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Edema

Related terms: Edema, Oedema, Lymphedema

Edema or Lymphedema

Not all swelling is lymphedema, some is edema caused by an underlying medical condition. This section includes articles that will help explain the difference.

If you have unexplained swelling, it is crucial for you to work with your doctor to find the underlying cause. Don't assume it is lymphedema. You must get treatment for the condition that is causing your edema.

Edema - Definition and Discussion

Simply defined, edema is the abnormal pooling of fluid in tissues or the accumulation of excess interstitial fluids. It can be throughout the body which is referred to as generalized edema. It can also occur in a specific region, part or even spot, then it is called localized edema. The condition may be caused by increased pressure in the capillaries, blocking of vein, varicose veins, thrombophlebitis, venous obstruction, pressure from casts, tight bandages, congestive heart failure, kidney failure, liver cirrhosis, overactive adrenal glands, steroid therapy or inflammatory reactions.

Edema may also occur because of loss of serum protein in burns, draining wounds, excessive bleeding, nephrotic syndrome or chronic diarrhea. It is also seen in malnutrition, allergic reactions.

But perhaps the most common edema experience by even millions of healthy individuals is inflammatory edema. This type of localized edema is a one of the body's most immediate reaction to trauma or injury to tissues. This can be caused by sprained muscles, torn ligaments, insect bites, cuts and abrasions. It is also caused by venous thrombosis or sudden vascular blockages. Joint swelling caused by arthritis is another common type of localized edema.

The treatment of edema is directed at correcting or curing the underlying condition. Once this condition is resolved the edema dissipates. If this does not occur than it can be treated with diuretics and/or decongestive massage therapy. In the situation of edema caused by vascular anomalies, support compression hosiery may be worn. Treatment may also include dietary changes which focuses on a low sodium intake. The symptoms of edema include unexplained weight gain, ring or shoe tightness, facial swelling or puffiness, swollen arms or legs and abdominal distention. Tissue changes in early edema are known as non pitting edema. When pressed with a finger, there is no indentation. Also, with edema the skin of the affected area may appear stretched and or shiny. In long standing edema, the tissue will experience (as with lymphedema) what is known as pitting edema.

Incidentally, all edemas used to be known as dropsy.

Infections can be a complication of both edema or lymphedema. It should be noted though, that edema may be caused by infection wheras in lymphedema infections are a direct complication of the condition itself. Also, with lymphedema, the affected limb is known as immuno-compromised and infections generally are much more severe and readily develop into cellulitis, or lymphangitis.

Lymphedema however is a disorder where lymph collects in soft tissue (sub-cutaneous) because damage to the lymphatic system. This can be from a genetic malformation (hereditary); infection or injury in utero (congenital); a side effect to a developmental disorder of the lymphatics (also a type of hereditary lymphedema), or by removal of lymph nodes for cancer biopsy, injury, trauma or infection of the lymphatics, infection caused by a parasitic infection or damage done by the crushing of the lymphatics in morbid obesity.

Since the destruction or injury to the lymphatics is the underlying cause, there is no cure for this swelling, only treatment and management. The preferred treatment for lymphedema is decongestive therapy. Other treatment modalities may include surgical management, and compression pumps. The use of diuretics should not be used and in fact may cause additional complications in lymphedema.

The general symptom of lymphedema is the swelling of an arm or leg unexpectedly and or without explanation or may suddenly appear after trauma, injury or lymph node removal for biopsy. In early lymphedema, when the limb is pressed with a finger, it will leave an indentation. This is known as pitting edema.

General Types of Edema

·anasarca. Refers to a generalized edema or swelling throughout the body. ·Dependent edema. Involves swelling of the feet, legs and ankles. It occurs most often at the end of the day or after long periods of traveling while in a seated position. ·Periorbital edema. Refers to the swelling around the eyes commonly seen when first waking up. It may also occur during allergic or hypersensitivity reactions. ·Pitting edema. Refers to a pit or depression in the swollen tissues that remains after the skin has been pressed down. ·Mechanical edema. Can be caused by tight socks, stockings or undergarments. The pressure of a pregnant uterus on pelvic veins can also cause mechanical edema. ·High Altitude Edema. This condition occurs when an oxygen deficiency at high altitudes causes fluid in the blood to leak from the smallest blood vessels (capillaries) into the surrounding tissues, resulting in swelling (edema). ·Lymphedema. Caused by obstruction of the lymph vessels (not the veins) and can appear either in the arms or the legs. It is commonly seen in the arms of post-mastectomy or lumpectomy patients on the same side as their surgery. ·Laryngeal edema. May occur in upper respiratory tract infections (particularly in children), allergic reactions and with exposure to toxins. The condition may be life threatening and requires immediate medical attention. ·Peripheral Edema. This is by far and wide the most common form of edema. It involves the arms and or legs and is generally cause by such conditions as lymphatic obstruction, congestive heart failure, infection, cancer, varicose veins, malnutrition, cirrhosis, nephrotic syndrome, deep venous thrombosis, chronic venous insufficiency, inflammation and lymphatic filariasis.

