EDEMALeyiGuRenalDivision,RenjiHospitalDEFINITIONExpansionoftheinterstitial（間質）fluidvolume.WeightgainprecedesovertedemaMassiveandgeneralizededemaiscalledanasarca（全身性水腫）Pitting(壓凹性)andnon-pitting(非壓凹性)edemaSchrothBE,JAAPA200511EdemaPittingedemaNon-pittingedemaAnatomyandpathophysilolgy1/3oftotalbodywaterisextracellularspace,and2/3isintracellularspace;Extracellularspaceiscomposedoftheintravascularplasmavolume(25%)andtheextravascularinterstitialspaces(75%);Starling’slaw:Extravascularandintravascularhydrostaticpressurs;Differencesinoncoticpressureswithintheinterstitialspaceandplasma;Thepermeabilityofthebloodvesselwall.AnatomyandpathophysilolgyVascularsystemInterstitialspaceHydrostaticpressure（流體靜水壓）

HydrostaticpressureColloidoncoticpressure(tissuetension)（膠體滲透壓）

ColloidoncoticpressureReducedPlasmaOsmoticPressureAlbuminis

theserum

proteinMOSTresponsibleforthemaintenanceofcolloidosmoticpressureAdecreaseinosmoticpressurecanresultfromincreasedproteinlossordecreasedproteinsynthesisCapillaryDamageDamagetothecapillaryendotheliumIncreaseitspermeabilityandpermitsthetransferofproteinintointerstitialcompartment

Injuryagents

DrugsViral/bacterialagentsThermal/mechanicaltraumaImmuneResponsibleforinflammatoryedema

NonpittinglocalizedrednessandtendernessClinicalCausesofEdemaSystemicedemaCongestiveheartfailureCirrhosisNephroticsyndrome/other

hypoalbuminemiaDrug-inducedIdiopathic

LocalizededemaVenous/lymphaticobstructionSystemicEdema

CongestiveheartfailureCongestiveheartfailure

Left-sidedheartfailure:shortnessofbreathwithexertionandwhenlyingdownatnight(orthophea,端坐呼吸)－－pulmonaryedemaRight-sidedheartfailure:swellinginthelegsandfeet－－peripheraledemaThephysicianexaminingapatientwhohascongestiveheartfailurewithfluidretentionlooksforcertainsigns:pittingedema;ralesinthelungs,agalloprhythmanddistendedneckveins.SystemicEdemaNephroticSyndrome/HypoalbuminemicstatesTheprimaryalteration:decreasedcolloidoncoticpressureproteinlossintheurine

severenutritionaldeficiencyproteinlossenteropathycongenitalhypoalbuminemialivercirrhosisPromotesfluidmoveintotheinterstitiumCauseshypovolemia

salt/waterretentionactivationRAAaxisetcIdiopathicEdemaDiurnalalterationsinweightoccurringwithorthostaticretentionofsodiumandwaterIncreaseincapillarypermeability

fluctuateinseverityaggravatedbyhotweatherReductioninplasmavolumeinthisconditionwithsecondaryactivationoftheRAAsystemDrug-inducededemaNonsteroidalanti-inflammatorydrugsAntihypertensiveagents

Directarterial/arteriolarvasodilatorsCalciumchannelantagonistsa-AdrenergicantagonistsSteroidhormones

GlucocorticoidsAnabolicsteroidsEstrogensProgestinesCyclosporineGrowthhormoneImmunotherapies

Interleukin2OKT3monoclonalantibodyLocalizededema

InflammationVenous/lymphaticobstructionChroniclymphangitisResectionofregionallymphnodesFilariasis(絲蟲病)DiagnosisOfparticularimportanceisexcludingmajororgansystemdysfunction,especiallycardiac,liver,andrenaldysfunction.Askquestionssuchasthefollowing:Dotheringsonyourfingersgettight?Haveyouhadtoletyourbeltout?Haveyourclothesorshoesgottentootight?Payspecialattentiontothepatient’smedications;Also,obtainathoroughdietaryhistory,payingcarefulattentiontothepatient’sdietarysodiumintake,totaldailyfluidintake;Physicalexamination&Diagnostictesting

Inadditiontothestandardphysicalexamination,chartthepatient’sweightandnotegeneralappearance,payingspecialattentiontotheedemawithrespecttolocation,symmetry,pittingornonpittingappearance,tenderness,andassociatedskinchanges.Assesstheseverityofedemawithamethodsuchasthefour-pointscale(+1,slight,to+4,verymarked);Includingachemistrypanelandurinalysistoevaluaterenalandliverfunctionandalbuminlevelstoassessnutritionalstatus.Considermeasuringthethyrotropinleveltoruleouthypothyroidism.Incaseswherescreeningforacardiacetiologyisrequired,anECGandchestradiographmaybehelpfulinassessingcardiacfunction.DifferentialdiagnosisHeartfailureRenaldiseasesCirrhosisNutritionaloriginIdiopathicOthersDifferentialdiagnosis

HeartFailureEdemainitiallyoccursatlowerpartofthebody(lowerextremities)symmetriclocationThepresenceofheartdiseasescardiacenlargementgalloprhythmdyspneabasilarralesvenousdistentionhepatomegalyNoninvasivetestsmaybehelpful

echocardiographyradionuclideangiographyDifferentialdiagnosis

Renaldiseases

Mainlyduetohypoabluminemiaandsalt/waterretentionAssociatedwithhematuria,proteinuria,

hypertentionandimpairedrenalfunctionalCharacteriasticofedemaofrenalorigin:

puffinessofthefaceprominentintheperiorbitalareasDifferentialdiagnosis

Cardiac/Renaldisease

Renal

CardiacLocationonsetfromtheface,onsetfromthelowerperiobitalareaspartofthebodyProgressionprogressquicklyprogressslowlyIdentitysoftandmobilerelativelysolid,lessmobileOthersignsproteinuriasignsofheartfailure:hypertensioncardiacenlargementimpairedrenalvenousdistentionfunctionaltesthepatomegaly

Differentialdiagnosis

Liverdiseases(cirrhosis)

Clinicalevidenceofhepatic