II. Definitions

  1. Edema
    1. Abnormal interstitial fluid accumulation in the intercellular space

III. Pathophysiology

  1. Mechanisms
    1. Loss of vascular integrity
      1. Changes in capillary hemodynamics
    2. Oncotic pressure gradient changes across the capillary membrane (between capillary and interstitial space)
      1. Increased tissue oncotic pressure (increased interstitial Protein concentration) or
      2. Decreased plasma oncotic pressure (decreased Serum Albumin)
    3. Increase in capillary hydrostatic pressure
      1. Norepinephrine results in renal Vasoconstriction
      2. Renin results in Sodium absorption
      3. Aldosterone results in water retention
  2. Localized Edema
    1. See Localized Edema
  3. Generalized Edema
    1. See Generalized Edema Below the Diaphragm
    2. See Generalized Edema Above the Diaphragm
    3. Implies >3 Liters interstitial fluid accumulation
    4. Sodium and water retention mediated by renal Vasoconstriction and renin and Aldosterone (as above)
      1. Kidney senses decreased perfusion
      2. Kidney senses decreased circulating volume

IV. Causes

V. History

  1. Onset in last 72 hours?
    1. Exclude DVT, Cellulitis, Trauma
  2. Dependent Edema?
    1. Venous Insufficiency improves with limb elevation
    2. Will not improve with elevation in conditions with decreased plasma oncotic pressure (e.g. Cirrhosis, Nephrotic Syndrome, malabsorption)
  3. Unilateral or bilateral
    1. See Localized Edema Causes
    2. Generalized Edema Above the Diaphragm
    3. Generalized Edema Below the Diaphragm
    4. Medication Causes of Edema

VI. Symptoms

  1. Unexplained weight gain
  2. Ring tightness
  3. Shoe tightness
  4. Facial swelling or puffiness
  5. Swollen arms or legs
  6. Abdominal Distention

VII. Signs

  1. See Edema Exam
  2. Palpable swelling of skin or subcutaneous tissue
    1. Pitting Edema
    2. Non-Pitting Edema (Brawny Edema)

VIII. Diagnostics

IX. Imaging

  1. Chest XRay Indications
    1. Dyspnea or
    2. BNP not available
  2. Echocardiogram Indications
    1. Suspected Pulmonary Hypertension (e.g. Obstructive Sleep Apnea)
    2. Suspected Congestive Heart Failure
      1. Increased BNP or
      2. Generalized Leg Edema in age over 45 years old (or other risks for Cardiomyopathy or CHF)
      3. Blankfield (1998) Am J Med 105:192-7 [PubMed]
  3. Extremity Doppler Ultrasound Indications
    1. Unilateral or asymmetric extremity edema
    2. Deep Vein Thrombosis suspected
    3. Confirm Venous Insufficiency
  4. Indirect radionuclide lymphoscintigraphy
    1. Confirmation of Lymphedema
  5. Magnetic Resonance Angiography with venography of lower extremity and Pelvis
    1. Pelvic or thigh Deep Vein Thrombosis suspected despite negative venous Doppler Ultrasound

X. Labs: First-line

  1. B-Type Natriuretic Peptide
    1. CHF unlikely if BNP normal
      1. Test Sensitivity 90%: BNP <100 pg/ml
      2. Test Sensitivity 96%: BNP <50 pg/ml)
    2. Maisel (2001) N Engl J Med 347(3): 161-7 [PubMed]
  2. Urinalysis
    1. Evaluate for large Proteinuria (Nephrotic Syndrome)
  3. Comprehensive metabolic panel
    1. Renal Function test (Serum Creatinine, Blood Urea Nitrogen or BUN)
    2. Liver Function Test
      1. Optional if examiner can reliably exclude significant Ascites based on examination or Bedside Ultrasound

XI. Labs: As indicated

  1. Serum Albumin
    1. Indicated for large Urine Protein positive suggestive of Nephrotic Syndrome
  2. Thyroid Stimulating Hormone (TSH)
  3. Urine test for Thiazides or Phenolphthalein
    1. Indicated in suspected Eating Disorder
    2. Confirms Diuretic abuse or Laxative abuse

