Anasarca

Anasarca
CT scan showing generalized edema of skin
ICD-10	R60.1
ICD-9	782.3

Anasarca Microchapters
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Patient Information
Overview
Classification
Causes
Differential Diagnosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Mydah Sajid, MD[2]

Synonyms and keywords: Generalized edema, generalized swelling, leucophlegmatia

Overview

Edema is characterized by the collection of excess fluid in the interstitial space. Anasarca is severe edema characterized by generalized swelling throughout the body. The main underlying cause of edema is an imbalance in the hemodynamic status of the capillaries resulting in excess filtration of fluid in the intercellular space due to increased hydrostatic pressure, increased permeability of the capillaries and decreased oncotic pressure. It exceeds the absorptive capacity of lymph vessels. It can be caused by systemic diseases including chronic heart failure, liver cirrhosis, hypersensitivity reaction, and chronic renal failure.

Classification

The edema is classified in different types depending upon the severity of fluid accumulation assessed clinically:

Grade	Visibility of edema	Pitting over tibia	Level of edema
0+	No	Absent	Cannot assess
1+	Yes	Slight	Cannot assess
2+	Yes	Moderate	Below knee
3+	Yes	Moderate	Above knee
4+	Yes	Severe (cannot reach tibia)	Above knee

Causes

Life-threatening Causes

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

• Burns
• Anaphylaxis

Common Causes

Common causes of anasarca may include the following:

• Congestive cardiac failure
• Urticaria
• Hepatic cirrhosis
• Renal failure
• Kwashiorkor disease
• Obstructive sleep apnea
• Pregnancy
• Nephrotic syndrome
• Use of certain medications (Beta blockers, calcium channel blockers, clonidine, methyldopa, hydralazine, androgen, corticosteroid)

Differential Diagnosis

On the basis of onset of symptoms, ascities, and hypertension, anasarca must be differentiated from congestive heart failure, chronic kidney disease, liver cirrhosis, anaphylaxis, nephrotic syndrome, and protein-calorie malnutrition.

Diseases	Clinical manifestation						Para-clinical findings		Gold Standard
	Onset	Abdominal distention due to ascities	Associated symptoms	Blood pressure	Tachycardia	Physical examination findings	Lab findings	Imaging
Congestive Cardiac Failure	Chronic	+	Dyspnea,Orthopnea, Proxysmal nocturnal dyspnea	↓ /↑	+	Tachypnea, jugular venous distention, elevated CVP, S3, decreased breath sounds in lower lung fields, hepatojugular reflex	Elevated BNP	Chest X-ray: Cardiomegaly, pleural effusion, Berkley lines Cardiac ECHO: Reduced Ejection fraction	LVEF on echocardiography
Liver cirrhosis	Chronic	+	Nausea,vomitting, jaundice, telangiactesia, palmar erythema, hematemsis, anorectal varicies	↓	-	Jaundice, pallor, caput meducae, splenomegaly, inintially hepatomegaly, clubbing, Dupuytren's contracture	Elevated ALP, AST, ALT, GGT, bilirubin, hypoalbuminemia, prolonged prothrombin time	USG liver will show cirrhotic, irregular nodular liver with increased echogenicity.	Liver biopsy
Chronic kidney disease	Chronic	+	Anorexia, Nausea, bleeding, fatigue, weakness	↑	+	Pallor, tachypnea, pericardial friction rub, crackles on chest ascultation, uremic fetor	Elevated BUN,creatinine, decrease hemoglobin, acidosis, hyperkalemia, elevated TAG	USG kidney will show atrophied kidney with cortical thinning and increased echogenecity.	GFR
Protein losing nephropathy	Chronic	+	Dyspnea, headache, irratibility, bacterial or viral infections, recent H/O of URTI	↑ /N	+/-	Hematuria in some patients, Facial malar rash in SLE patients.	Hypoalbuminemia, 24 hour urine protein excretion>3.5g, Elevated TAG and cholesterol.	USG kidney may show increased echogenecity.	Renal biopsy
Protein Calorie malnutrition	Chronic	+	Muscle wasting, stunted growth, swollen face, dry skin, brittle hair	↓ /N	+	Hepatomegaly, Scaling, hyperpigmentation and hypopigmentation of skin	Hypoalbuminemia	NA	NA
Allergic reactions	Acute	-	Dyspnea, difficulty breathing, raised erythematous skin rashes, abdominal cramping	↓	+	Bronchial wheezing on chest ascultation	Elevated tryptase and plasma histamine levels	NA	NA
Pregnancy	Chronic	-	Amenorrhea, morning sickness, fatigue, breast tenderness, constipation, back pain	↓	+	Fundal height of the fetus, pallor, melasma	Urine pregnancy test positive, increased serum beta hcG	USG Abdomen will show an intrauterine pregnancy.	Blood levels of beta hcG
Medication-induced	Chronic	-	Temporal relation between medicine intake and appearance of symptoms	N/ ↓	-	Specific to the medication	Resolution of symptoms after discontinuing medication	NA	NA
Obstructive sleep apnea	Chronic	Due to obesity	Snoring, Frequent night-time awakening, daytime drowsiness	↑	-	High BMI, increase neck size and waist circumference, enlarged tongue, hypertrophy of tonsils, enlarged uvula, nasal polyps and high arched palate.	Polysomnography	NA	Polysomnography

Abbreviations: CVP: Central venous pressure, BNP: Brain natriuretic peptide, LVEF: Left ventricular ejection fraction, ALP: Alkaline phosphatase, AST: Aspartate transferase, ALT: Alanine transferase, GGT: Gamma Glutamyl transferase, BUN: Blood urea nitrogen, N: Normal, TAG: Triglycerides, URTI: Upper respiratory tract infection, USG: Ultrasound, hcG: human chorionic gonadotropin, BMI: Body mass index, N/A: Not applicable.

Treatment

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