Download LOWER LIMB OEDEMA:

LOWER LIMB OEDEMA:
Large and leaky!
Prof. Donald G. MacLellan
Executive Director
Health Education & Management Innovations
Vasculature
Aorta
Large
Arteries
Capillaries
Large
Veins
Vena
Cava
Number
One
Several
Hundred
Ten Billion
Several
Hundred
Two
Total Crosssectional
Area
4.5(cm2)
6,000(cm2)
40(cm2)
20(cm2)
20(cm2)
Capillary Structure
It leaks!
Transport across the capillary wall
Lymphatic System
 Initial lymphatic vessels have wide intercellular
junctions that act as flap valves.
 Freely allow passage of fluid & proteins but prevent
back flow.
 Afferent lymphatic vessels travel alongside major
vascular bundles and have muscular contractile walls
and valves.
 Afferent lymphatics drain into lymph nodes and then
lymph fluid passes through to the thoracic duct which
drains into the Lt Subclavian Vein.
Oedema
Oedema develops when
the capillary filtration rate exceeds
the lymphatic drainage rate
for a sufficient period of time
Oedema
• Increased capillary hydrostatic pressure (when
venous pressures become elevated due to venous
valvular dysfunction or in heart failure).
Oedema
• Increased capillary hydrostatic pressure (when
venous pressures become elevated due to venous
valvular dysfunction or in heart failure).
• Decreased plasma oncotic pressure (with
hypoproteinaemia during malnutrition or protein loss in
the nephrotic syndrome or severe burns)
Oedema
• Increased capillary hydrostatic pressure (when
venous pressures become elevated due to venous
valvular dysfunction or in heart failure).
• Decreased plasma oncotic pressure (with
hypoproteinaemia during malnutrition or protein loss in
the nephrotic syndrome or severe burns)
• Increased capillary permeability caused by
proinflammatory mediators (e.g. histamine, bradykinin) or
by damage to the structural integrity of capillaries so they
become more "leaky" (in tissue trauma, burns and
severe inflammation)
Oedema
• Increased capillary hydrostatic pressure (when
venous pressures become elevated due to venous
valvular dysfunction or in heart failure).
• Decreased plasma oncotic pressure (with
hypoproteinaemia during malnutrition or protein loss in
the nephrotic syndrome or severe burns)
• Increased capillary permeability caused by
proinflammatory mediators (e.g. histamine, bradykinin) or
by damage to the structural integrity of capillaries so they
become more "leaky" (in tissue trauma, burns and
severe inflammation)
• Lymphatic obstruction (in filariasis, malignancy or with
tissue injury)
Oedema
Oedema - Causes
Peripheral Oedema- Diagnosis
Oedema is a sign not a diagnosis
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Regional venous hypertension
Inferior vena caval/iliac compression
Deep venous thrombosis
Chronic venous insufficiency
Compartment syndrome
Systemic venous hypertension
Heart failure
Constrictive pericarditis
Restrictive cardiomyopathy
Tricuspid valvular disease
Cirrhosis/liver failure
Heart failure
Renal failure (acute, chronic)
Drugs
Pregnancy
Premenstrual oedema
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Malabsorption
Pre-eclampsia
Nephrotic syndrome
Cirrhosis/liver failure
Malnutrition (e.g., kwashiorkor)
Malabsorption
Beriberi
Allergic reactions: histamine
release (hives), serum sickness,
Burns
Inflammation/local infections
Interleukin 2 therapy
Lymphatic obstruction
Lymphedema
Myxoedema
Idiopathic causes
Peripheral Oedema - History
Full medical history:
Duration: acute consider DVT
Painful: DVT; CVI - low grade aching
Overnight improvement: CVI
Systemic Disease: heart, liver, kidney
Local Disease: Hx of Pelvic/Abdominal neoplasm or radiation
Hx Sleep Apnoea: Pulmonary Hypertension
Medications: many associated with oedema
Drugs that can cause Peripheral Oedema
Antidepressants
Monoamine oxidase inhibitors
Antihypertensive medications
Calcium channel blockers: dihydropyridines (e.g., nifedipine,
amlodipine, felodipine), phenylalkylamines (e.g., verapamil),
benzothiazepines (e.g., diltiazem)
Direct vasodilators: hydralazine, minoxidil, diazoxide
Beta-blockers
Centrally acting agents: clonidine, methyldopa
Antisympathetics: reserpine, guanethidine
Hormones
Corticosteroids
Oestrogens/progesterones
Testosterone
Nonsteroidal anti-inflammatory agents
Nonselective cyclooxygenase inhibitors
Selective cyclooxygenase-2 inhibitors
Others
Troglitazone, rosiglitazone, pioglitazone
Phenylbutazone
Peripheral Oedema - Examination
General examination:
Weigh patient (BMI)
Pitting in dependent areas – limb, sacrum
Tenderness – DVT
Varicosities
Skin Changes
Bilateral oedema
Suggests systemic factors
Look for features of
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Heart failure
Liver failure
Renal disorders
Malignancy
Unilateral oedema
Suggests cause within that body quadrant or lower limb.
DVT, CVI, lymphoedema
Check inguinal or axillary lymph nodes
Peripheral Oedema - Investigations
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Complete blood count
Urinalysis
Electrolytes
Creatinine
Blood sugar
Albumin
Thyroid-Stimulating Hormone
Other tests relevant to specific system(s)
Peripheral Oedema - Treatment
Directed to underlying cause
CVI:
- graduated compression stockings
- pneumatic compression devices
- e-stim devices
Diuretics
Efferent
Oedema Treatment
Peripheral oedema:
• Capillary hydrostatic pressure and therefore capillary
fluid filtration is strongly influenced by venous pressure.
• Diuretics will reduce blood volume and venous pressure
and thus lower capillary hydrostatic pressure
• That reduces net capillary fluid filtration and tissue
oedema