We have seen our esteemed guests, and they are us! Paul Williams (@PaulNWilliamz) leads the discussion with Matt Watto (@DoctorWatto) and Beth “Garbs” Garbitelli (@bethgarbitelli) on the evaluation and management of common causes of edema.
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The case of Lynn Fedema
Pathophysiology of edema
Differential diagnosis of chronic edema
Chronic edema work-up
Management of chronic edema
Calvin Fedema and acute edema
Evaluation of acute edema
The pathophysiology behind edema is an imbalance between oncotic pressure and hydrostatic pressure within the venous system.
Chronic venous insufficiency is the most common cause of chronic lower extremity edema, especially in older patients.
Again, bilateral lower extremity cellulitis is extremely uncommon.
Edema may be a sign cardiopulmonary, renal, hepatic, or thyroid dysfunction – so look at the patient in front of you and evaluate for risk factors.
Lymphedema results from impairment of lymphatic return, and can sometimes be distinguished from other causes of edema by the Stemmer sign.
Medications are a common cause of lower extremity edema – don’t forget about the gabapentinoids!
May-Thurner syndrome is caused by anatomical compression of the left iliac vein, and can result in unilateral edema or recurrent deep vein thrombosis.
Acute edema can be caused by deep vein thrombosis, cellulitis, or ruptured popliteal cyst, all of which may be difficult to differentiate from each other.
The physical examination should be directed at finding underlying systemic causes of lower extremity edema.
Management of edema usually includes compression, elevation, and avoidance of exacerbating medications.
Lower Extremity Edema Notes
Edema – Pathophysiology
Generally speaking, venous circulation maintains a balance between hydrostatic pressure and oncotic pressure. Edema can result from perturbations in these forces (Trayes et al 2013).
Increased hydrostatic pressure
Venous hypertension from right-sided heart failure, venous insufficiency, constrictive pericarditis, etc.
Low-protein states like nephrotic syndrome, hepatic failure, protein-energy malnutrition
Vasodilation from warmer weather
Inflammatory states such as burns or cellulitis
Additionally, as Cardi B teaches us, a lot of things need to be working for effective venous return. Recall that venous return is largely a passive process and requires functional valves and muscle contraction. Defects in either of these can result in diminished venous return, increased venous pressure, and resultant edema.
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Listeners will explain the basic pathophysiology, diagnosis, and management of common causes of lower extremity edema.
After listening to this episode listeners will…
Recognize the basic pathophysiology underlying lower extremity edema.
Develop a realistic differential diagnosis for causes of chronic and acute lower extremity edema.
Outline the initial diagnostic work-up of lower extremity edema.
Describe general management principles for common causes of lower extremity edema.
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