Rey Vivo, MD

• 65M with long-standing RA presents to the office with 3-month bilateral lower extremity swelling which was progressive despite diuretic therapy started by his former PCP. Physical exam: elevated JVP with an increase during inspiration; a high-pitched third heart sound; diminished breath sounds on both bases; bilateral pitting edema up to both knees. Jugular venous tracing revealed prominent x and y descent. EKG displayed low voltage. Chest x-ray is shown.
What is the most likely diagnosis?
• A. Cardiac tamponade
• B. Constrictive pericarditis
• C. Right ventricular infarction
• D. Left-sided heart failure

Radiograph from utdol.com

– Definition of edema
– Pathophysiology
– Etiologies
– Diagnosis
– Management

• Figure 1: Etiology and causative factors of peripheral edema
Illustration from Am J Med . 2002;113:580-586
.

• Figure 2. Renal and neurohumoral factors in edema
Illustration from images.MD

• 43F diagnosed to have scleroderma with limited cutaneous involvement presents with worsening dyspnea on exertion in the last 5 months associated with leg swelling. She used to be physically active but now is unable to walk from her bed to her bathroom without SOB. PE: facial telangiectasias; skin sclerosis limited to both hands; elevated JVP; wide splitting of the 2 nd heart sound with prominent P2; (+) S3 and S4; highpitched holoystolic murmur on the left sternal border; clear lungs; palpable liver edge; pitting edema up to both calves. EKG is shown:
An echocardiogram is ordered. What echo findings will best explain her symptoms?
• A. Mitral regurgitation, LVH, elevated PA pressure
• B. Mitral regurgitation, RVH, normal PA pressure
• C. Tricuspid regurgitation, LVH, elevated PA pressure
• D. Tricuspid regurgitation, RVH, elevated PA pressure

Electrocardiogram from utdol.com

• 57F was brought to the hospital after being found lying on the street. On exam, the patient was drowsy but her vital signs were stable. She smelled of alcohol, appeared disheveled and jaundiced; abdomen was protruberant with bulging flanks and (+) fluid wave; liver was difficult to palpate; palmar erythema and bilateral pitting edema of both lower extremeties were present. Pertinent labs were: Hgb 10.2, MCV 101.9, AST 360, ALT 176, albumin 1.8, INR 1.79. CT scan of the abdomen showed hepatomegaly and ascites. What is the best therapeutic regimen for this patient’s ascites and edema?
• A. Dietary sodium restriction
• B. Furosemide
• C. Spironolactone
• D. Alcohol abstinence
• E. All of the above

• 48M with Hodgkin’s disease was referred for evaluation of bilateral leg swelling for 2 months. Examination revealed unremarkable heart findings, clear lungs and pitting edema of both legs up to his thighs. When told that he had some swelling around his eyes, he said that he was unaware of this.
Blood work showed marked hypoalbuminemia, hypercholesterolemia and hypertriglyceridemia. Urine: 4+ protein and oval fat bodies; 24-hour urine:
8g protein. Which one is the LEAST likely explanation of edema in this case?
• A. Increased capillary hydrostatic pressure
• B. Reduced plasma oncotic pressure due to hypoalbuminemia
• C. Reduced effective circulating volume
• D. Primary renal sodium retention

• The same patient was referred to Nephrology and was managed with dietary sodium restriction, diuretics and ACE-inhibitors. He responded well and eventually observed his edema improve. 6 months later, he came back in the clinic complaining of swelling in his left leg. He denied any trauma, insect bite or pre-existing wound. On exam, he was afebrile; the rest of his vital signs were within normal. His left leg had pitting edema; it was also erythematous and warm to touch. His right leg had no signs of edema.
There was no evidence of wounds or fungal infection. What is the most likely diagnosis given his condition?
• A. Cellulitis
• B. Lymphangitis
• C. Deep vein thrombosis
• D. Ruptured Baker’s cyst

Table 1. Causes of Peripheral Edema
• Increased capillary hydrostatic pressure
– Regional venous hypertension (often unilateral)
• Inferior vena caval/iliac compression
•
Deep venous thrombosis
• Chronic venous insufficiency
•
Compartment syndrome
• Systemic venous hypertension
• Increased plasma volume
•
Drugs
• Decreased plasma oncotic pressure
–
Protein loss
– Reduced protein synthesis
• Increased capillary permeability (usually clinically obvious)
– Allergic reactions: histamine release (hives), serum sickness, angioedema
–
Burns
– Inflammation/local infections
–
Interleukin 2 therapy
• Lymphatic obstruction or increased interstitial oncotic pressure
–
Lymphedema (primary or secondary [nodal enlargement due to malignancy, postsurgical/radiation, filariasis])
• Other
– Idiopathic
– Myxedema
Table from Am J Med . 2002;113:580-586
.

• You are on the Cardiology consult service and get a referral to see a 64F for new-onset bilateral leg swelling. She was admitted to the hospital 5 days ago for symptoms consistent with transient ischemic attack. She has a 10year history of difficult-to-control hypertension and has been taking hydrochlorthiazide 25mg/d, atenolol 100mg/d and lisinopril 40mg/d.
Amlodipine 5mg/d was added 3 days ago. PE: BP 137/68; HR 65; no JVP; regular rhythm with no extra heart sounds; clear lungs; (+) bilateral ankle pitting edema without varicosities or pigmentation. Labs were normal.
What is the most likely cause of her ankle edema?
• A. Heart failure
• B. Lymphedema
• C. Myxedema
• D. Drug reaction

Table 2. Drugs that Cause Peripheral Edema
• Antidepressants
• Monoamine oxidase inhibitors
• Antihypertensive medications
• Calcium channel blockers: dihydropyridines (e.g., nifedipine,
• amlodipine, felodipine), phenylalkylamines (e.g.,
• verapamil), benzothiazepines (e.g., diltiazem)
• Direct vasodilators: hydralazine, minoxidil, diazoxide
• Beta-blockers
• Centrally acting agents: clonidine, methyldopa
• Antisympathetics: reserpine, guanethidine
• Hormones
• Corticosteroids
• Estrogens/progesterones
• Testosterone
• Nonsteroidal anti-inflammatory agents
• Nonselective cyclooxygenase inhibitors
• Selective cyclooxygenase-2 inhibitors
• Others
• Troglitazone, rosiglitazone, pioglitazone
• Phenylbutazone
Table from Am J Med . 2002;113:580-586
.

• Peripheral edema is non-specific but is a valuable clue to distinct medical conditions
• Starling forces/Renal factors
• History is crucial
• Simple tests may lead to diagnosis
• Indications for: diuretic treatment, rate of fluid removal, choice and dose of diuretic
• Non-diuretic management