Edema resident survival guide

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Edema Resident Survival Guide Microchapters
Overview
Causes
Diagnosis
Treatment
Do's
Don'ts


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

Overview

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.

Causes

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

Diagnosis

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
 
 
 
 
 
 
 
 
Malignancy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Painful
 
 
 
 
 
Clinical history
 
 
 
 
 
Onset (acute,chronic)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Aggravated by activity
 
 
 
 
 
 
 
 
Systemic diseases
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Changing in medications
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


 
 
 
 
 
 
 
 
 
 
 
 
 
Pulse examination
 
 
 
 
 
 
 
 
 
 
 
Ulcer
 
 
 
 
 
 
 
 
Lymphadenopathy/masses
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Pitting
 
 
 
 
 
Physical examination
 
 
 
 
 
Unilateral/bilateral
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Skin texture, color
 
 
 
 
 
 
 
 
Distribution
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Temperature
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 



 
 
 
 
 
 
 
 
Edema
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Generalized
 
 
 
 
 
 
 
Localized
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
JVP estimation
 
 
 
 
 
Unilateral edema
 
 
 
Bilateral edema
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Normal
 
Prominent
 
 
 
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
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Lymphedema
 
Chronic venous insufficiency, systemic illnesses
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Normal cardiac size
 
 
 
Cardiomegaly
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Pulmonary evaluation for pulmonary hypertension or cor pulmonale
 
 
 
Echocardiography
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Normal
 
Abnormal
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Prealbumin, cholesterol level
 
Evaluation for liver disease
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Prealbumin<20 mg/dl, low cholesterol
 
Malnutrition
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Lymphedema
 
Lymphatic obstruction, lymph node dissection, malignancy, filariasis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Cellulitis
 
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
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Cellulitis
 
Increased capillary permeability
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Pregnancy
 
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
 
 
 
 


Treatment

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
 
 
 
 
Lymphedema
 
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
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Cellulitis
 
Antibiotic therapy, compression stocking
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Pregnancy
 
External pneumatic compression, compression stockings
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Lipedema
 
Suction lipectomy
 
 
 
 
 
 

Do's

Dont's

References

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