Rosen & Barkin's 5-Minute Emergency Medicine Consult (235 page)

• Generalized:
  
  • Heart failure
    
  • Cor pulmonale
    
  • Cardiomyopathies
    
  • Constrictive pericarditis
    
  • Pulmonary HTN:
    
    • Sleep apnea
      
    • COPD
      
  • Acute glomerulonephritis
    
  • Renal failure
    
  • Medication related (often secondary to salt retention):
    
    • Steroids/estrogens/progestins
      
    • NSAIDs
      
    • Antihypertensives (especially vasodilators)
      
    • Lithium
      
    • Cyclosporine
      
    • Insulin
      
    • Thiazolidinediones (glitazones)
      
    • Growth hormone
      
    • Interleukin-2
      
    • MAOIs
      
    • Pramipexole
      
    • Docetaxel
      
    • Minoxidil
      
    • Acute withdrawal of diuretics
      
  • Idiopathic (cyclic) edema
    
  • Myxedema
    
  • Cirrhosis
    
  • Nephrotic syndrome
    
  • Protein-losing enteropathy/malabsorption
    
  • Starvation
    
  • Pregnancy
    
• Localized:
  
  • Deep vein thrombosis
    
  • Venous insufficiency
    
  • Thrombophlebitis
    
  • Chronic lymphangitis
    
  • Cellulitis
    
  • Baker cyst
    
  • Vasculitis
    
  • Angioedema:
    
    • Allergic
      
    • Acquired
      
  • Hypothyroidism (myxedema)
    
  • Mechanical trauma
    
  • Thermal injuries
    
  • Radiation injuries
    
  • Chemical burns
    
  • Hemiplegia
    
  • Reflex sympathetic dystrophy
    
  • Compressive or invasive tumor
    
  • Postsurgical resection of lymphatics
    
  • Postirradiation
    
  • Filariasis
    

DIAGNOSIS

• Weight gain of several kilograms
  
• Discomfort in the affected areas
  
• Swelling
  
• Tenderness
  
• Pitting edema:
  
  • Increased venous hydrostatic pressure or decreased oncotic pressure
    
• Nonpitting edema:
  
  • Protein-rich extravasated fluid
    
• Generalized edema (anasarca):
  
  • Edema is most prominent in dependent areas:
    
    • Feet
      
    • Sacrum
      
    • Bilateral lower extremities
      
    • Face/periorbital (especially in the morning)
      
  • Cardiac:
    
    • Dyspnea
      
    • Orthopnea
      
    • Paroxysmal nocturnal dyspnea
      
    • Increased jugular venous pressure
      
    • Rales
      
    • S3 gallop
      
  • Renal:
    
    • Anorexia
      
    • Puffy eyelids
      
    • Frothy urine
      
    • Oliguria
      
    • Dark urine
      
    • Hematuria
      
    • HTN
      
  • Hepatic:
    
    • Jaundice
      
    • Spider angiomas
      
    • Palmar erythema
      
    • Gynecomastia
      
    • Testicular atrophy
      
    • Ascites
      
  • Myxedema:
    
    • Pretibial nonpitting edema
      
    • Dry waxy swelling of skin and SC tissues
      
    • Periorbital most common (puffy eyes)
      
    • Nondependent areas
      
    • Fatigue
      
    • Cold intolerance
      
    • Weight gain
      
    • Constipation
      
    • Slowed deep-tendon reflex relaxation
      
  • Idiopathic:
    
    • Diurnal weight gain/loss
      
• Localized:
  
  • Chronic venous insufficiency:
    
    • Chronic pitting
      
    • Skin discoloration (hemosiderin deposits)
      
    • Dermatitis/ulceration
      
    • Varicose veins
      
  • History of trauma:
    
    • Mechanical, thermal, radiation
      
  • Infectious/inflammatory:
    
    • Chills
      
    • Fever
      
    • Erythema
      
    • Increased warmth
      
  • Allergic:
    
    • Pruritus
      
    • Hives
      
    • Involvement of the lips and the oral mucosa
      

• Common secondary to hormonally mediated fluid retention
  
• When involving hands and face, may be early sign of preeclampsia
  
• Dependent edema:
  
  • Usually in late pregnancy
    
  • From impedance of venous return
    
• Diuretics contraindicated
  

Diagnostic studies should be directed by the underlying etiology suggested by the history and physical exam.

