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LEG S W ELLIN G
Gatot Sugiharto, MD,
Internist
Internal Medicine
Department
Faculty of Medicine, Wijaya
Kusuma University Surabaya
Introduction
Edema:
Expansion of the interstitial fluid volume
Non-specific finding common to a host of
diseases
Reflects either:
Increased venous pressure
Decreased lymphatic drainage
Increased plasma volume
Or a combination
Severe Underlying Illness:
DVT
Heart failure
Severe volume overload
Pathophysilolgy
Starlings law:
Extravascular and intravascular hydrostatic
pressure
Differences in oncotic pressures within the
interstitial space and plasma;
The permeability of the blood vessel wall.
Vascular system
Interstitial space
Hydrostatic pressure
Hydrostatic pressure
Colloid oncotic pressure
(tissue
tension)
Colloid oncotic pressure
R ED U C ED P LA S M A
O S M O TIC P R ESS U R E
Albumin is the serum protein MOST
C A P ILLA R Y D A M A G E
H ISTO RY
P H YSIC A L EX A M
Blood Pressure, HR
Venous pressure, rhales, murmur / gallop
Ascites
asymmetry
varicose veins, scars
dermal changes, ulcers
degree of pitting (1-4+) [subjective]
ED EM A
Pitting
Pittingedema
edema
Non-pitting
Non-pittingedema
edema
TESTIN G
RFT, LFT, CBC, TFT, Albumin, U/A, thiroid
ECG + ECHO (LV/RV fctn, valve disease, PA
pressure)
BNP?
CXR
Venous Duplex U/S (DVT, venous insufficiency,
popliteal aneurysm or cyst)
CT abdomen/pelvis (suspected pelvic obstruction)
V/Q scan or CT-A
Cardiac cath (CHF, Pulmonary HTN, Contrictive /
Restrictive Cardiomyopathy)
Arterial doppler studies (if ulcer or before
compression Rx.)
LO C A LIZ ED ED EM A
Inflammation
Venous/lymphatic obstruction
Chronic lymphangitis
Resection of regional lymph nodes
Filariasis
A P P R O A C H TO TH E
PATIEN T
Heart
Liver
Kidney
Generaliz
Generaliz
ed
ed
or
Venous obstruction
Lymphatic obstruction
Localized
Localized
ClinicalCauses ofEdem a
Systemic
edema
Congestive heart failure
Cirrhosis
Nephrotic
syndrome/other
hypoalbuminemia
Drug-induced
Idiopathic
Localized
edema
Venous/lymphatic
obstruction
(2% of population)
Venous incompetence venous
hypertension
women, multiparity, estrogen use
- hereditary
occupational (prolonged standing)
post-phlebitic syndrome
iatrogenic (CABG, FPBPG, pelvic
surgery)
obesity, age
C hronic Venous
(2)
I
nsuf
c
i
f
i
ency
Unilateral or bilateral
Exacerbated by prolonged standing, or
hot days
Typically worse in PM, less upon arising
Often complain of generalized leg aching
Often hyperpigmentation due to
hemosiderin deposition
(lipodermatosclerosis thick, brawny
skin)
TR EATM EN T
Venous Insufficiency
life-style changes : weight loss,
limit dietary salt, exercise (calf
muscle pump) avoid prolonged
immobility, standing
leg elevation (night, 30min 3-4X
daily)
Graduated compression
stockings : mainstay of treatment
(30-40mmHg @ ankle)
Diuretics
Age > 50
Immobilization / surgery /
GA
Hx. DVT
Malignant disease /
hypercoaguable state
Pregnancy hormonal
contraception
Trauma
D rugs:
Antihypertensives
Ca-blockers* Vasodilators (minoxidil,
NSAIDs
Hormones
estrogens, testosterone, corticosteroids,
progesterone, androgens
Hypoglycemics
thioglitazones
Antidepressants
R EN A L D IS EA S ES
Mainly due to hypoabluminemia
N
H R primary
O TIC
EP
The
alteration:
S Ydecreased
N D R O M E/Hcolloid
Y P O A LBoncotic
U M IN EM IC
S TATES
C O N G ES TIV E H EA R T
FA
I
LU
R
E
Left-sided heart failure: shortness of
breath with exertion and when lying down
at night pulmonary edema
Right-sided heart failure: swelling in the
legs and feet, peripheral edema
The physician examining a patient who
has congestive heart failure with fluid
retention looks for certain signs: pitting
edema; rales in the lungs, a gallop
rhythm, distended neck veins,
hepatomegali, ascites
Systemic Edema
Congestive heart failure
the lower
periobital areas
of the body
Progression
progress quickly
D IFFER EN TIA L D IA G
slowly
Identity
soft and mobile
relatively solid, less
mobile
Other signs
proteinuria
heart failure:
hypertension
cardiac enlargement
impaired renal
venous distention
functional test
hepatomegaly
part
progress
N O S IS
signs of
LIV ER D IS EA S ES (C IR R H O S IS )
ascites
Systemic Edema
ID IO PATH IC ED EM A
Exclusive in women
Periodic episodes
Accompanied by abdominal
distention
ID IO PATH IC ED EM A
Diurnal alterations in weight
O TH ER C A U S ES O F ED EM A
Hypothyroidism (myxedema,