Edema

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Student project on EDEMA (3rd MBBS,University of Med,Mandalay, Myanmar)

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PATHOPHYSIOLOGY OF EDEMA:

PATHOPHYSIOLOGY OF EDEMA . 8.3.2013 1

3rd MBBS Morning Group A1 (Roll No. 1-10):

3 rd MBBS Morning Group A1 (Roll No. 1-10) Kay Zin Soe K Thari Swe Kaung Sett Lwin Kaung Zaw Htet Kaung Htet Kyaw Kaung Htet Kyaw Kaung Htet Lin Kaung Naing Maw Kaung Myat Kyawe Kaung Myat Phyoe 8.3.2013 2

DEFINITION:

DEFINITION Oedema results from the accumulation of excess fluid in the interstitial space s or serous cavities. 8.3.2013 3

Classification:

Classification Depending on nature of fluid Inflammatory edema ( due to increased vascular permeability ) Non-inflammatory edema ( due to osmotic or hydrostatic pressure imbalance) 8.3.2013 4

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. Depending on site of collection Generalized edema due to transudation of salt and water, as in e.g - hypoproteinemic syndrome congestive cardiac failure acute glomerular nephritis nephrotic syndrome cirrhosis Localized edema d ue to increased permeability of small blood vessels, e.g , infection, trauma, burns, allergy lymphatic obstruction, e.g – malignancy, filariasis , chronic infection. venous obstruction, e.g – thrombosis, malignant infiltration 8.3.2013 6

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. Causes of Edema (Mnemonics) THE LEAK OF VEINS T umor H eart failure E nteropathy (protein-losing) L iver failure E ndocrine (hypothyroidism, aldosterones,diabetes ) A ltitude sickness K idney disease (renal failure, nephrotic syndrome) O bstruction of lymphatics F ilariasis V enous thrombosis E clampsia / pregnancy I atrogenic N utritional deficiency S epsis / capillary leakage (from Davidson Differential Diagnosis Mnemonics) 8.3.2013 7

General Principles in the formation of Interstitial Fluid:

General Principles in the formation of Interstitial Fluid About 24 litres of fluid are filtered through the capillaries per day. 85 % - reabsorbed into the capillaries . 15 % - returned to the circulation via lymphatics The formation of ISF is regulated according to the Starling hypothesis , which incorporates 5 factors – capillary hydrostatic pressure, interstitial tissue pressure, plasma oncotic pressure, endothelial permeability and lymphatic function. 8.3.2013 8

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. The arterial hydrostatic pressure, in excess of tissue pressure, tends to cause transudation of salt and water out of the capillaries The oncotic pressure of plasma proteins tends to draw fluid back in . There is thus on overall loss of fluid from the capillary at its arterial end, reabsorption at the venous end . About 15% of fluid accumulating in the interstitial space passes into lymphatic vessels. From here, it passes into the general circulation via the main lymphatic channels. 8.3.2013 10

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A low plasma oncotic pressure or increased hydrostatic pressure at the venous end of capillary will tend to cause edema . 8.3.2013 11

Generalized Edema :

Generalized Edema Na+ is the most important osmotically active constituent of the ECF. The control of EFC volume ( & the formation of edema) mainly control by the factors that regulate the accumulation of Na+ in the body and excretion of Na+ by the kidneys . About 85% of filtered Na + is reabsorbed in proximal convoluted tubules . The remaining 15% is variably reabsorbed in the distal tubule , partly with Cl - ions and partly in exchange for K + a nd H + ions. 8.3.2013 12

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The regulation of sodium excretion is probably mainly through adjustment of this 15 %. 'Aldosterone ' effects on distal renal tubule, causing Na + reabsorption and K + excretion. This effect is blocked by spironolactone. 8.3.2013 13

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Angiotensin II Stimulate " aldosterone " secretion from adrenal cortex Vasoconstriction Secretion of ADH by acting on hypothalamus Final result is salt & water retentions . 8.3.2013 15

Generalized Edema:

Generalized Edema 8.3.2013 16

Hypoproteinemic State :

