Edema
Definition
? Clinically apparent increase in the interstitial
(间质 ) fluid volume
? Weight gain precedes overt edema
? Weight loss in edematous patients before
,dry weight”
? Massive edema is called Anasarca
Edema
? Localized or generalized
? Generalized form,
puffiness（浮肿） of the face
edema of periorbital areas
Indentation of the skin,pitting edema”
凹陷性水肿
? Fluid may also accumulate in body cavities
ascite（腹水） hydrothorax (胸水）
Edema
Pitting edema
Pathogenesis
Reduced plasma osmotic pressure
Capillary damage
Reduction of effective arterial volume
Reduced cardiac output
Renal factors
Renin-Angiotension-Aldosterone
Starling forces
? 1/3 body water,extracellular space
plasma volume (25% ) interstitial space (75% )
? Regulating the disposition of fluid between two
compartment (Law of Capillaries)
Vascular system Interstitial space
Hydrostatic pressure
（流体静水压） Hydrostatic pressure
Colloid oncotic pressure (tissue tension)
（胶体渗透压） Colloid oncotic pressure
Reduced Plasma
Osmotic Pressure
Vascular system Interstitial space
Hydrostatic pressure
Hydrostatic pressure
Colloid oncotic pressure (tissue tension)
Colloid oncotic pressure
Reduced Plasma
Osmotic Pressure
Albumin is the serum protein MOST responsible
for the maintenance of colloid osmotic pressure
(胶体渗透压 ）
A decrease in osmotic pressure can result from
increased protein loss or decreased protein
synthesis
Increase in capillary pressure may be due to
congestive heart failure
Capillary Damage
? Damage to the capillary endothelium(内皮 )
? Increase its permeability and permits the
transfer of protein into interstitial compartment
? Injury agents
Drugs Viral/bacterial agents
Thermal/mechanical trauma Immune
? Responsible for inflammatory edema
? Nonpitting localized redness and tenderness
Reduction of Effective
Arterial Volume
? In many form of edema,the effective arterial
volume is reduced
? a series of physiologic responses designed to
restore it to normal
Reduction of Effective
Arterial Volume
? A key element of these responses
Salt and water retention by renal proximal tubule
? If the retention of salt and water is insufficient to
restore and maintain the effective arterial blood,the
stimuli are not dissipated,the retention of salt and
water continues,the edema may ultimately develop
? Operative in dehydration and hemorrhage
Reduced Cardiac Output
Renal Factors
? Decreased renal perfusion activates the Renal
Defense Mechanisms,
--- Renin-Angiotension-Aldosterone Axis
--- Renal Vasoconstriction
--- Increased Renal Anti-diuretic Hormone (ADH)
Reduced Cardiac Output
Renin-Angiotention-Aldosterone Axis-
AngiotensionII
Reduced Cardiac Output
Renal Vasoconstriction
Reduced Cardiac Output
Anti-Diuretic Hormone
Clinical Causes of Edema
Systemic edema
Congestive heart failure
Nephrotic syndrome/other
hypoalbuminemic states
Cirrhosis
Drug-induced
Idiopathic
Localized edema
Venous/lymphatic
obstruction
Systemic Edema
Congestive heart failure
Systemic edema
Nephrotic Syndrome/
Hypoalbuminemic states
? The primary alteration,decreased colloid
oncotic pressure
protein loss in the urine severe nutritional deficiency
protein loss enteropathy congentital hypoalbuminemia
liver cirrhosis
? Promotes fluid move into the interstitium
? Causes hypovolemia
salt/water retention activation RAA axis etc
Systemic Edema
Systemic Edema
Drug - induced Edema
? Renal vasoconstriction (NASID,cyclosporine)
? Arterial dilatation (vasodilators)
? Augmented renal sodium reabsorption
(steroid hormone)
? Capillary damage (interleukin-2)
Drug associated with edema
formation
Nonsteroidal anti-inflammatory drugs
Antihypertensive agents
Direct arterial/arteriolar vasodilators
Calcium channel antagonists a-Adrenergic antagonists
Steroid hormones
Glucocorticoids Anabolic steroids Estrogens Progestines
Cyclosporine
Growth hormone
Immunotherapies
Interleukin 2 OKT3 monoclonal antibody
Systemic Edema
Idiopathic Edema
? Diurnal alterations in weight occurring with
orthostatic retention of sodium and water
? Increase in capillary permeability
fluctuate in severity
aggravated by hot weather
? Reduction in plasma volume in this condition
with secondary activation of the RAA system
Localized edema
? Inflammation
? Venous/lymphatic obstruction
? Chronic lymphangitis
? Resection of regional lymph nodes
? Filariasis (丝虫病 )
Differential diagnosis
? Heart failure
? Renal diseases
? Cirrhosis