XII. Approach: Bilateral Leg Edema in Emergency Department

  1. Most critical causes to exclude
    1. Congestive Heart Failure
    2. Nephrotic Syndrome
    3. Cirrhosis
  2. Diagnostics
    1. B-Type Natriuretic Peptide (BNP)
      1. Obtain Echocardiogram if BNP >100 pg/ml (especially if age >45)
    2. Basic metabolic panel
      1. Adding Liver Function Tests and Serum Albumin is optional (if Ascites excluded on exam or Bedside Ultrasound)
    3. Urinalysis
      1. Evaluate for large Proteinuria
    4. Bedside Abdominal Ultrasound
      1. Evaluate for Ascites (if body habitus or other confounding factors limit exam)
      2. Consider Inferior Vena Cava Ultrasound for Volume Status
  3. Consider important other diagnoses (if diagnostics and examination otherwise negative above)
    1. See Generalized Edema Below the Diaphragm
    2. See Generalized Edema Above the Diaphragm
    3. See Medication Causes of Edema
    4. Hypothyroidism
    5. Pelvic Mass
    6. Pregnancy Induced Hypertension (after 20 weeks gestation)
    7. Deep Vein Thrombosis evaluation indications
      1. Unilateral or asymmetric edema or
      2. Bilateral extremity edema and significant VTE Risk factors
        1. Cancer in last year
        2. Joint replacement
        3. Trauma
        4. Immobilization
        5. Hypercoagulability or prior Venous Thromboembolism
  4. Consider common alternative diagnoses (if diagnostics and examination otherwise negative above)
    1. Venous Insufficiency (most common)
    2. Lymphedema
      1. See Stemmer's Sign (pathognomonic)
    3. Cyclic edema

XIII. Management: General

  1. Treat specific underlying cause
  2. Diuretics if indicated (see below)
    1. Avoid in venous or lymphatic insufficiency
  3. Elevate legs
  4. Limit Dietary Sodium to 1500-2000 mg/daily
  5. Compression Stockings (Venous Insufficiency)
    1. Contraindicated in Peripheral Arterial Disease (consider Ankle-Brachial Index before compression stocking use)
    2. Mild edema: 20-30 mmHg
    3. Severe edema: 30-40 mmHg

XIV. Management: Diuretics

  1. Precautions
    1. Avoid Diuretics in conditions where they are unlikely to offer benefit
      1. Venous Insufficiency
      2. Lymphatic insufficiency (Lymphedema)
      3. Cyclic edema
    2. Close interval follow-up (within 7-10 days) to monitor progression
    3. Monitor Serum Potassium
    4. Monitor weight loss to keep above dry weight (base weight)
  2. Diuretic indications
    1. Pulmonary Edema
    2. Congestive Heart Failure
    3. Nephrotic Syndrome
    4. Cirrhosis
  3. Diuretic dosing (initiation)
    1. Furosemide 10-20 mg orally twice daily
    2. Add Spironolactone in Cirrhotic Ascites

XV. References

  1. Borhart et al in Majoewsky (2013) EM:Rap 13(7):5-6
  2. Traves (2013) Am Fam Physician 88(2): 102-110 [PubMed]

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Related Studies

Ontology: Edema (C0013604)

Definition (UWDA) Pathological transudate within one or more tissues.
Definition (MEDLINEPLUS)

Edema means swelling caused by fluid in your body's tissues. It usually occurs in the feet, ankles and legs, but it can involve your entire body.

Causes of edema include

To keep swelling down, your health care provider may recommend keeping your legs raised when sitting, wearing support stockings, limiting how much salt you eat, or taking a medicine called a diuretic - also called a water pill.