Hypoproteinemic State The major part of plasma oncotic pressure can be attributed to its albumin content . Hypoalbuminemia may be due to - failure of synthesis protein malnutrition (Kwashiorkor ) cirrhosis long lasting ill-health from many causes increased loss as in nrephrotic syndrome . When serum albumin falls below 25 g/l, there is transudation of solutes (mainly salt and water) out of the capillaries into intercellular space. When this comportment is expanded by about 10%, clinically evident edema appears. 8.3.2013 17

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. . ↓ Plasma protein level (esp . albumin) ↓oncotic pressure transudation of solutes Edema 8.3.2013 18

Heart Failure:

Heart Failure ↓ Cardiac output Accumulation of fluid in LV Congestion of blood in LA Congestion of blood in pulmonary veins ↑ Capillary hydrostatic pressure Pulmonary edema ↓ Effective arterial blood volume ↓ Renal perfusion RAA System activation ↑ADH ↑aldosterone Salt & water retentions Fluid overload Left Heart Failure 8.3.2013 19

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. ↓ Contraction of RV Congestion of RA Congestion of SVC & IVC ↑Congestion in venules & capillaries ↓Cardiac output from LV ↓Arterial Blood Volume RAA System activation ↑ADH Salt & Water retentions Right Heart Failure Generalized Edema 8.3.2013 20

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Passive congestion of " Liver“ Liver function ↓ Plasma protein synthesis ↓ Plasma oncotic pressure Generalized Edema In Heart failure, unless the cardiac output is restored or renal sodium and water retention is reduced (e.g.- diuretics, or aldosterone antagonists), fluid retentions occurs and edema worsens. 8.3.2013 21

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. Nephrotic Syndrome H eavy Proteinuria Hypoalbuminuria Leaky glomerular capillary wall ↓ Plasma oncotic pressure Generalized edema Fluid retention Hypervolemia Salt & Water RAA system Retention 8.3.2013 23

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Cirrhosis :

Cirrhosis Cirrhosis Nodule & fibrosis plasma protein synthesis Sinusoidal hypertension ↓ oncotic pressure Portal Hypertension Generalize Edema Ascities 8.3.2013 25

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Investigations of Generalized edema :

Investigations of Generalized edema Chest X-ray - sign of heart failure, cardiomegaly Plasma albumin - low in nephrotic syndrome, cirrhosis, malnutrition Blood urea and electrolytes - diminished GFR in renal disease or in severe cardiac failure 8.3.2013 27

Localized edema :

Localized edema Oedema due to increased Permeability of small Blood vessels Increased permeability is due to local release of inflammatory mediators, e.g.-histamine, bradykinin , and cytokines ,which cause vasodilation and increase capillary permeability. e.g . Acute inflammatory edema(e.g .- infection) Allergic edema 8.3.2013 28

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. Angio -edema is a specific form of allergic edema, affecting face, lip & mouth. Swelling may develop rapidly and may be life-threatening if upper airway is involved. 8.3.2013 30

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. (2)Lymphatic Obstruction Impaired lymphatic drainage result in edema ( lymphedema ). Lymph vessels have a large collateral circulation, so that , with any block, edema extend over a wide area . Secondary cancer in lymph nodes may cause edema , but usually the block is more extensive by dissection of nodes and radiography , e.g.-in the treatment of breast cancer . In filariasis , lymphatic obstruction occurs due to the widespread fibrosis in lymphatic channels caused by the adult filarial worms. 8.3.2013 31

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. (3)Venous obstruction Major cause - deep vein thrombosis, external pressure from a tumor or pregnancy, or valvular incompitance . SVCO is caused by a tumor in superior mediastinum, commonly lung cancer. 8.3.2013 33

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Investigations of Localized edema :

Investigations of Localized edema Chest X-ray – SVCO Pelvic ultrasound or CT scan – pelvic tumor or lymphatic enlargement Lymphangiography – abnormal lymphatic architecture, lymph nodes replaced by tumor Doppler ultrasound or venography – to confirm diagnosis of venous obstruction 8.3.2013 35

Examination of Edema:

