Clinical Reasoning -- Edema

Edema

a palpable swelling produced by expansion of the interstitial fluid volume

an alteration in hemodynamics factors causes the movement of fluid from the vascular space into the interstitium

Edema occurs when..

Starling's law of the capillaries

the volume of fluid and solutes reabsorbed normally is almost as large as the volume filtered

congestive heart failure, cirrhosis, nephrotic syndrome, venous and lymphatic disease

conditions that can cause edema

Anasarca

severe generalized edema

increase

increased capillary permeability and decreased lymphatic drainage may also result in _______ fluid entry into the interstitium

interstitial fluid

excess __________ is manifested as edema.

capillary hydrostatic pressure, interstitial fluid hydrostatic pressure, capillary osmotic pressure, interstitial fluid pasmotic pressure.

Starling's forces are dependent on four factors. What are they?

increased capillary hydrostatic pressure, decreased interstitial hydrostatic pressure

what changes in pressure can cause fluids to move from the capillaries into the interstitium

within the cells

most water is found...

plasma and interstitial fluid

extracellular fluid subdivisions

Semipermeable membrane

partition between 2 fluid compartments which is only permeable to water

low, high

water moves from an area of ___ solute concentration to an area of ____ solution concentration bu osmosis to maintain equilibrium

the salt

water follows...

Tonicity

the concentration of dissolved substances that cannot cross the semipermeable membrane

fluid movement

Tonicity (osmotic pressure) dictates...

lower, higher

the body strives to maintain osmotic pressure equal in all compartments by moving water from Panarea of ______ tonicity to an area of _____ tonicity

increased ICP

what happens when the cells within the brain swell?

LE, UE, head and chest wall, periorbital area, peritoneal cavity, presacral area, EVERYWHERE (anasacra)

where can you have edema?

DVT, cellulitis, lymphedema, venous insufficiency, CHF, pregnancy, medication-related, idiopathic (dx of exclusion)

what can cause edema in the lower extremity?

DVT

any patient with bi/unilateral LE edema has a ____ until proven otherwise

DVT, cellulitis, lymphedema, SVC syndrome

what can cause edema in the upper extremity?

DVT

any patient with unilateral UE edema has a ____ until proven otherwise

SVC syndrome (head, chest wall, upper extremities); Nephrotic syndrome (periorbital area), liver failure (peritoneal cavity), pre-sacral area (bed-ride patients), anasarca (massive and generalized edema)

what can cause edema in MISC sites?

SVC syndrome

what can cause edema in the head, chest wall, and upper extremities?

nephrotic syndrome

what can cause edema in the periorbital area?

liver failure

what can cause edema in the peritoneal cavity?

bed-ridden patient

what can cause edema in the pre-sacral area?

DVT, cellulitis, pregnancy, lymphedema, SVC syndrome, venous insufficiency (diagnosis of exclusion)

local processes that can cause edema

CHF, liver failure, nephrotic syndrome, medication-related, idiopathic (dx of exclusion)

systemic processes that can cause edema

Starling's forces (capillary and interstitial hydrostatic and osmotic pressures), increased, lymphatic

Edema may be due to an imbalance of ______ or from _____ capillary permeability or _______ obstruction

deep venous thrombosis (DVT)

acute, unilateral (usually) lower or upper extremity swelling and pain; may be erythmatous; severe disease may affect perfusion (compartment syndrome)

Virchow's triad

postulates the presence of three factors that predisposes a person to develop vascular thrombosis.

venous stasis (immobility), vessel wall injury, hyper coagulability

what are the components of Virchow's triad?

recent surgery, recent prolonged trip, recent prolonged bedrest, morbid obesity, pregnancy, paralysis, extremity casting

what in a pt's history can indicate immobility/stasis?

recent (within last 3 months) vascular surgery, local venous trauma, central venous catheters (PICC lines), prior DVT

what in a pt's history can indicate vessel wall injury?

cancer, oral contraceptives, congenital clotting disorders (FH), pregnancy, postpartum state (highest risk)

what in a pt's history can indicate hypercoagulability?

edema, chest pain, SOB

the components of Virchow's triad are pertinent for those complaining of what associated symptoms...

Cellulitis

diffuse, acute infection of the skin marked by local heat, redness, pain, and swelling

similar prior epsideo, local trauma, underlying tinea pedis infection

causes of cellulitis

fever, chills, pain, erythema, swelling, warmth,lymphagnitis streaking, proximal lymphadenopathy

symptoms of cellulitis

those with diabetes mellitus or other immunosuppressed states

what populations are more at risk for cellulitis?

Lymphedema

non-tender, pitting edema.

local tumor, previous radiation therapy

what is a common cause of lymphedema in the LE?

history of breast cancer requiring axillary lymph node dissection, local tumor, previous radiation therapy

what is a common cause(s) of lymphedema in the UE?

lymph node dissection

what is a common cause of lymphedema as a whole?

SVC syndrome

syndrome caused by obstruction of the SVC, most commonly done by lung cancer; complain of headache and facial fullness; present with forehead and facial edema, venous distention of the neck and chest wall, and bilateral upper extremity edema.

headache, facial fullness

people with SVC syndrome tend to complain of __________

forehead and facial edema

people with SVC syndrome tend to present with __________

lung cancer

SVC syndrome is often secondary to...

increased venous pressure resulting from an enlarging uterus near term may lead to being lower extremity edema and varicosities

how does pregnancy cause edema?

acute DVT

one should always consider ________ in DDX of lower extremity swelling during pregnancy and in the postpartum state

Venous insufficiency

inadequacy of the venous valves and impairment of venous return from the lower limbs (venous stasis), often with edema and sometimes with skin ulcers (particularly at the ankles)

unilateral or bilateral edema

venous insufficiency may produce either...

brown hemosiderin

venous insufficiency is often associated with _______ skin deposits of the lower legs

older people, patients who site in wheelchairs for long periods of time

populations at risk for venous insufficiency

bilateral lower extremity swelling; may propagate to the groin and genital area in severe disease

how can CHF manifest as edema?

SOB, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, increased nocturia

what are some associated symptoms with CHF other than edema?

JVD

what is a common finding on neck exam for those with CHF?

S3

what is a common finding on heart exam for those with CHF?

bilateral rales

what is a common finding on lung exam for those with CHF?

hepatomegaly

what is a common finding on abdominal exam for those with CHF?

RUQ abdominal pain, clay-colored stools, dark urine, easy brushing, confusion, jaundice, scleral icterus, hepatomegaly and ascites

common findings in liver failure

Nephrotic syndrome

group of clinical signs and symptoms caused by excessive protein loss in urine

plasma osmotic pressure

in nephrotic syndrome, _______ drops resulting in edema

foamy urine

patients with nephrotic syndrome may complain of...

periorbital edema

children with nephrotic syndrome frequently present with...

DM/CT disease

adults with nephrotic syndrome may have underlying...

CCBs, NSAIDS, corticosteroids

what mediations can cause edema?

menstruating women in their 20s/30s; symptoms persist throughout the menstrual cycle (different from premenstrual edema)

idiopathic edema most commonly occurs in what population?

facial and hand edema in addition to leg swelling

common complaint associated with idiopathic edema

diuretics

abuse of what is common as self-treatment in idiopathic edema?

they are hypercoaguable

how does cancer meet Virchow's triad criteria?

venous stasis/hypercoagulable

how does pregnancy meet Virchow's triad criteria?