Definition (NCI_NCI-GLOSS) Swelling caused by excess fluid in body tissues.
Definition (NCI) Accumulation of an excessive amount of fluid in cells or intercellular tissues.
Definition (CSP) swelling from excessive accumulation of serous fluid in tissue.
Definition (MSH) Abnormal fluid accumulation in TISSUES or body cavities. Most cases of edema are present under the SKIN in SUBCUTANEOUS TISSUE.
Concepts Pathologic Function (T046)
MSH D004487
ICD9 782.3
ICD10 R60.9
SnomedCT 206891002, 206888002, 206894005, 423666004, 158247007, 161979002, 139241006, 158241008, 158244000, 161988006, 139250008, 155375008, 266308000, 79654002, 20741006, 267038008
LNC MTHU019803, LA17263-7, LA19035-7
English Dropsy, Edema, Hydrops, EDEMA NOS, OEDEMA, OEDEMA NOS, Edema NOS, Oedema NOS, [D]Dropsy, [D]Edema, [D]Edema NOS, [D]Oedema, [D]Oedema NOS, Edema, unspecified, Oedema, unspecified, [D]Dropsy (context-dependent category), [D]Edema (context-dependent category), [D]Edema NOS (context-dependent category), Edema (observable entity), edema (diagnosis), edema, edema (physical finding), Edema (NOS), Edema [Disease/Finding], oedemas, excess fluid, dropsies, interstitial edema, edema interstitial, watery swelling, swelling due to excess fluid, swells, interstitial oedema, swelled, swellings, edematous, edemas, swell, oedema, oedematous, swelling, Oedema - symptom, [D]Oedema NOS (situation), [D]Oedema (situation), Edema - symptom, [D]Dropsy (situation), Edema NOS (finding), Oedema NOS (finding), [D]Edema NOS (situation), [D]Edema (situation), Waterlogged, EDEMA, Edematous, Interstitial edema, Interstitial oedema, Oedema, Oedematous, Edema - lesion, Oedema - lesion, Edema (finding), Edema (morphologic abnormality), Hydrops (morphologic abnormality), hydrops, Dropsy, NOS, Edema, NOS, Hydrops, NOS, Oedema, NOS, dropsy
French OEDEME, Oedèmes SAI, Oedème SAI, OEDEME SAI, Oedème
Portuguese EDEMA, Edema NE, Edema, Hidropisia, Hidropsia
Spanish EDEMA, Edema NEOM, Edema (NEOM), [D]edema (categoría dependiente del contexto), edema (entidad observable), [D]hidropesía (categoría dependiente del contexto), [D]edema, SAI (categoría dependiente del contexto), EDEMA SE, Edema NOS, [D]edema (situación), Oedema NOS, [D]edema, SAI, edema, SAI, [D]hidropesía (situación), edema, SAI (hallazgo), [D]hidropesía, [D]edema, [D]edema, SAI (situación), edema (anomalía morfológica), edema (hallazgo), edema - lesión, edematoso, edema, hidropesía (anomalía morfológica), hidropesía, Edema, Hidropesía, Hidropsia
German OEDEM, Oedem NNB, Oedem (NNB), OEDEM NNB, Oedem, nicht naeher bezeichnet, Oedem, Hydrops, Wassersucht, Ödem
Dutch oedeem (NAO), oedeem NAO, Oedeem, niet gespecificeerd, oedeem, Hydrops, Oedeem, Oedema, Waterzucht
Italian Edema (NAS), Edema NAS, Anasarca, Idropi, Edema
Japanese 浮腫NOS, 浮腫(NOS), フシュ, フシュNOS, 浮腫, 水症
Swedish Svullnad
Czech otok, edém, Otok, Edém (NOS), Edém, Edém NOS, hydrops
Finnish Turvotus
Korean 상세불명의 부종
Croatian EDEM
Polish Obrzęk
Hungarian Oedema, Ödéma (k.m.n.), Oedema k.m.n., Ödéma, Ödéma k.m.n.
Norwegian Hevelser, Vattersott, Ødemer, Vannsott, Væskeansamling, Ødem, Hevelse, Hydrops

Ontology: Anasarca (C0151603)

Definition (NCI) A condition that is characterized by the presence of generalized edema. Causes include congestive heart failure, liver failure, renal failure, and severe malnutrition.
Concepts Pathologic Function (T046)
MSH D004487
ICD10 R60.1
SnomedCT 206890001, 206889005, 442433009, 139247005, 158242001, 161985009, 158243006, 32951000009107, 16740003, 271808008
English EDEMA GENERALIZED, FLUID RETENTION IN TISSUES, OEDEMA GENERALISED, [D]Edema, generalized, Generalized oedema, [D]Anasarca (context-dependent category), [D]Edema, generalized (context-dependent category), [D]Anasarca, edema anasarca, edema anasarca (physical finding), anasarca, [D]Oedema, generalised, Edema generalized, Fluid retention in tissues, Oedema generalised, Oedema generalized, Anasarca (finding), fluid retention tissue, Anasarca, Oedema, generalised (finding), [D]Oedema, generalised (situation), [D]Anasarca (situation), [D]Edema, generalized (situation), Edema, generalized, Generalized edema, Oedema, generalised, Generalised oedema, Edema, generalized (finding), Anasarca (morphologic abnormality), edema; generalized, generalized; edema, generalised oedema, generalized edema, Edema;generalized, Oedema;generalised
Italian Edema generalizzato, Ritenzione di liquidi nei tessuti, Anasarca
Dutch oedeem gegeneraliseerd, anasarca, vochtretentie in weefsels, gegeneraliseerd; oedeem, oedeem; gegeneraliseerd, Gegeneraliseerd oedeem, gegeneraliseerd oedeem
French Rétention de liquide dans les tissus, Anasarque, OEDEME GENERALISE, RETENTION DE LIQUIDE DANS TISSUS, Oedème généralisé
German Oedem, generalisiert, Fluessigkeitsretention in Geweben, Anasarka, generalisiertes Oedem, FLUESSIGKEITSRETENTION GEWEBE, Generalisiertes Oedem, OEDEM GENERALISIERT, generalisierte Oedeme
Portuguese Retenção de líquidos nos tecidos, Anasarca, EDEMA GENERALIZADO, EDEMA TECIDUAL, Edema generalizado
Spanish Anasarca, Retención de líquidos en tejidos, [D]edema generalizado (categoría dependiente del contexto), [D]anasarca (categoría dependiente del contexto), EDEMA GENERALIZADO, LIQUIDOS EN TEJIDOS, RETENCION, anasarca (hallazgo), [D]anasarca (situación), [D]edema generalizado (situación), [D]edema generalizado, [D]anasarca, anasarca (anomalía morfológica), anasarca, edema generalizado, edema, generalizado (hallazgo), edema, generalizado, Edema generalizado
Japanese 全身性浮腫, 組織内液貯留, ゼンシンセイフシュ, ソシキナイエキチョリュウ, 重症全身浮腫, ジュウショウゼンシンフシュ
Czech Anasarka, Retence tekutin ve tkáních, Generalizovaný edém, anasarka
Korean 전신 부종
Hungarian Anasarca, Generalizált ödéma, Folyadékretentio a szövetekben, Általánosult ödéma, Oedema, generalisált, Generalizált oedema
Norwegian Hudvannsott, Anasarka

