Edema resident survival guide

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Edema Resident Survival Guide Microchapters

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sara Zand, M.D.[2]

Synonyms and keywords: Generalized edema, localized edema, unilateral edema, bilateral edema


Edema is an abnormal collection of fluid in interstitial space because of increased hydrostatic pressure, decreased oncotic pressure, increased capillary permeability, and obstruction in lymphatic drainage. Edema may be due to underlying systemic diseases such as nephrotic syndrome, right sided heart failure, hypothyroidism, hyperthyroidism, side effect of some drugs, complications of recent surgery and malignancy. Edema may be generalized due to cardiac, thyroid, kidney diseases or localized due to cellulitis, deep vein thrombosis (DVT), chronic venous insufficiency and lymphedema. Diagnosis is based on taking history of recent surgery, trauma, systemic illness, malignancy and doing physical examination about the distribution of edema and determination of pitting or non pitting edema, inducing pain on palpation. Duplex sonography is helpful for finding the evidence of DVT. For more investigation about localized edema with unknown etiology, abdominal computer tomography, magnetic resonance venography maybe required.


Life Threatening Causes of peripheral edema

Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated.

Common Causes of peripheral edema


Shown below is an algorithm summarizing the diagnosis of edema.[11][12][13][14][15][16][17][2][18][19][20][21][22][23]

Associated injury/illness
Recent surgery/procedure
Clinical history
Onset (acute,chronic)
Aggravated by activity
Systemic diseases
Changing in medications

Pulse examination
Physical examination
Skin texture, color

JVP estimation
Unilateral edema
Bilateral edema
Acute DVT, cellulitis, chronic venous insufficiency, lymphedema, tumor, baker cyst, trauma compartment syndrome, hematoma, complex regional pain syndrome, popliteal aneurysm, dependency
Non pitting, non tender
Pitting, tender
Chronic venous insufficiency, systemic illnesses
Normal cardiac size
Pulmonary evaluation for pulmonary hypertension or cor pulmonale
Serum albumin
Normal albumin
Decreased albumin
Thyroid function test
Urinary protein
24 hours proteinuria <3.5 gram
24 hours proteinuria >3.5 gram
Normal urinary sediment
Nephrotic syndrome
Liver function test
Prealbumin, cholesterol level
Evaluation for liver disease
Prealbumin<20 mg/dl, low cholesterol
Prealbumin>20 mg/dl
Capillary leak, protein losing entropathy, abnormal protein synthesis

Heart failure
Increased capillary hydrostatic pressure from systemic venous hypertension, volume overload
Hepatic disease
Increased capillary hydrostatic pressure from systemic venous hypertension, decreased oncotic pressure from reduced protein synthesis
Mechanism of Edema
Chronic venous insufficiency
Increased capillary hydrostatic pressure due to venous hypertension, venous reflux, poorly functioning venous valves, incompetent venous valves, reduced venous return, blood pooling, hypoxia, and inflammation
Lymphatic obstruction, lymph node dissection, malignancy, filariasis
Increased capillary permeability
Obstructive sleep apnea
Increased capillary hydrostatic pressure due to pulmonary hypertension
Renal disease
Increased capillary hydrostatic pressure and plasma volume, decreased plasma oncotic pressure from protein loss
Protein losing entropathy
Decreased plasma oncotic pressure
Deep vein thrombosis
Increased capillary hydrostatic pressure due to venous obstruction
Increased capillary permeability
Increased capillary hydrostatic pressure, increased plasma volume



Diagnostic tools:
Duplex sonography in patients with unilateral lower limb swelling and positive D-dimer or high clinical suspicion for thrombosis
❑ Abdominal or pelvic CT scan in patients with lower limb swelling and evidence of malygnancy
Magnetic resonance venography of the lower leg in patients with unilateral leg swelling without evidence of thrombosis on duplex ultrasonography if there is high clinical suspicion for deep venous thrombosis
Echocardiography in patients with obesity, obstructive sleep apnea, and edema for evaluation of pulmonary arterial pressures and also in patients with evidence of heart failure for assessment of ejection fraction and pulmonary artery pressure and structural heart disease.
Ankle-brachial index in patients with chronic venous insufficiency and cardiovascular risk factors before compression therapy in suspicion of peripheral arterial disease
Lymphoscintigraphy and magnetic resonance lymphangiography in patients with lymphedema


Shown below is an algorithm summarizing the treatment of edema.[24][25][26][1][27][28][29][30]

Congestive heart failure
Loop diuretic, sodium restriction, compression stocking
Nephrotic syndrome
Loop diuretic
Edema Treatment
Compression stocking, topical steroid , manual lymphatic dranage, bandage
Chronic venous insufficiency
Compression stocking, bandage, topical steroids, venoactive drugs such as daflon
Deep vein thrombosis
Anticoagulant therapy, early walking, compression stocking
Antibiotic therapy, compression stocking
External pneumatic compression, compression stockings
Suction lipectomy




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