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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 • • • • • • • • • • • • • • • • 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 • • • • • • • • • • • • • • 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 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 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