Ontology: Fluid overload (C0546817)

Definition (CCC) Fluid retention, overload, or edema
Definition (NCI) Too much fluid in the blood.
Definition (NAN) Increased isotonic fluid retention
Definition (CSP) abnormal increase in the volume of circulating fluid (plasma) in the body.
Concepts Disease or Syndrome (T047)
ICD9 276.6
ICD10 E87.7 , E87.70
SnomedCT 33024009, 234175000, 190899008, 21639008
LNC MTHU013364
English FLUID OVERLOAD, HYPERVOLAEMIA, Fluid overload NOS, Volume overload, Excess Fluid Volume, fluid overload (diagnosis), fluid overload, rndx fluid volume excess (diagnosis), rndx fluid volume excess, volume excess, volume overload, fluid excess, excess fluid volume, fluid excess volume, fluid volume excess, fluids overload, overloaded volume, excess fluid, excess fluids, hypervolaemia, Fluid overload, unspecified, Alteration in fluid volume: excess (finding), Excess fluid volume, Alteration in fluid volume: excess, Hypervolaemia (disorder), Fluid overload NOS (disorder), Hyperhydration, HYPERVOLEMIA, Fluid Volume Excess, Hypervolemia, Fluid excess, Fluid volume excess, Volume excess, Hypervolaemia, Hypervolemia (disorder), EXCESS FLUID VOLUME, hypervolemia, excess; fluid, fluid; excess, fluid; overload, overload fluid, overload; fluid, Fluid overload
Italian Ipervolemia, Sovraccarico di liquidi, Sovraccarico di volume, Iperidratazione
Japanese 血液量増加症, 水分過負荷, ケツエキリョウゾウカショウ, スイブンカフカ, 容量過負荷, ヨウリョウカフカ, スイブンカジョウ, 水分過剰
Spanish Sobrecarga de volumen, HIPERVOLEMIA, LIQUIDOS, SOBRECARGA, exceso de volumen de líquido, alteración del volumen de líquido: exceso, sobrecarga de líquidos, SAI, líquido extracelular aumentado, alteración del volumen de líquido: exceso (hallazgo), sobrecarga de líquidos, SAI (trastorno), L.E.C. aumentado, Hiperhidratación, exceso de líquidos, hipervolemia (trastorno), hipervolemia, Hipervolemia, Sobrecarga de líquido
French Surcharge en volume, HYPERVOLEMIE, SURCHARGE LIQUIDIENNE, Hyperhydratation, Hypervolémie, Surcharge liquidienne
Dutch volume overbelasting, hyperhydratatie, overbelasting; vocht, overmaat; vocht, vocht; overbelasting, vocht; overmaat, Overmaat aan vocht, hypervolemie, vochtopstapeling
Portuguese Sobrecarga de líquido, HIPERVOLEMIA, SOBRECARGA DE LIQUIDOS, Hiper-hidratação, Hipervolemia, Sobrecarga de líquidos
German Volumenueberlastung, FLUESSIGKEITSUEBERLASTUNG, Fluessigkeitsueberschuss, HYPERVOLAEMIE, Hyperhydrierung, Hypervolaemie, Ueberwaesserung
Czech Přeplnění tekutiny, Hypervolemie, Hyperhydratace
Korean 체액과부하
Hungarian Folyadék túlterhelés, Hypervolemia, Térfogat túltöltése, Hypervolaemia, Hyperhydratio

Ontology: Disorder characterized by edema (C1290849)

Concepts Disease or Syndrome (T047)
SnomedCT 118654009
English Disorder characterised by oedema, Disorder characterized by edema (disorder), Disorder characterized by edema
Spanish trastorno caracterizado por la presencia de edema (trastorno), trastorno caracterizado por la presencia de edema