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Approach to
Peripheral Edema
Rey Vivo, MD
Department of Internal Medicine
Texas Tech University Health Sciences Center
Case 1
•
65M with long-standing RA presents to the office with 3-month bilateral
lower extremity swelling which was progressive despite diuretic therapy
started by his former PCP. Physical exam: elevated JVP with an increase
during inspiration; a high-pitched third heart sound; diminished breath
sounds on both bases; bilateral pitting edema up to both knees. Jugular
venous tracing revealed prominent x and y descent. EKG displayed low
voltage. Chest x-ray is shown.
What is the most likely diagnosis?
•
•
•
•
A.
B.
C.
D.
Cardiac tamponade
Constrictive pericarditis
Right ventricular infarction
Left-sided heart failure
Radiograph from utdol.com
Objectives
• Discuss:
– Definition of edema
– Pathophysiology
– Etiologies
– Diagnosis
– Management
Pathophysiology-I
•
Figure 1: Etiology and causative factors of peripheral edema
Illustration from Am J Med. 2002;113:580-586.
Pathophysiology-II
•
Figure 2. Renal and neurohumoral factors in edema
Illustration from images.MD
Case 2
•
43F diagnosed to have scleroderma with limited cutaneous involvement
presents with worsening dyspnea on exertion in the last 5 months
associated with leg swelling. She used to be physically active but now is
unable to walk from her bed to her bathroom without SOB. PE: facial
telangiectasias; skin sclerosis limited to both hands; elevated JVP; wide
splitting of the 2nd heart sound with prominent P2; (+) S3 and S4; highpitched holoystolic murmur on the left sternal border; clear lungs; palpable
liver edge; pitting edema up to both calves. EKG is shown:
An echocardiogram is ordered. What echo findings will best explain her
symptoms?
•
•
•
•
A.
B.
C.
D.
Mitral regurgitation, LVH, elevated PA pressure
Mitral regurgitation, RVH, normal PA pressure
Tricuspid regurgitation, LVH, elevated PA pressure
Tricuspid regurgitation, RVH, elevated PA pressure
Electrocardiogram from utdol.com
Case 3
•
57F was brought to the hospital after being found lying on the street. On
exam, the patient was drowsy but her vital signs were stable. She smelled
of alcohol, appeared disheveled and jaundiced; abdomen was protruberant
with bulging flanks and (+) fluid wave; liver was difficult to palpate; palmar
erythema and bilateral pitting edema of both lower extremeties were
present. Pertinent labs were: Hgb 10.2, MCV 101.9, AST 360, ALT 176,
albumin 1.8, INR 1.79. CT scan of the abdomen showed hepatomegaly and
ascites. What is the best therapeutic regimen for this patient’s ascites and
edema?
•
•
•
•
•
A.
B.
C.
D.
E.
Dietary sodium restriction
Furosemide
Spironolactone
Alcohol abstinence
All of the above
Case 4
•
48M with Hodgkin’s disease was referred for evaluation of bilateral leg
swelling for 2 months. Examination revealed unremarkable heart findings,
clear lungs and pitting edema of both legs up to his thighs. When told that
he had some swelling around his eyes, he said that he was unaware of this.
Blood work showed marked hypoalbuminemia, hypercholesterolemia and
hypertriglyceridemia. Urine: 4+ protein and oval fat bodies; 24-hour urine:
8g protein. Which one is the LEAST likely explanation of edema in this
case?
•
•
•
•
A.
B.
C.
D.
Increased capillary hydrostatic pressure
Reduced plasma oncotic pressure due to hypoalbuminemia
Reduced effective circulating volume
Primary renal sodium retention
Case 4B
•
The same patient was referred to Nephrology and was managed with
dietary sodium restriction, diuretics and ACE-inhibitors. He responded well
and eventually observed his edema improve. 6 months later, he came back
in the clinic complaining of swelling in his left leg. He denied any trauma,
insect bite or pre-existing wound. On exam, he was afebrile; the rest of his
vital signs were within normal. His left leg had pitting edema; it was also
erythematous and warm to touch. His right leg had no signs of edema.
There was no evidence of wounds or fungal infection. What is the most
likely diagnosis given his condition?
•
•
•
•
A.
B.
C.
D.
Cellulitis
Lymphangitis
Deep vein thrombosis
Ruptured Baker’s cyst
Answer
Table 1. Causes of Peripheral Edema
•
Increased capillary hydrostatic pressure
–
•
•
Regional venous hypertension (often unilateral)
• Inferior vena caval/iliac compression
• Deep venous thrombosis
• Chronic venous insufficiency
• Compartment syndrome
Systemic venous hypertension
Increased plasma volume
•
•
Decreased plasma oncotic pressure
–
–
•
Allergic reactions: histamine release (hives), serum sickness, angioedema
Burns
Inflammation/local infections
Interleukin 2 therapy
Lymphatic obstruction or increased interstitial oncotic pressure
–
•
Protein loss
Reduced protein synthesis
Increased capillary permeability (usually clinically obvious)
–
–
–
–
•
Drugs
Lymphedema (primary or secondary [nodal enlargement due to malignancy, postsurgical/radiation, filariasis])
Other
–
–
Idiopathic
Myxedema
Table from Am J Med. 2002;113:580-586.
Case 5
•
You are on the Cardiology consult service and get a referral to see a 64F for
new-onset bilateral leg swelling. She was admitted to the hospital 5 days
ago for symptoms consistent with transient ischemic attack. She has a 10year history of difficult-to-control hypertension and has been taking
hydrochlorthiazide 25mg/d, atenolol 100mg/d and lisinopril 40mg/d.
Amlodipine 5mg/d was added 3 days ago. PE: BP 137/68; HR 65; no JVP;
regular rhythm with no extra heart sounds; clear lungs; (+) bilateral ankle
pitting edema without varicosities or pigmentation. Labs were normal.
What is the most likely cause of her ankle edema?
•
•
•
•
A.
B.
C.
D.
Heart failure
Lymphedema
Myxedema
Drug reaction
Answer
Table 2. Drugs that Cause Peripheral Edema
•
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
•
Estrogens/progesterones
•
Testosterone
•
Nonsteroidal anti-inflammatory agents
•
Nonselective cyclooxygenase inhibitors
•
Selective cyclooxygenase-2 inhibitors
•
Others
•
Troglitazone, rosiglitazone, pioglitazone
•
Phenylbutazone
Table from Am J Med. 2002;113:580-586.
Take home points
• Peripheral edema is non-specific but is a
valuable clue to distinct medical conditions
• Starling forces/Renal factors
• History is crucial
• Simple tests may lead to diagnosis
• Indications for: diuretic treatment, rate of fluid
removal, choice and dose of diuretic
• Non-diuretic management
Thank you