? Nutritional origin
? Idiopathic
? Others
Differential diagnosis
Heart Failure
? Edema initially occurs at lower part of the
body (lower extremities)
? symmetric location
? The presence of heart diseases
cardiac enlargement gallop rhythm dyspnea
basilar rales venous distention hepatomegaly
? Noninvasive tests may be helpful
echocardiography radionuclide angiography
Differential diagnosis
Renal diseases
? Mainly due to hypoabluminemia and
salt/water retention
? Associated with hematuria,proteinurial,
hypertention and impaired renal functional test
? Characteriastic of edema of renal origin,
puffiness of the face
prominent in the periorbital areas
Differential diagnosis
Cardiac/Renal disease
Renal Cardiac
Location onset from the face,onset from the lower
periobital areas part of the body
Progression progress quickly progress slowly
Identity soft and mobile relatively solid,less mobile
Other signs proteinuria signs of heart failure,
hypertension cardiac enlargement
impaired renal venous distention
functional test hepatomegaly
Differential diagnosis
Liver diseases (cirrhosis)
? Clinical evidence of hepatic disease
jaundice spider angiomas ascites
? Ascites refractory to the treatment
? Edema may also occur in other part of the body
due to,hypoalbuminemia
increased intraabdominal pressure
impede venous return from the lower extremities
Differential diagnosis
Nutritional origin
? Prolonged diet protein deficient
hypoproteinemia
? Intensified by the berbiberi (脚气病） heart disease
? Reduced effective systemic perfusion / arterial blood volume
? Edema becomes intensified,
An adequate diet is provided
More food more salt ingested
Increased release of insulin
? Hypokalemia and caloric deficits may also be involved
Refeeding edema
Differential diagnosis
Idiopathic edema
? Exclusive in women
? periodic episodes
? accompanied by abdominal distention
Differential diagnosis
Other Causes of Edema
? Hypothyroidism (myxedema,粘液水肿 )
periotibial region periorbital puffiness nonpitting
? Exogenous hyperadrenoncortism
? Pregnancy
? Estrogens
? angioneurotic
Approach to the patient
Generalized
Localized
or
Heart
Liver
Kidney
Venous obstruction
Lymphatic obstruction
Definition
? Clinically apparent increase in the interstitial
(间质 ) fluid volume
? Weight gain precedes overt edema
? Weight loss in edematous patients before
,dry weight”
? Massive edema is called Anasarca
Edema
? Localized or generalized
? Generalized form,
puffiness（浮肿） of the face
edema of periorbital areas
Indentation of the skin,pitting edema”
凹陷性水肿
? Fluid may also accumulate in body cavities
ascite（腹水） hydrothorax (胸水）
Edema
Pitting edema
Pathogenesis
Reduced plasma osmotic pressure
Capillary damage
Reduction of effective arterial volume
Reduced cardiac output
Renal factors
Renin-Angiotension-Aldosterone
Starling forces
? 1/3 body water,extracellular space
plasma volume (25% ) interstitial space (75% )
? Regulating the disposition of fluid between two
compartment (Law of Capillaries)
Vascular system Interstitial space
Hydrostatic pressure
（流体静水压） Hydrostatic pressure
Colloid oncotic pressure (tissue tension)
（胶体渗透压） Colloid oncotic pressure
Reduced Plasma
Osmotic Pressure
Vascular system Interstitial space
Hydrostatic pressure
Hydrostatic pressure
Colloid oncotic pressure (tissue tension)
Colloid oncotic pressure
Reduced Plasma
Osmotic Pressure
Albumin is the serum protein MOST responsible
for the maintenance of colloid osmotic pressure
(胶体渗透压 ）
A decrease in osmotic pressure can result from
increased protein loss or decreased protein
synthesis
Increase in capillary pressure may be due to
congestive heart failure
Capillary Damage
? Damage to the capillary endothelium(内皮 )
? Increase its permeability and permits the
transfer of protein into interstitial compartment
? Injury agents
Drugs Viral/bacterial agents
Thermal/mechanical trauma Immune
? Responsible for inflammatory edema
? Nonpitting localized redness and tenderness
Reduction of Effective
Arterial Volume
? In many form of edema,the effective arterial
volume is reduced
? a series of physiologic responses designed to
restore it to normal
Reduction of Effective
Arterial Volume
? A key element of these responses
Salt and water retention by renal proximal tubule
? If the retention of salt and water is insufficient to
restore and maintain the effective arterial blood,the