• Cardiac etiology suspected:
  
  • BNP or NT-proBNP
    
• Deep vein thrombosis suspected:
  
  • d
    -dimer (for patients with low clinical probability to rule out DVT)
    
• Renal etiology suspected:
  
  • Electrolytes
    
  • BUN and creatinine
    
  • Urinalysis
    
  • Urine electrolytes and protein
    
  • Serum lipids
    
• Hepatic etiology suspected:
  
  • Serum albumin
    
  • Liver function tests
    
  • Prothrombin time and partial thromboplastin time
    
• Myxedema suspected:
  
  • Thyroid function tests
    

• Cardiac etiology suspected:
  
  • EKG
    
  • CXR
    
  • ECG
    
• Localized edema to an extremity:
  
  • US (duplex scanning) or contrast venography
    
• High suspicion for abdominal or pelvic malignancy:
  
  • Abdominal/pelvic CT
    

• Cellulitis
  
• Contact dermatitis
  
• Diffuse SC infiltrative process
  
• Lymphedema
  
• Obesity
  

TREATMENT

See “ED Treatment.”

• Treatment should be directed toward the underlying cause.
  
• Diuretics are usually indicated in cases of generalized edema but are not required emergently.
  
• Diuretics may be deleterious in patients with cirrhosis and ascites, as rapid fluid shifts may precipitate hepatorenal syndrome.
  

• Amiloride: 5–10 mg PO daily
  
• Captopril: 6.25–100 mg PO TID (max. 450 mg/d)
  
• Furosemide: 20–80 mg IV/PO QID (max. 600 mg/d)
  
• Hydrochlorothiazide: 25–100 mg PO BID
  
• Spironolactone: 25–200 mg PO BID
  

FOLLOW-UP

• Base the decision to admit the patient on the underlying etiology.
  
• Concomitant cardiovascular or pulmonary compromise
  
• Inability to ambulate without adequate home support
  
• Hypoxia
  

• Patient should be advised to decrease salt intake.
  
• Elastic support stockings
  
• Elevation of involved limbs
  

• Patients >45 yr with chronic edema, or whose symptoms suggest a cardiopulmonary etiology require follow-up EKG.
  
• Patients with pulmonary HTN of unknown cause should be referred for a sleep study to evaluate for sleep apnea.
  
• A negative US in a patient at high risk for DVT requires urgent repeat study in 5–7 days.
  

Patients with chronic edema may follow-up with primary care doctor for continued workup and treatment.

• Classify edema as generalized vs. localized, pitting vs. nonpitting.
  
• Pitting edema is caused by “protein-poor” extravasated fluid (by increased hydrostatic pressure or decreased oncotic pressure).
  
• Nonpitting edema is caused by “protein-rich” extravasated fluids (lymphedema or increased capillary permeability).
  
• Generalized or bilateral leg edema necessitates workup of systemic disease.
  
• Acute unilateral leg edema requires evaluation for DVT.
  
• Consider preeclampsia in pregnant patients.
  

• Braunwald E, Loscalzo J. Edema. In: Longo DL, Fauci AS, Kasper DL, et al., eds.
  Harrison’s Principles of Internal Medicine
  . 18th ed. New York, NY: McGraw-Hill; 2012.
  
• Ely JW, Osheroff JA, Chambliss ML, et al. Approach to leg edema of unclear etiology.
  J Am Board Fam Med
  . 2006;19:148–160.
  
• Mockler J, Neher JO, St Anna L, et al. Clinical inquiries. What is the differential diagnosis of chronic leg edema in primary care?
  J Fam Pract
  . 2008;57:188–189.
  
• O’Brien JG, Chennubhotla SA, Chennubhotla RV. Treatment of edema.
  Am Fam Physician
  . 2005;71:2111–2117.
  
• Stern SC, Cifu AS, Altkorn D. I Have a patient with edema. How do I determine the cause? In: Stern SC, Cifu AS, Altkorn D, eds.
  Symptom to Diagnosis: An Evidence-based Guide
  . 2nd ed. New York, NY: McGraw-Hill; 2010.
  

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