Approach to patient with oedema Flashcards
What is the definition of oedema?
clinically apparent increase in interstitial fluid volume
What are the relevant hx to take in a patient with oedema
How long is the duration of the oedema?
- Acute: think of DVT, ruptured Baker’s cyst, infection, compartment syndrome
- Chronic (>72 hrs)
Is the edema painful?
- Pain 🡪 red flag
- Think of DVT, compartment syndrome, cellulitis, necrotising fasciitis, baker’s cyst, reflex sympathetic dystrophy
- CVI may have low grade aching
Any diurnal variation?
- Improve overnight? Think of venous cause > lymphatic cause
- Intermittence? – common premenstrual symptom (treatment is not necessary)
Any history suggestive of systemic disease: cardiac, liver or renal?
Any history of pelvic or abdominal malignancy or radiation therapy?
Any intake of drugs associated with edema formation?
Pitting
- Non pitting: lymphedema, (pretibial) myxoedema
- Pitting: HF, CRF, Nephrotic Syndrome, CLD, Idiopathic edema
Travel history: Filariasis 🡪 travel to Malaysia, Indonesia, India 🡪 walking barefoot
What are the basic investigations conducted for patients with edema?
- FBC
- Urinalysis
- Serum creatinine, albumin
- TSH
- ECG
- Chest X Ray
What are the basic investigations conducted for patients with edema if there are clinical suspicions?
- DVT: D dimer, venous duplex scan
- Cardiac disease: BNP, 2DEcho
- Liver disease: ALT, AST, ALP, bilirubin, albumin, PT, US liver
- Renal disease: UFeme, 24 hour urine protein, US kidneys
- Pelvic malignancy: CT scan of abdomen and pelvis
- CVI: Venous reflux study
What are the differentials to acute unilateral LL swelling?
Cellulitis: erythematous, warm and tender limb, often associated with fever and raised inflammatory markers
Necrotising Fasciitis: systemic toxicity
DVT
- Environmental: Recent surgery, prolonged bed rest, travel
- Previous Hx of DVT
- Coagulopathies, HRT, OCP use
- Ai Diseases, APLS (DVT + Recurrent Miscarriages)
- Diffusely swollen, warm, erythematous and tender leg. There may be low grade fever.
Compartment Syndrome (6Ps: Pain Pallor Poikilothermia Paraesthesia Paralysis Pulselessness)
Ruptured Baker’s cyst (history of rheumatoid arthritis, osteoarthritis, meniscal injury)
Ruptured medial head of gastronemius (history of sudden foot dorsiflexion)
What are the differentials to chronic unilateral LL swelling?
Chronic venous insufficiency: An aching, swollen leg worse at the end of the of the day, with varicose veins and venous skin changes.
Bilateral lymphedema: cutaneous and subcutaneous thickening
What are the differentials to bilateral LL swelling with elevated JVP?
Congestive cardiac failure
Chronic kidney disease
What are the differentials to bilateral LL swelling with normal JVP and low albumin?
Cirrhosis
Nephrotic syndrome
Protein losing enteropathy
What are the differentials to bilateral LL swelling with normal JVP and low albumin?
Thyroid
Drug induced edema
[Bilateral edema] What are the common drugs associated with edema formation?
NSAIDs/ ACE-Is
- reduce GFR
- NSAIDs 🡪 inhibition of renal vasodilatory prostaglandins 🡪 increased renal sodium reabsorptio
Vasodiators
- Calcium channel blockers
- Hydralazine
- Clonidine
- Alpha blockers
OHGAs: rosiglitazone, pioglitazone (stimulate sodium reabsorption)
- Increases GLUT protein exp on muscle cells; induce insulin sensitisation
Steroids: glucocorticoids, anabolic steroids, estrogens and progestins 🡪 increases risk of DVT and thrombotic event
Cyclosporin
Methotrexate
- hepatotoxic
[Bilateral edema] What are the clinical features pointing towards congestive cardiac failure?
How can it be worked up?
- Chest pain, palpitations, SOB, exertional dypsnea, orthopnea and paroxysmal nocturnal dypsnea
- Ischemic risk factors (HTN, HLD, DM, Smoking)
- History of CAD/IHD, valvular heart disease, arrhythmias
- acute precipitant of worsening fluid overload e.g. new MI, uncontrolled arrhythmia, non compliance to fluid restruction or intercurrent infection
- CXR: cardiomegaly +/- pulmonary edema
- ECG: prior infarction (e.g. q waves, poor R wave progression)
- elevated NT- proBNP levels and echocardiac evidence of reduced ejection fraction
[Bilateral edema] What are the clinical features pointing towards CKD, nephrotic syndrome?
Acute onset swelling, Frothy urine
History of renal disease, risk factors (DM, HTN)
[Bilateral edema] What are the clinical features pointing towards hepatic (CLF)?
Jaundice
History of alcohol, drug abuse, hepatitis
[Bilateral edema] What are the clinical features pointing towards myxedema ?
Myxedema – a non-pitting edema
- Due to deposition of GAGs in the dermis 🡪 draws water in
- A dermatological change seen in Hypothyroidism (eg: Hashimoto’s Thyroiditis, long standing hypothyroid)
- Hence a/w cold intolerance, weight gain, constipation, lethargy, dry skin
Pretibial Myxedema
- Refers to Myxedema in the LL (the only form of myxedema in Hyperthyroid patient)
- Hallmark of Grave’s
[Bilateral edema] What are the clinical features pointing towards pulmonary hypertension?
