hours is familydoctor/en/diseases- interstitial fluid volume. The fluid more characteristic of deep venous thrombo- conditions/edema.html. E between the interstitial and intravascular sis (DVT), cellulitis, ruptured popliteal cyst, spaces is regulated by the capillary hydro- acute compartment syndrome from trauma, More online at http://www. static pressure gradient and the oncotic or recent initiation of calcium channel block- aafp.org/afp. pressure gradient across the capillary.1-3 The ers (Figures 1 and 2). The chronic accumula- accumulation of fluid occurs when local or tion of more generalized edema is due to the CME This clinical content systemic conditions disrupt this equilib- onset or exacerbation of chronic systemic conforms to AAFP criteria 1-13 for continuing medical rium (Table 1 ), leading to increased capil- conditions, such as congestive heart failure education (CME). See CME lary hydrostatic pressure, increased plasma (CHF), renal disease, or hepatic disease.4,5 Quiz on page 95. volume, decreased plasma oncotic pressure Dependent edema caused by venous insuf- Author disclosure: No rel- (hypoalbuminemia), increased capillary ficiency is more likely to improve with eleva- evant financial affiliations. permeability, or lymphatic obstruction. tion and worsen with dependency.5,14 Edema associated with decreased plasma oncotic Assessment of Edema pressure (e.g., malabsorption, liver failure, HISTORY nephrotic syndrome) does not change with The history should include the timing of the dependency. edema, whether it changes with position, Unilateral swelling from compression and if it is unilateral or bilateral, as well as or compromise of venous or lymphatic 102 DownloadedAmerican from Family the American Physician Family Physician website at www.aafp.org/afp.www.aafp.org/afp Copyright © 2013 American AcademyVolume of Family 88, Physicians. Number For2 ◆ the July private, 15, 2013 non- commercial use of one individual user of the website. All other rights reserved. Contact [email protected] for copyright questions and/or permission requests. Edema drainage can result from DVT, venous insufficiency, a systemic cause, such as CHF (especially right-sided), venous obstruction by tumor (e.g., tumor obstruction pulmonary hypertension, chronic renal or hepatic dis- of the iliac vein), lymphatic obstruction (e.g., from a ease (causing hypoalbuminemia), protein-losing enter- pelvic tumor or lymphoma), or lymphatic destruction opathies, or severe malnutrition.1,4,5 (e.g., congenital vs. secondary from a tumor, radiation, Edema can be an adverse effect of certain medications or filariasis). Bilateral or generalized swelling suggests (Table 31-5). The mechanism often includes the retention of salt and water with increased capillary hydrostatic pressure. Diuretic use may Table 1. Systemic and Localized Causes of Edema cause volume depletion and reflex stimu- lation of the renin-angiotensin system. Cause Mechanism of action The history should also include ques- tions about cardiac, renal, thyroid, or Systemic hepatic disease. Graves disease can lead Allergic reaction, urticaria, and Increased capillary permeability angioedema to pretibial myxedema, whereas hypo- Cardiac disease Increased capillary permeability from thyroidism can cause generalized myx- systemic venous hypertension; edema. Although considered a diagnosis increased plasma volume of exclusion, obstructive sleep apnea has Hepatic disease Increased capillary permeability from been shown to cause edema. One study systemic venous hypertension; decreased plasma oncotic pressure evaluated the apnea-hypopnea index in from reduced protein synthesis patients with obstructive sleep apnea Malabsorption/protein-calorie Reduced protein synthesis leading to and found that even when adjusted for malnutrition decreased plasma oncotic pressure age, body mass index, and the presence Obstructive sleep apnea Pulmonary hypertension resulting in of hypertension and diabetes mellitus, increased capillary hydrostatic pressure the index was higher in patients who had Pregnancy and premenstrual edema Increased plasma volume edema.15 Renal disease Increased plasma volume; decreased plasma oncotic pressure from protein PHYSICAL EXAMINATION loss Localized The physical examination should assess Cellulitis Increased capillary permeability for systemic causes of edema, such as heart Chronic venous insufficiency Increased capillary permeability caused failure (e.g., jugular venous distention, by local venous hypertension crackles), renal disease (e.g., proteinuria, Compartment syndrome Increased capillary permeability caused oliguria), hepatic disease (e.g., jaundice, by local venous hypertension ascites, asterixis), or thyroid disease Complex regional pain syndrome type Neurogenically mediated increased 1 (reflex sympathetic dystrophy) capillary permeability (e.g., exophthalmos, tremor, weight loss). Deep venous thrombosis Increased capillary permeability Edema should also be evaluated for pit- Iliac vein obstruction Increased capillary permeability caused ting, tenderness, and skin changes. by local venous hypertension Pitting describes an indentation that Lipedema Accumulation of fluid in adipose tissue remains in the edematous area after pres- Lymphedema Lymphatic obstruction sure is applied (Figure 3). This occurs Primary: congenital lymphedema, when fluid in the interstitial space has lymphedema praecox, a low concentration of protein, which lymphedema tarda is associated with decreased plasma Secondary: from axillary lymph node dissection, surgery (e.g., oncotic pressure and disorders caused by coronary artery bypass graft, increased capillary pressure (e.g., DVT, inguinal lymphadenectomy), CHF, iliac vein compression).4,16 The phy- trauma, radiation, tumor, filariasis sician should describe the location, tim- May-Thurner syndrome (compression Increased capillary permeability caused ing, and extent of the pitting to determine of left iliac vein by right iliac artery) by local venous hypertension from compression treatment response. Lower extremity examination should focus on the medial Information from references 1 through 13. malleolus, the bony portion of the tibia, and the dorsum of the foot. Pitting edema July 15, 2013 ◆ Volume 88, Number 2 www.aafp.org/afp American Family Physician 103 Edema Table 2. Diagnosis and Management of Common Causes of Localized Edema Etiology Onset and location Examination findings Evaluation methods Treatment Unilateral predominance Chronic venous Onset: chronic; begins in Soft, pitting edema Duplex ultrasonography Compression stockings insufficiency middle to older age with reddish-hued Ankle-brachial index to Pneumatic compression Location: lower skin; predilection for evaluate for arterial device if stockings are extremities; bilateral medial ankle/calf insufficiency contraindicated distribution in later Associated findings: Horse chestnut seed extract stages venous ulcerations Skin care (e.g., emollients, over medial malleolus; topical steroids) weeping erosions Complex regional Onset: chronic; following Soft tissue edema distal History and examination Systemic steroids pain syndrome trauma or other inciting to affected limb Radiography Topical dimethyl sulfoxide type 1 (reflex event Associated findings: Three-phase bone solution sympathetic Location: upper or lower
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