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A Guide to Peripheral Oedema

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A Guide to Peripheral Oedema PEER REVIEWED FEATURE 2 CPD POINTS A guide to peripheral oedema GAYATHRI KUMARASINGHE MB BS, FRACP GERARD CARROLL AM, MB BS(Hons), FRACP, FCSANZ Peripheral oedema is a nonspecific symptom with a wide range of potential causes. A systematic time-efficient review of the patient will aid in differentiating the benign from the more serious causes, guide initial investigations and determine who can be managed in the community and who requires specialist referral or hospitalisation. eripheral oedema is a nonspecific finding common to a KEY POINTS wide range of medical conditions and can therefore pose a diagnostic challenge. The causes range from benign • The differential diagnosis of peripheral oedema is wide, conditions that can be managed in the community to requiring a systematic approach for diagnosis and Pmajor organ failure requiring specialist referral or hospitali- management. sation. A systematic review of the patient and rational, cost- • Initial assessment of whether the oedema is generalised effective investigations are recommended as initial steps in or localised is essential to tailor the differential diagnosis. management. • Patients whose condition is stable with localised disease processes can be investigated and managed in the Here we outline conditions that can cause peripheral oedema, community. details of history taking and examination, and baseline invest- • Patients with signs of advanced heart failure or of hepatic igations aimed at refining the differential diagnosis and guiding or renal disease require early specialist involvement or management and referral. hospital admission. • Constrictive pericarditis is a medical emergency that can Physiological mechanisms of peripheral oedema present with peripheral oedema. A high index of suspicion Peripheral oedema is most commonly caused by extravasation is required and patients with suggestive signs should be of fluid from the vasculature into the interstitium as a result of referred for urgent cardiologist review. altered vascular haemodynamics. Starling described the phys- iological mechanisms causing peripheral oedema as:1 • increased intravascular hydrostatic pressure • decreased intravascular or plasma oncotic (colloid osmotic) pressure • increased vascular permeability. MedicineToday 2015; 16(6): 26-34 Any one or more of these factors can underlie peripheral oedema (Figure 1). 2 Other important causes of peripheral oedema include: Dr Kumarasinghe is a Consultant Cardiologist at the Mater Hospital, Sydney. • impaired lymphatic flow Copyright _Layout 1 17/01/12 1:43 PM Page 4 Professor Carroll is a Consultant Physician and Cardiologist at Riverina • pregnancy IAN LISHMAN/JUICE IMAGES/DIOMEDIA.COM LISHMAN/JUICE IAN Cardiology, Wagga Wagga, and the Mater Hospital, Sydney, NSW. • physiological changes, such as cyclical premenstrual changes. © 26 MedicineToday ❙ JUNE 2015, VOLUME 16, NUMBER 6 Downloaded for personal use only. No other uses permitted without permission. © MedicineToday 2015. Causes of peripheral oedema Conditions that are associated with gen- Decreased Increased Precapillary interstitial interstitial eralised or localised peripheral oedema sphincter hydrostatic oncotic are summarised in Figure 2. pressure pressure Generalised peripheral oedema Vein Heart failure Artery Heart failure is a common and serious Lymphatics Lymphoedema cause of generalised peripheral oedema (Figure 3). Left heart failure – either sys- Increased capillary Increased Decreased plasma hydrostatic pressure capillary oncotic pressure tolic or diastolic – can cause pulmonary • Venous obstruction permeability • Malabsorption oedema, giving rise to dyspnoea. Right • Hepatic cirrhosis • Nephrotic syndrome heart failure causes peripheral oedema, • Heart failure • Liver failure pleural effusions and sometimes ascites, • Constrictive • Malnutrition which can be exacerbated by severe tri- pericarditis • Restrictive cuspid regurgitation. cardiomyopathy In heart failure, the inability of the • Renal failure heart to effectively circulate blood volume • Pregnancy throughout the body leads to increased venous pressure that is transmitted to the Figure 1. Changes in vascular haemodynamics underlying peripheral oedema. capillaries. This causes extravasation of Adapted from Cho S. Am J Med 2002; 113: 580-586.2 electrolytes and fluid into the interstitium, producing oedema. A low-output state and hypoperfusion of vital organs lead to Localised oedema Generalised oedema neurohormonal activation, which aims to restore circulatory homeostasis but in effect worsens cardiac failure and exacer- Myxoedema bates oedema. Neurohormonal activation includes stimulation of the sympathetic nervous system, which leads to peripheral Heart failure