Examination of Edema Apply firm pressure with your thumb for at least 15 sec on antero -medial aspect of shin. ( Macleod’s ) Finger pressure leaves temporary indentions in the skin Pitting Edema Lymphoedema and myxoedema do not pit on pressure. 8.3.2013 36

References:

References Macleod's Clinical Examination, 12 th Edition Robbins and Cotran Pathologic Basis of Disease,8 th Edition Davidson's Principles & Practice of Medicine, 21 st Edition Tutorials in Differential Diagnosis, 4 th Edition Dr. Daw Myint Myint Khin's Symptom Analysis Internet Websites. 8.3.2013 37

Case Discussion:

Case Discussion Presented By Ma Kay Zin Soe

Patient’s History :

Patient’s History Particulars of the patient A 64 year old, gentleman, U Hla Win, a bank manager, was admitted to MU (II), MGH on 23.2.2013 with the chief complaint of - Breathlessness for 3 months Swelling of the leg for 2 weeks Cough for 2 weeks

History of Present Illness:

History of Present Illness Breathlessness - The patient complained of breathlessness for 3 months which worsen in cold weather and at night. He was not able to lie flat (orthopnoea) and woke up at night due to difficulty in breathing (PND). He was dyspnoeic at rest and couldn’t do light works. ( Dyspnoea on exertion ) NYHA- grade IV Cough - The patient complained of dry cough sometimes with sputum (white color ). He became dyspnoeic after coughing and also complained of wheezing . Swelling of the leg - He had swelling of the leg for 2 weeks. It started from foot and progressed to the knee. There is swelling of the abdomen . Associated symptoms- He has palpitation when hungry but no chest pain.

System Review:

System Review On reviewing respiratory system, he has cough sometimes with sputum , dyspnoea , wheezing but no haemoptysis and chest pain. On reviewing gastrointestinal system, he has loss of appetite, abdominal distension but no vomiting, nausea , indigestion, heartburn, abdominal pain and change in bowel habit. On reviewing genito -urinary system, he has reduced urine output but no dysuria and haematuria . There are no cardinal symptoms of central nervous system such as headache, dizziness, faints, fits, altered sensation, weakness, visual disturbance, hearing problems. On reviewing endocrine system, he has palpitation but neither fine finger tremor nor eye signs.

Past Medical and Surgical History :

Past Medical and Surgical History The patient has a history of tuberculosis in 1994 and took proper medication. He has no history of hospitalization, blood transfusion, rheumatic fever, hepatitis, heart disease, diabetes mellitus and hypertension.

Family History :

Family History He is married and has 9 children. All are healthy. There is no sign of similar illness in his family.

Drug History :

Drug History He has no regular taking drugs and no known drug allergy.

Social History :

Social History He had been smoking for about 30 years and betel chewing for about 20years. He has a habit of alcohol drinking .

Physical Examination:

Physical Examination General Survey A 64 year old gentleman with average height and weight is lying in his bed. He is well conscious and well cooperated. He is rather dyspnoeic but not restless. (He is given oxygen ). A canular is inserted in the right hand. No gynaecomastia and no spider naevi .

General Examination :

General Examination Forehead - febrile Eye-pallor (-), jaundice (+) , subconjunctival hemorrhage (-), xanthelesma (-), corneal arcus (+) , features of Horner’s syndrome Nose- nasal flaring (-), nasal polyp (-) Ear and nose discharge- discharge (-) Mouth- angular stomatitis (-) Lips- tobacco staining (-), pursed lip breathing (-)

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Tongue- central cyanosis (-), oral thrush (-) Teeth and gums - dental caries (+) Tonsillar enlargement (-) Neck- dilated veins (+), visible neck gland enlargement (-), accessory muscles of respiration are working, supraclavicular excavatum (+) Upper extremities - clubbing (+), peripheral cyanosis (-), pallor (-), flapping tremor (-), features of CO 2 retention (-), Osler’s node (-), Janeway’s leision (-) Lower extremities- peripheral cyanosis (-), clubbing (+), dependent oedema (+)

Systemic Examination:

Systemic Examination Cardiovascular System Pulse Rate-68 beats/min Rhythm- regular Volume- moderate Character- no special character Condition of the vessel wall- not thickened Equality on both sides-equal on both sides Radio-femoral delay- no radio-femoral delay All peripheral pulses are intact Blood pressure-100/ 70 mmHg JVP-5.5cm above the sternal angle(raised)

Examination of the Precordium :

Examination of the Precordium Inspection -shape of the chest is symmetrical on both side and there is no precordial bulging. Diffuse precordial pulsation is not seen. Apex beat not visible. There is no epigastric pulsation. There is no scar, skin lesion, dilated veins over the Precordium .

