Dropsy redirects here. For other uses, see Dropsy (disambiguation). Edema (also oedema, dropsy, and hydropsy) (/dim/; Greek odma, swelling) [1] is an abnormal ac- cumulation of uid in the interstitium, located beneath the skin and in the cavities of the body. Clinically, edema is manifest as swelling; the amount of interstitial uid is determined by the balance of uid homeostasis, and the increased secretion of uid into the interstitium, or the impaired removal of the uid can cause edema. 1 Classications Cutaneous edema is referred to as pitting when, after pressure is applied to a small area, the indentation per- sists after the release of the pressure. Peripheral pitting edema, as shown in the illustration, is the more common type, resulting from water retention. It can be caused by systemic diseases, pregnancy in some women, either di- rectly or as a result of heart failure, or local conditions such as varicose veins, thrombophlebitis, insect bites, and dermatitis. Non-pitting edema is observed when the indentation does not persist. It is associated with such conditions as lymphedema, lipedema, and myxedema. Edema caused by malnutrition denes kwashiorkor, an acute form of childhood protein-energy malnutrition characterized by edema, irritability, anorexia, ulcerating dermatoses, and an enlarged liver with fatty inltrates. The insucient protein consumption, but with sucient calorie intake, distinguishes it from marasmus. Kwash- iorkor cases occur in areas of famine or poor food supply. Cases in the developed world are rare. 1.1 Generalized A rise in hydrostatic pressure occurs in cardiac failure. A fall in osmotic pressure occurs in nephrotic syndrome and liver failure. [3] Causes of edema which are generalized to the whole body can cause edema in multiple organs and peripherally. For example, severe heart failure can cause pulmonary edema, pleural eusions, ascites and peripheral edema. In rare cases, a Parvovirus B19 infection may cause gen- eralized edemas. [4] Although a lowplasma oncotic pressure is widely cited for the edema of nephrotic syndrome, most physicians note that the edema may occur before there is any signicant protein in the urine (proteinuria) or fall in plasma protein level. Most forms of nephrotic syndrome are due to bio- chemical and structural changes in the basement mem- brane of capillaries in the kidney glomeruli, and these changes occur, if to a lesser degree, in the vessels of most other tissues of the body. Thus the resulting increase in permeability that leads to protein in the urine can ex- plain the edema if all other vessels are more permeable as well. [5] As well as the previously mentioned conditions, edemas often occur during the late stages of pregnancy in some women. This is more common with those of a history of pulmonary problems or poor circulation also being intensied if arthritis is already present in that particu- lar woman. Women that already have arthritic problems most often have to seek medical help for pain caused from over-reactive swelling. Edemas that occur during preg- nancy are usually found in the lower part of the leg, usu- ally from the calf down. 1.2 Organ-specic An edema will occur in specic organs as part of in- ammations, tendinitis or pancreatitis, for instance. Cer- tain organs develop edema through tissue specic mech- anisms. Examples of edema in specic organs: Cerebral edema is extracellular uid ac- cumulation in the brain. It can occur in toxic or abnormal metabolic states and conditions such as systemic lupus or re- duced oxygen at high altitudes. It causes drowsiness or loss of consciousness. Pulmonary edema occurs when the pres- sure in blood vessels in the lung is raised because of obstruction to the removal of blood via the pulmonary veins. This is usually due to failure of the left ventricle of the heart. It can also occur in altitude sickness or on inhalation of toxic chem- icals. Pulmonary edema produces short- ness of breath. Pleural eusions may oc- 1 2 2 MECHANISM cur when uid also accumulates in the pleural cavity. Edema may also be found in the cornea of the eye with glaucoma, severe conjunc- tivitis or keratitis or after surgery. Suer- ers may perceive coloured haloes around bright lights. Edema surrounding the eyes is called pe- riorbital edema or eye puness. The periorbital tissues are most noticeably swollen immediately after waking, per- haps as a result of the gravitational redis- tribution of uid in the horizontal posi- tion. Common appearances of cutaneous edema are observed with mosquito bites, spider bites, bee stings (wheal and are), and skin contact with certain plants such as Poison Ivy or Western Poison Oak, [6] the latter of which are termed contact dermatitis. Another cutaneous form of edema is myxedema, which is caused by increased deposition of connective tissue. In myxedema (and a variety of other rarer conditions) edema is caused by an in- creased tendency of the tissue to hold water within its extracellular space. In myxedema this is because of an in- crease in hydrophilic carbohydrate-rich molecules (perhaps mostly hyaluronan) deposited in the tissue matrix. Edema forms more easily in dependent areas in the elderly (sitting in chairs at home or on aeroplanes) and this is not well un- derstood. Estrogens alter body weight in part through changes in tissue water con- tent. There may be a variety of poorly understood situations in which transfer of water from tissue matrix to lymphatics is impaired because