Basic Course of Diagnosis
– Edema –
-水肿
-Xiaoqi XU
Renal Divison,Renji Hospital,
Shanghai Second Med.Univ,
Definition
? A clinical apparent increase in
the interstitial fluid volume,
? Distribution,local
general
? Special form,ascites
hydrothorax
Pathogenesis
Total body water(TBW),2/3 body weight
TBW
intracellular 2/3
extracellular 1/3
Interstitial 3/4
intravascular 1/4
starling
force
Starling force depends on, hydrostatic pressure(静水压 )
colloid oncotic pressure（ 胶体渗透压）
? Disturbed starling forces(reduced effective circulating
volume,edema formation)
systemic venous pressure increase
right-sided heart failure,constrictive pericarditis
local venous pressure increase
left-sided heart failure,vena cava obstruction,portal vein
obstruction
reduced oncotic pressure
nephrotic syndrome,decreased albumin synthesis
combined disorders
cirrhosis
Pathogenesis
? Primary hormone excess
(increased effective circulating volume)
primary aldosteronism
Cushing ‘s syndrome
SIADH
? Primary renal sodium retention
(increased effective circulating volume)
renal failure
SIADH,syndrome of inappropriate antidiuretic hormone production
? Capillary damage
inflammation due to the bacteria
infection,allergic
reaction,immune reaction
? Lymphatic obstruction
Clinical causes of edema
General edema,
? Congestive Heart Failure
? Nephrotic Syndrome and Other
Hypoalbuminemic States
? Cirrhosis
? Drug-Induced
? Idiopathic Edema
Localized edema,
? Obstruction of venous (and
lymphatic) drainage of a limb
Cardiac
Dyspnea with exertion
prominent-often associated
with orthopnea-or
paroxysmal nocturnal
dyspnea
Elevated jugular venous
pressure,ventricular (S3)
gallop; occasionally with
displaced or dyskinetic
apical pulse; peripheral
cyanosis,cool extremities,
small pulse pressure when
severe
Elevated BUN/Cr
ratio common;
elevated uric acid;
serum Na
diminished; liver
enzymes
occasionally
elevated with
hepatic congestion Hepatic
Dyspnea infrequent,
except if associated with
significant degree of
ascites; most often a
history of ethanol abuse
Frequently associated with
ascites; jugular venous
pressure normal or low; BP
lower than in renal or
cardiac disease; jaundice,
palmar erythema,
Dupuytren's contracture,
spider angiomata,male
gynecomastia; asterixis and
other signs of
encephalopathy
reductions in Alb,
Cho,transferrin,
fibrinogen liver
enzymes elevated,
tendency toward
hypokalemia,
respiratory alkalosis;
macrocytosis from
folate deficiency
NOTE,S3,third heart sound.SOURCE,From GM Chertow,GE Thibault,Approach to the patient
with edema,in L Goldman,E Braunwald (eds),Primary Cardiology,Philadelphia,Saunders,1998,
Table 37-2,Principal Causes of Generalized Edema,History,
Physical Examination,and Laboratory Findings
Organ
System
History
Physical Examination
Laboratory
Findings
Renal
chronic,decreased appetite,
metallic or fishy taste,altered
sleep pattern,difficulty
concentrating,restless legs
or myoclonus,dyspnea can
be present,but generally less
prominent than in heart
failure
BP may be elevated;
hypertensive or diabetic
retinopathy in selected
cases; nitrogenous fetor;
periorbital edema may
predominate; pericardial
friction rub in advanced
cases with uremia
hypoalbuminemia;
elevation of serum
creatinine and urea
hyperkalemia,
metabolic acidosis,
hyperphosphatemia,
hypocalcemia,
anemia (usually
normocytic)
Malnutrition,weight loss occurs from lower
extremities
? diet grossly deficient in protein over a
long period
? Protein-losing enteropathy
? Severe burn
Idiopathic edema,exclusive in
♀,periodic episodes of edema(unrelated
to MC)
Miscellaneous:located pretibial
region,periorbital region
?hypothyroidism(myxedema)
?Drug-induced edema
Exogenous hyperadremocortism
Estrogen
vasodilators
Localized edema,
?Local inflammation
?Thrombosis
?Thrombophlebitis
?filariasis
Accompanied symtoms
? With hepatomegaly
? With gross proteinuria
? With dyspnea
? Related with menstrual cycle
Approach to the Patient
? Localized or generalized?
? Hydrothorax or ascites?
? Sites
? accompanied symptom