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EDEMALeyiGuRenalDivision,RenjiHospitalDEFINITIONExpansionoftheinterstitial(間質(zhì))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
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