vasoconstriction and increases cardiac Lymphoedema Constrictive pericarditis inotropy and chronotropy, thereby Restrictive cardiomyopathy increasing afterload and cardiac work. The release of additional neurohormones Hepatic cirrhosis of the renin–angiotensin–aldosterone Nephrotic syndrome system causes sodium and water retention, End-stage renal failure while arginine vasopressin (AVP) causes Acute renal failure further water retention and peripheral vasoconstriction. The natriuretic peptides, atrial (ANP) Nutritional deficiency and B-type (BNP), are markers of atrial Lipoedema and ventricular distension and are elevated in heart failure. Serum BNP levels can Pregnancy Premenstrual disorder therefore be used to determine whether heart failure is the cause of peripheral Venous incompetence oedema. Deep vein thrombosis Medications Dermatitis Constrictive pericarditis and restrictive Cellulitis cardiomyopathy Constrictive pericarditisCopyright and _Layout restrictive 1 17/01/12 Figure 1:43 2. PMCauses Page of 4generalised and localised peripheral oedema. PHOTOBANK GALLERY/SHUTTERSTOCK PHOTOBANK © cardiomyopathy are less common causes MedicineToday ❙ JUNE 2015, VOLUME 16, NUMBER 6 27 Downloaded for personal use only. No other uses permitted without permission. © MedicineToday 2015. PERIPHERAL OEDEMA continued a. Normal heart b. Dilated cardiomyopathy cardiac tamponade, which is a cardiac emergency. If there is any clinical suspi- cion of tamponade (e.g. dyspnoea, elevated jugular venous pressure and signs of right heart failure) then patients require urgent cardiology referral. Hepatic cirrhosis End-stage liver disease predominantly causes ascites, but patients also often present with bipedal oedema. Oedema arises due to: • severe hypoalbuminaemia • salt and water retention • formation of multiple arteriovenous c. Constrictive pericarditis d. Restrictive cardiomyopathy fistulae. Ascites can be severe, and care is needed when performing paracentesis to prevent sudden fluid shifts. Plasma volume and oncotic pressure should be maintained by administering intrave- nous 20% concentrated albumin while performing slow paracentesis over a few days. Renal disease Nephrotic syndrome, acute renal failure and end-stage renal failure can all give rise to peripheral oedema. Nephrotic syn- drome is characterised by peripheral Thickened pericardium Stiff heart muscle © CHRIS WIKOFF, 2015 oedema in association with high-level Figures 3a to d. Cardiac conditions that can cause peripheral oedema. a. Healthy heart. proteinuria, low serum albumin levels and b. Dilated cardiomyopathy with poor systolic and diastolic function of the heart, causing high serum cholesterol levels. Diabetic peripheral oedema. c. Constrictive pericarditis causing impaired venous return. d. Restrictive cardiomyopathy causing impaired relaxation of the heart and diastolic heart failure. nephropathy is a common cause of pro- teinuria in adults. Acute renal failure caused by severe renal insults and end- of peripheral oedema but are important therapy, malignancy and idiopathic stage renal failure can be associated with differential diagnoses to consider (Figure causes. Worldwide, the most common oliguria or anuria accompanied by fluid 3). Patients with either of these conditions cause is tuberculosis. retention, generalised oedema and present with dyspnoea and elevated jugular The causes of restrictive cardiomyo- elevated central venous pressure. venous pressure and often have signs of pathy include: hepatic congestion and ascites as well as • infiltrative diseases such as amyloid- Medications peripheral oedema. Echocardiography osis and haemochromatosis Peripheral oedema is a common side effect usually shows normal left ventricular • connective tissue diseases such as of medications, including: systolic function, but Doppler readings can scleroderma • calcium channel blockers (e.g. be used to diagnose pericardial constriction • hypertrophic cardiomyopathy. dihydropyridines such as nifedipine, or restriction. Both constrictive pericarditis and amlodipine, felodipine and lercan- In Australia, the more common causes restrictive cardiomyopathy require imag- idipine, and nondihydropyridines of constrictive pericarditis include con- ing and right heart catheterisation for such as verapamil and diltiazem) nective tissue diseases,Copyright recurrent _Layout acute 1 17/01/12 definitive 1:43 PM diagnosis. Page 4 • vasodilators (e.g. minoxidil and less pericarditis, previous surgery or radiation Constrictive pericarditis can cause commonly hydralazine) 28 MedicineToday ❙ JUNE 2015, VOLUME 16, NUMBER 6 Downloaded for personal use only. No other uses permitted without permission. © MedicineToday 2015. • NSAIDs high-output cardiac failure in patients venous return. This may present with • corticosteroids with severe hyperthyroidism.
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