stimuli are not dissipated,the retention of salt and
water continues,the edema may ultimately develop
? Operative in dehydration and hemorrhage
Reduced Cardiac Output
Renal Factors
? Decreased renal perfusion activates the Renal
Defense Mechanisms,
--- Renin-Angiotension-Aldosterone Axis
--- Renal Vasoconstriction
--- Increased Renal Anti-diuretic Hormone (ADH)
Reduced Cardiac Output
Renin-Angiotention-Aldosterone Axis-
AngiotensionII
Reduced Cardiac Output
Renal Vasoconstriction
Reduced Cardiac Output
Anti-Diuretic Hormone
Clinical Causes of Edema
Systemic edema
Congestive heart failure
Nephrotic syndrome/other
hypoalbuminemic states
Cirrhosis
Drug-induced
Idiopathic
Localized edema
Venous/lymphatic
obstruction
Systemic Edema
Congestive heart failure
Systemic edema
Nephrotic Syndrome/
Hypoalbuminemic states
? The primary alteration,decreased colloid
oncotic pressure
protein loss in the urine severe nutritional deficiency
protein loss enteropathy congentital hypoalbuminemia
liver cirrhosis
? Promotes fluid move into the interstitium
? Causes hypovolemia
salt/water retention activation RAA axis etc
Systemic Edema
Systemic Edema
Drug - induced Edema
? Renal vasoconstriction (NASID,cyclosporine)
? Arterial dilatation (vasodilators)
? Augmented renal sodium reabsorption
(steroid hormone)
? Capillary damage (interleukin-2)
Drug associated with edema
formation
Nonsteroidal anti-inflammatory drugs
Antihypertensive agents
Direct arterial/arteriolar vasodilators
Calcium channel antagonists a-Adrenergic antagonists
Steroid hormones
Glucocorticoids Anabolic steroids Estrogens Progestines
Cyclosporine
Growth hormone
Immunotherapies
Interleukin 2 OKT3 monoclonal antibody
Systemic Edema
Idiopathic Edema
? Diurnal alterations in weight occurring with
orthostatic retention of sodium and water
? Increase in capillary permeability
fluctuate in severity
aggravated by hot weather
? Reduction in plasma volume in this condition
with secondary activation of the RAA system
Localized edema
? Inflammation
? Venous/lymphatic obstruction
? Chronic lymphangitis
? Resection of regional lymph nodes
? Filariasis (丝虫病 )
Differential diagnosis
? Heart failure
? Renal diseases
? Cirrhosis
? Nutritional origin
? Idiopathic
? Others
Differential diagnosis
Heart Failure
? Edema initially occurs at lower part of the
body (lower extremities)
? symmetric location
? The presence of heart diseases
cardiac enlargement gallop rhythm dyspnea
basilar rales venous distention hepatomegaly
? Noninvasive tests may be helpful
echocardiography radionuclide angiography
Differential diagnosis
Renal diseases
? Mainly due to hypoabluminemia and
salt/water retention
? Associated with hematuria,proteinurial,
hypertention and impaired renal functional test
? Characteriastic of edema of renal origin,
puffiness of the face
prominent in the periorbital areas
Differential diagnosis
Cardiac/Renal disease
Renal Cardiac
Location onset from the face,onset from the lower
periobital areas part of the body
Progression progress quickly progress slowly
Identity soft and mobile relatively solid,less mobile
Other signs proteinuria signs of heart failure,
hypertension cardiac enlargement
impaired renal venous distention
functional test hepatomegaly
Differential diagnosis
Liver diseases (cirrhosis)
? Clinical evidence of hepatic disease
jaundice spider angiomas ascites
? Ascites refractory to the treatment
? Edema may also occur in other part of the body
due to,hypoalbuminemia
increased intraabdominal pressure
impede venous return from the lower extremities
Differential diagnosis
Nutritional origin
? Prolonged diet protein deficient
hypoproteinemia
? Intensified by the berbiberi (脚气病） heart disease
? Reduced effective systemic perfusion / arterial blood volume
? Edema becomes intensified,
An adequate diet is provided
More food more salt ingested
Increased release of insulin
? Hypokalemia and caloric deficits may also be involved
Refeeding edema
Differential diagnosis
Idiopathic edema
? Exclusive in women
? periodic episodes
? accompanied by abdominal distention
Differential diagnosis
Other Causes of Edema
? Hypothyroidism (myxedema,粘液水肿 )
periotibial region periorbital puffiness nonpitting
? Exogenous hyperadrenoncortism
? Pregnancy
? Estrogens
? angioneurotic
Approach to the patient
Generalized
Localized
or
Heart
Liver
Kidney
Venous obstruction
Lymphatic obstruction