of changes in the hy- drophilicity of the tissue or failure of the 'wicking' function of terminal lymphatic capillaries. In lymphedema abnormal removal of in- terstitial uid is caused by failure of the lymphatic system. This may be due to obstruction from, for exam- ple, pressure from a cancer or enlarged lymph nodes, destruction of lymph ves- sels by radiotherapy, or inltration of the lymphatics by infection (such as elephantiasis). It is most commonly due to a failure of the pumping action of muscles due to immobility, most strik- ingly in conditions such as multiple scle- rosis, or paraplegia. It has been suggested that the edema that occurs in some peo- ple following use of aspirin-like cyclo- oxygenase inhibitors such as ibuprofen or indomethacin may be due to inhibition of lymph heart action. Hydrops fetalis is a condition of the fe- tus characterized by an accumulation of uid, or edema, in at least two fetal com- partments. 2 Mechanism Six factors can contribute to the formation of edema: 1. increased hydrostatic pressure; 2. reduced oncotic pressure within blood vessels; 3. increased tissue oncotic pressure; 4. increased blood vessel wall permeability e.g. inammation; 5. obstruction of uid clearance in the lymphatic sys- tem; 6. changes in the water retaining properties of the tis- sues themselves. Raised hydrostatic pressure of- ten reects retention of water and sodium by the kidney. [7] Generation of interstitial uid is regulated by the forces of the Starling equation. [8] Hydrostatic pressure within blood vessels tends to cause water to lter out into the tissue. This leads to a dierence in protein concentration between blood plasma and tissue. As a result the oncotic pressure of the higher level of protein in the plasma tends to draw water back into the blood vessels from the tissue. Starlings equation states that the rate of leakage of uid is determined by the dierence between the two forces and also by the permeability of the vessel wall to water, which determines the rate of ow for a given force imbalance. Most water leakage occurs in capillaries or post capillary venules, which have a semi-permeable membrane wall that allows water to pass more freely than protein. (The protein is said to be reected and the eciency of re- ection is given by a reection constant of up to 1.) If the gaps between the cells of the vessel wall open up then permeability to water is increased rst, but as the gaps in- crease in size permeability to protein also increases with a fall in reection coecient. 3 Changes in the variables in Starlings equation can con- tribute to the formation of edemas either by an increase in hydrostatic pressure within the blood vessel, a decrease in the oncotic pressure within the blood vessel or an increase in vessel wall permeability. The latter has two eects. It allows water to owmore freely and it reduces the oncotic pressure dierence by allowing protein to leave the vessel more easily. 3 Edema safety factors Three major safety factors prevent excessive uid accu- mulation in the interstitium: 1. low compliance of the interstitium when interstitial uid pressure is negative 2. increased lymph ow 3. washdown of interstitial uid proteins, which re- duces interstitial uid colloid osmotic pressure as capillary ltration increases. 4 Treatment Vein obstruction caused facial edema while lying down. After sitting upright all day, the swelling had disappeared. When possible, treatment involves resolving the underly- ing cause. Treatment may also involve positioning the aected body parts to improve drainage. For example, swelling in feet or ankles may be reduced by having the person lie down in bed or sit with the feet propped up on cushions. Intermittent pneumatic compression can be used to pres- surize tissue in a limb, forcing uids to ow out of pres- surized area. 5 In plants Edema in plants is the extended swelling in plant organs caused primarily by an excessive accumulation of water, a condition most damaging in Cacti, Fuchsias, Pelargo- nium and Succulents. The excess absorption of water can cause cells to rupture, partly due to the cell walls being composed of exible cellulose. 6 Gallery Foot, c. 2 weeks post surgery because of compartment syndrome Left and right ring ngers of the same individual. The distal phalanx of the nger on the right exhibits edema due to acute paronychia. 7 References [1] , Henry George Liddell, Robert Scott, A Greek- English Lexicon, on Perseus [2] Nutrition in Emergencies > Measuring dema. Erin Boyd, reviewed by Diane Holland, Nutrition in Emergen- cies Unit, UNICEF. Retrieved Nov 2012 [3] Renkin EM (1994). Cellular aspects of transvascular exchange: a 40-year perspective. Microcirculation 1 (3): 15767. doi:10.3109/10739689409148270. PMID 8790586. [4] Wiggli B, Imhof E, Meier CA, Laifer G (2013). Wa- ter, water, everywhere. Acute parvovirus B19 infec- tion. Lancet 381 (9868): 776. doi:10.1016/S0140- 6736(12)61894-7. PMID 23472922. [5] Palmer BF, Alpern RJ (1997). Pathogenesis of edema formation in the nephrotic syndrome. Kidney Int. Suppl. 59: S217. PMID 9185099. [6] C.Michael Hogan (2008) Western poison-oak: Toxi- codendron diversilobum, GlobalTwitcher, ed. Nicklas Strmberg [7] Kumar, Abbas, Fausto (1999). Pathologic Basis of Dis- ease, 7th edition. China: Elsevier Saunders. p. 122. ISBN 0-7216-0187-1. [8] Walter F., PhD. Boron. Medical Physiology: A Cellular And Molecular Approaoch, Elsevier/Saunders. 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