DEFINITION OF EDEMA

The Accumulation of AbnormalAmounts of Extravascular,

Extracellular Fluid.

ANASARCA: Severe, widelydistributed pitting edema.

TYPES OF EDEMA

LOCALIZEDGENERALIZED

•Inflammation•Lymphatic Obstruction•Venous Obstruction•Thrombophlebitis

•CARDIAC•HEPATIC•RENAL

NEPHROTIC SYNDROMEACUTE GNCRF

•IDIOPATHIC•Other

CyclicMyxedemaVasodilator-inducedPregnancy-inducedCapillary leak syndrome

MECHANISMS OFEDEMA FORMATION

IS

Pcapcap

PISalance of

Starling Forces

Filtration < or = Lymphatic Drainage

Filtration > Lymphatic Drainage

odema

DEMA

(Capillary Permeability)

nterstitial Space

CARDIAC EDEMADiagnosis

•History of Heart Disease•Evidence of Pulmonary Edema

•Orthopnea•SOB•Exertional Dyspnea

•Evidence of Volume Expansion•Hepatic Congestion•Hepatojugular Reflux

•Ventricular Gallop Rhythm

CARDIAC EDEMAPathophysiology

HEART DISEASE

Left VentricularDysfunction

Right VentricularDysfunction

IncreasedPulmonary

Venous Pressure

Pulmonary Edema Systemic Edema

Hypotension

Renal Na Retention

HEPATIC EDEMADiagnosis

•History of Liver Disease•Diminished CrCl (Normal Serum Cr)•Evidence of Chronic Liver Disease

•Spider Angiomata•Palmar Erythema•Jaundice•Hypoalbuminemia

•Evidence of Portal Hypertension•Venous Pattern on Abdominal Wall•Esophogeal Varices•Ascites

LIVER DISEASE

Neurohumoral Activation(Increased “Volume Hormones”)

Liver Cirrhosis

Increased Pressure in Hepatic Sinusoids

Exudation of Fluid Into Peritoneal Cavity

Systemic Edema

Ascites

Renal Na Retention

HEPATIC EDEMAPathophysiology

Functional Renal Insufficiency(Hepatorenal Syndrome)

RENAL EDEMADiagnosis

History of Renal Disease

Evidence of Albumin Loss•Narrow, pale transverse bands in nail beds•Proteinuria (3+ to 4+)•Hypoalbuminuria

Renal Imaging•Enlarged Kidneys Nephrotic Syndrome or AGN•Shrunken Kidneys CKD ( chronic kidney disease )

An abnormality in the kidney can be detected by the following :

1. Changes in the serum creatinine concentration, reflected by GFR

2. Abnormalities urinalysis3. Altered renal homeostasis mechanism; hypertension,

abnormal volume regulation , hyperphosphatemia, anemia4. Abnormal renal imaging study

RENAL EDEMADiagnosis

RENAL EDEMADiagnosis

Nephrotic Syndrome•Hyaline Casts•Oval Fat Bodies•Lipid Droplets/Casts

Acute Glomerulonephritis•Hematuria•Erythrocyte Casts•Leukocyte Casts•Pyuria

Chronic Kidney Dissease•Broad Waxy Casts

Urinalysis

RENAL EDEMAPathophysiology

RENAL DISEASE

Urinary Loss of Albumin Reduced GFR

Hypoalbuminemia

Altered Starling Forces

Systemic Edema

Renal Na Retention

NE

PHR

OT

IC P

AT

HW

AY NEPH

RITIC PATHW

AY

NEPHRITIC PATH

WAY

IDIOPATHIC EDEMADiagnosis

•Women of Childbearing Age•Associated with Eating Disorders•Dependent Edema•Facial Edema•Abdominal Bloating

IDIOPATHIC EDEMAPathophysiology

IS

Pcapcap

PISalance of

Starling Forces

Filtration > Lymphatic Drainage DEMA

(Capillary Permeability)

nterstitial Space

Classification of diuretic

Proximal diuretics Loop diuretics DCT diuretics CCT diuretics

CAI ( diamox ) bumetadin hygroton aldacton etc furosemid edecrin

Edema pulmonum / over hydration

1. Large dose , 40 mg/hr - 12 hr2. Dopamin / dobutamin + furosemid3. Dialysis, haemofiltration, CAVH4. hBNP ( nesitirid ), CHF