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Palpation- apex beat is palpable at left 5 th ICS within the midclavicular line with normal character and no thrill. There is no left parasternal heave. There is no epigastric pulsation. There is palpable P2 but no palpable A2. Percussion - is omitted . (not pericardial effusion) Auscultation - - At the MITRAL AREA-normal first and second heart sounds. No added sound and no murmur. - At the TRICUSPID AREA- normal first and second heart sounds. No added sound and no murmur. - At the PULMONARY AREA -normal first heart sound and loud second heart sound . No added sound and no murmur. - At the AORTIC AREA- normal first and second heart sounds. No added sound and no murmur.

Signs of Congested Heart Failure :

Signs of Congested Heart Failure Raised JVP(+) Bilateral fine basal crepitation (+) Dependent bilateral oedema (+) Enlarge tender liver (-)

Respiratory System :

Respiratory System Lying position Inspection -Shape of the chest is symmetrical on both sides. Respiratory rate is 15 times/min. -Chest wall movement is symmetrical on both sides . -Apex beat is not visible. -There is no scar, skin lesion, dilated veins. There is no supraclavicular , suprasternal , intercostal , sub costal muscles indrawing .

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Palpation - trachea is slightly deviated to right . Chest wall movement is symmetrical on both sides. Vocal fremitus is reduced on left lower zone. Palpable accompaniments are absent. Percussion - normal resonance (+). Liver dullness starts at 5 th ICS . Cardiac dullness is from 2 nd to 5 th ICS . Auscultation - vesicular breath sound with r onchi is heard all over the lungs' field. Vocal resonance is reduced on the left lower zone.

Sitting position :

Sitting position Inspection- shape of the chest wall is symmetrical on both sides. Chest wall movements are equal on both sides. There is a cyst on the right upper part of the back. Palpation -chest wall movements are symmetrical on both sides. Vocal fremitus is reduced on the left lower zone . Percussion - normal r esonance ispressent all over the lungs' field . Auscultation- vesicular breath sound with bilateral basal crepitation is heard . Vocal resonance is reduced on the left lower zone.

Abdominal Examination :

Abdominal Examination Inspection- Contour is normal, flanks are full, abdomen moves with respiration, no visible mass, no visible peristalsis, no scar, skin lesions and dilated veins. Palpation- There is no tenderness and no palpable mass. Liver and spleen are not palpable. Kidneys are not blottable . Percussion - shifting dullness (+) Auscultation - Normal bowel sounds are present.

Differential diagnosis :

Differential diagnosis Generalize oedema and ascities are present, so this may be due to Congested cardiac failure Acute glomerulonephritis Nephrotic syndrome Cirrhosis of liver The patients has clubbed fingers and ascites which are the characteristics of cirrhosis of liver but no palmar erythema,no spider naevi , no gynaecomastia , no splenomegaly,no haematamesis , no malena . Therefore cirrhosis of liver is excluded.

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The patient has no smoky urine(no proteinuria ), no haematuria. So, Nephrotic syndrome and acute glomerulonephritis are excluded. And there is no weight loss, no diarrhea, and no steatorrhoea . Therefore nutritional disorder is excluded. Signs of heart failure such as dyspnoea , orthopnoea , PND, cough, ascites , ankle oedema are present.

Provisional Diagnosis :

Provisional Diagnosis Congested cardiac failure

Investigation :

Investigation ECG , Chest X-ray, Echocardiography, Blood for complete picture, Ultrasound abdomen, Urine REME, Serum electrolytes LFTs

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