Sleep apnea (STOPBANG) Chronic lung disease
[Bilateral edema] What are the clinical features pointing towards hypoalbumin?
Diarrhoea (protein losing enteropathy)
Malnutrition
[Unilateral edema, acute onset] What are the clinical features pointing towards DVT?
Swelling, pain, warmth (tenderness)
Edema, erythema: These findings can be found in v obvious pts, but in non obv patients, we look for at the gastrocnemius tendon (disappears in DVT)
Pulmonary embolism 🡪 fSOB
- Wells score ≥3 indicates likely DVT
Localized upper extremity edema may occur with upper extremity venous thrombosis
- Feeling of fullness in the fingers or difficulty with finger rings feeling “too tight”
- Can be spontaneous or catheter induced
Risk factors
- Taking os steroids: Combined OCP or HRT
- Immobilisation (eg. Plaster or paresis)
- Long distance travel
- Bedridden > 3 days
- Active cancer
- Pregnancy
- Previous DVT/Family Hx
- Major surgery within 4 weeks
[Unilateral edema, acute onset] What are the clinical features pointing towards compartment syndrome?
6 Ps – Pain (tenderness), pulselessness(late sign), paraesthesia (pins & needles or even numbness), paralysis (late sign), pallor, poikilothermia
Aetiology: Trauma, burns, tight splints/casts, LL fracture, crush injury
[Unilateral edema, acute onset] What are the clinical features pointing towards cellulitis?
Erythema, warmth, fever, tenderness of the leg swelling
Discrete area of symptoms
Aetiology
- Bacterial infection of the subcutaneous fat tissue via
trauma, penetrating injury, sepsis
- Can progress to necrotising fasciitis / abscess
[Unilateral edema, acute onset] What are the clinical features pointing towards necrotising fasciitis?
Stage I presentation initially similar to cellulitis (+ presence of tenderness)
Stage II & III: blistering, skin necrosis, anaesthesia, crepitus
Risk factors: DM, peripheral vascular disease, IV drug use, alcoholism, surgery, abscess, immunosuppression
Infection: MRSA, Group A Strep (eg: Strep Pyogenes)
[Unilateral edema, acute onset] What are the clinical features pointing towards baker’s cyst?
Swelling, pain (tenderness), warmth, erythema
What? Also known as a popliteal cyst 🡪 a benign swelling of the semimembranosus behind the knee
Aetiology: History of RA, OA, meniscal injury
[Unilateral edema, chronic onset] What are the clinical features pointing towards pelvic mass?
LOA, LOW
Previous pelvic cancer
PV (per-vaginal) bleeding (post-menopausal or intermenstrual)
[Unilateral edema, chronic onset] What are the clinical features pointing towards reflex sympathetic dystrophy?
AKA: Syndrome of pain (tenderness), swelling, vasomotor dysfunction post trauma / surgery
Presents with Painful extremity
[Unilateral & bilateral edema, chronic onset] What are the clinical features pointing towards lymphedema
Previous lymph node dissection or radiotherapy, filariasis
Lead to fluid accumulation within tissue due to impaired drainage
Skin becomes darkened and thickened (cobblestone appearance)
- Thickening occurs in cutaneous and subcutaneous tissues + cutaneous fibrosis
- Leads to +ve Kaposi-Stemmer sign = skin on the dorsum of the second toe cannot be pinched as a fold by the fingers. This can also be performed on any other part of the body.
- When positive, it confirms the presence of peripheral lymphedema
Hyperkeratosis + Brawny Induration of the skin
- In Developed Countries: Most common reason: Axillary LN dissection (breast cancer) & Axillary/Inguinal LN dissection (melanoma)
- In Developing Countries: Most common reason is Filiriasis – a parasitic disease caused by an infection with roundworms which occupy Lymphatics
[Unilateral & bilateral edema, chronic onset] What are the clinical features pointing towards chronic venous insufficiency?
Skin changes (haemosiderin pigmentation, atrophy, hair loss, varicose/stasis eczema, varicose veins, ulceration)
Elderly patient, F>M, family hx, obesity, pregnancy, previous DVT or vein harvesting
Painless however will cause pain when DVT reoccurs
What would you examine for generally in a patient with oedema?
- Body mass index: obesity associated with chronic venous insufficiency (CVI)
- Distribution of edema
- tenderness: DVT, cellulitis
- Pitting or non pitting
- Signs of systemic disease: heart failure, liver disease, renal failure
- Presence of varicose veins or stasis eczema suggestive of CVI
- Hyperkeratosis with brawny induration suggestive of lymphadema
- Kaposi- Stemmer’s sign: suggestive of lymphadema
What is Well’s score?
Risk factors
- Active cancer (or treated within 6 months): +1
- Paralysis of recent lower limb immobilisation: + 1
- Bedridden > 3 days or surgery within 4 weeks: +1
Physical findings
- Swelling of entire leg: +1
- Calf swelling > 3 cm, compared to the normal leg: +1
- Pitting edema, greater than the normal leg: +1
- Localised tenderness along the deep venous system: +1
- Collateral superficial veins (not varicose veins): +1
Differential: Alternative differential as likely or more likely than DVT (-2)
