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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Very well know podcasts: informative, just the right length, folksy--but not coming across as fake Would appreciate an episode on arthritis Thank you
Thank you for your input! Great topic!
Loved it! Suggest on infographic the recliner is misleading. To really move fluids out of lower extremities legs need higher than heart. I have patient lay on couch and use cushions to elevate and pump feet to activate calf muscles . I demo in office for them without the pillows-motivation for doc to have string core muscles ! Loved the episode
Great info! Thank you for listening!
I wish that the presentation can add the following discussions 1) How to differential lymphedema vs edema 2) Why do two patients with proteinuria could have significantly different degrees of edema. For example, secondary FSGS patients hardly have edema, or primary FSGS patients have awful anasarca. 3) I feel BNP is a very useful tool. If BNP is within the normal range, then the excessive intravascular volume is not the cause of edema. For example, patients with severe pulmonary hypertension can have terrible edema while BNP is normal
We appreciate your feedback!
You guys mentioned a role for RAS inhibition for reducing leg edema. I'd love to read more about that. Is there a reference you could share?