Expert lecture

APPROACH TO THE PATIENT WITH EDEMA

Davin Pratama Cahyadi 0818550590/0710710036

Introduction
The body is made of millions of cells, most of

them linked together to form tissues. The cells are filled with (and surrounded by) fluid. Therefore, the majority of a person's body weight (about 65%)consists of water.

Davin Pratama Cahyadi 0818550590/0710710036

Edema
Edema is fluid retention and it occurs when there is too much fluid (mainly water) in the body's tissues, causing swelling to occur in

the affected area. The swelling is usually related to the venous (veins) system, or the lymphatic system (tubes that carry lymph, a fluid that helps fight infection and clear fluid).

Davin Pratama Cahyadi 0818550590/0710710036

Effect of edema
Swelling of:
the hands, arms,

feet,
ankles and Legs , the brain (known as cerebral edema), and the eyes (known as macular edema).
Davin Pratama Cahyadi 0818550590/0710710036

Physiology of body fluid

Normally, the amount of water in the body is determined by the difference between fluid that is taken in and fluid that is taken out (discharged).
Fluid is taken into the body by eating and drinking, and by water produced by bodily processes. It is discharged from the body in the form of urine, feces, sweat, and non-visible perspiration, for example, when breathing out..
Davin Pratama Cahyadi 0818550590/0710710036

Factors such as the

surrounding air temperature, and strenuous exercise, can affect the amount of water that is taken in and out of the body.

Davin Pratama Cahyadi 0818550590/0710710036

 In people with edema, the excess

fluid can be caused by a number of factors. This is because edema is not a condition itself, but is often a symptom of an underlying condition. For example, it can be a sign of kidney disease, or lymphedema.
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 Lymphedema is a chronic swelling

that occurs when lymph fluid does not fully drain away from the tissues. Edema can also sometimes be caused by lifestyle factors, such as pregnancy, or a high dietary salt intake.
Davin Pratama Cahyadi 0818550590/0710710036

DEFINITION OF EDEMA
The Accumulation of Abnormal Amounts of Extravascular, Extracellular Fluid.

ANASARCA: Severe, widely distributed pitting edema.

Davin Pratama Cahyadi 0818550590/0710710036

TYPES OF EDEMA
GENERALIZED LOCALIZED
Inflammation Lymphatic Obstruction Venous Obstruction Thrombophlebitis CARDIAC HEPATIC RENAL NEPHROTIC SYNDROME ACUTE GN CRF IDIOPATHIC Other Cyclic Myxedema Vasodilator-induced Pregnancy-induced Capillary leak syndrome

GN: Glomerulo nephritis CRF: Chronic renal failure

Davin Pratama Cahyadi 0818550590/0710710036

MECHANISMS OF EDEMA FORMATION

(Capillary Permeability)

nterstitial Space
Filtration < or = Lymphatic Drainage Filtration > Lymphatic Drainage Davin Pratama Cahyadi 0818550590/0710710036

odema DEMA

CARDIAC EDEMA Diagnosis

History of Heart Disease Evidence of Pulmonary Edema Orthopnea SOB Exertional Dyspnea Evidence of Volume Expansion Hepatic Congestion Hepatojugular Reflux Ventricular Gallop Rhythm

SOB: Shortness of breath

Davin Pratama Cahyadi 0818550590/0710710036

CARDIAC EDEMA Pathophysiology

HEART DISEASE
Left Ventricular Dysfunction Right Ventricular Dysfunction

Increased Pulmonary Venous Pressure

Hypotension Renal Na Retention Systemic Edema

Pulmonary Edema

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HEPATIC EDEMA Diagnosis

History of Liver Disease Diminished CrCl (Normal Serum Cr) Evidence of Chronic Liver Disease Spider Angiomata Palmar Erythema Jaundice Hypoalbuminemia Evidence of Portal Hypertension Venous Pattern on Abdominal Wall Esophogeal Varices Ascites

Davin Pratama Cahyadi 0818550590/0710710036

LIVER DISEASE
Liver Cirrhosis

HEPATIC EDEMA Pathophysiology

Increased Pressure in Hepatic Sinusoids Neurohumoral Activation (Increased Volume Hormones)

Exudation of Fluid Into Peritoneal Cavity

Ascites

Functional Renal Insufficiency (Hepatorenal Syndrome)

Renal Na Retention

Systemic Edema
Davin Pratama Cahyadi 0818550590/0710710036

RENAL EDEMA Diagnosis

History of Renal Disease Evidence of Albumin Loss Narrow, pale transverse bands in nail beds Proteinuria (3+ to 4+) Hypoalbuminuria

Renal Imaging Enlarged Kidneys Shrunken Kidneys

Nephrotic Syndrome or AGN CRF

Davin Pratama Cahyadi 0818550590/0710710036

RENAL EDEMA Diagnosis

Urinalys is

Nephrotic Syndrome Hyaline Casts Oval Fat Bodies Lipid Droplets/Casts Acute Glomerulonephritis Hematuria Erythrocyte Casts Leukocyte Casts Pyuria Chronic Renal Failure Broad Waxy Casts

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RENAL EDEMA Pathophysiology

RENAL DISEASE
Urinary Loss of Albumin Reduced GFR

Hypoalbuminemia

Renal Na Retention

Altered Starling Forces

Systemic Edema

Davin Pratama Cahyadi 0818550590/0710710036

CARDIAC Dependent Edema Facial Edema Ascites Hypoalbuminemia Proteinuria

HEPATIC

RENAL

Severe Absent Absent/Mild Absent Absent/Tr ace

Moderate Absent Severe Moderate/Mild Absent/Trace

Mild Severe/Moderate Absent/Mild Severe Severe

Davin Pratama Cahyadi 0818550590/0710710036

IDIOPATHIC EDEMA Diagnosis

Women of Childbearing Age Associated with Eating Disorders Dependent Edema Facial Edema Abdominal Bloating

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IDIOPATHIC EDEMA Pathophysiology

(Capillary Permeability) nterstitial Space DEMA

Filtration > Lymphatic Drainage

Davin Pratama Cahyadi 0818550590/0710710036

Davin Pratama Cahyadi 0818550590/0710710036