Here's where lymphedema is commonly not recognized or diagnosed correctly. When a patient presents wih limb swelling of unkown etiology, various tests are imperative to ascertain the causative effect. It is my contention that once this testing is complete and other underlying conditions are ruled out, then a diagnosis of lymphedema must be considered. At that point the patient should undergo a complete exam for lymphedema. Our page How to Diagnose Lymphedema gives a detail on that procecss.

·Pulmonary Edema

     Symtoms:
Rapid and labored breathing 
Shortness of breath ([[glossary:dyspnea]]) 
Coughing, sometimes with frothy blood 
Bluish tint to the skin, lips, fingernails and other areas of the body (cyanosis) 
Cold extremities (e.g., cold feet) 
Sense of feeling suffocated

Diagnosis methods for edema

A physician will obtain a detailed medical history of the patient and conduct a physical examination before making a diagnosis of edema. In many cases, the presence of edema can be determined by visual inspection of the patient. Blood tests and urine tests are also useful in diagnosing certain forms edema, such as pulmonary edema. Low levels of albumin may be detected in patients with liver dysfunction or with other conditions such as nephritic syndrome. Abnormal kidney function can be assessed by blood tests.

If heart failure is suspected, the physician may order tests such as the following:

·Electrocardiogram (EKG). A test that measures the heart’s electrical activity. It is designed to detect any abnormal rhythms, heart chamber enlargement, conduction defects and heart attack (recent or old). ·Exercise stress test. A test in which an EKG is performed at rest and then under the physical stress of exercise, to compare the heart's performance at rest and during times of physical exertion. ·Chemical stress test. A test that uses chemicals rather than physical exercise to determine a patient’s heart response to stress. This test is used for patients who are unable to participate in an exercise stress test. ·Echocardiogram. This test uses ultrasound technology to closely examine the overall muscle function of the heart, allowing the physician to evaluate the size, thickness and pumping action of the heart, and how well the heart valves are functioning. A stress echocardiogram may also be useful in assessing how well the heart is functioning at rest and during exercise

·Radionuclide imaging tests, such as a radionuclide ventriculogram. These provide contrast images of the heart, which can pinpoint areas of damage and/or dysfunction and determine how well the heart is pumping. ·Chest x-ray to evaluate the size and shape of the heart, as well as to view the lungs and any fluid that may have built up, as with pulmonary edema. More invasive exploratory tests may be ordered in conjunction with, or instead of, the above. These tests can include a coronary angiogram, in which a contrast dye is delivered by catheter to the coronary arteries to visualize the blood vessels and left ventricle. It is used to identify heart damage or dysfunction. In addition, cardiac catheterization can evaluate the function of the various heart valves. (1) Heart Health Village

Edema

Definition

Edema is a condition of abnormally large fluid volume in the circulatory system or in tissues between the body's cells (interstitial spaces).

Description

Normally the body maintains a balance of fluid in tissues by ensuring that the same amount of water entering the body also leaves it. The circulatory system transports fluid within the body via its network of blood vessels. The fluid, which contains oxygen and nutrients needed by the cells, moves from the walls of the blood vessels into the body's tissues. After its nutrients are used up, fluid moves back into the blood vessels and returns to the heart. The lymphatic system (a network of channels in the body that carry lymph, a colorless fluid containing white blood cells to fight infection) also absorbs and transports this fluid. In edema, either too much fluid moves from the blood vessels into the tissues, or not enough fluid moves from the tissues back into the blood vessels. This fluid imbalance can cause mild to severe swelling in one or more parts of the body.

Causes & symptoms

Many ordinary factors can upset the balance of fluid in the body to cause edema, including:

·Immobility. The leg muscles normally contract and compress blood vessels to promote blood flow with walking or running. When these muscles are not used, blood can collect in the veins, making it difficult for fluid to move from tissues back into the vessels. ·Heat. Warm temperatures cause the blood vessels to expand, making it easier for fluid to cross into surrounding tissues. High humidity also aggravates this situation. ·Medications. Certain drugs, such as steroids, hormone replacements, nonsteroidal anti-inflammatory drugs (NSAIDs), and some blood pressure medications may affect how fast fluid leaves blood vessels. ·Intake of salty foods. The body needs a constant concentration of salt in its tissues. When excess salt is taken in, the body dilutes it by retaining fluid. ·Menstruation and pregnancy. The changing levels of hormones affect the rate at which fluid enters and leaves the tissues.

Some medical conditions may also cause edema, including:

·Heart failure. When the heart is unable to maintain adequate blood flow throughout the circulatory system, the excess fluid pressure within the blood vessels can cause shifts into the interstitial spaces. Left-sided heart failure can cause pulmonary edema, as fluid shifts into the lungs. The patient may develop rapid, shallow respirations, shortness of breath, and a cough. Right-sided heart failure can cause pitting edema, a swelling in the tissue under the skin of the lower legs and feet. Pressing this tissue with a finger tip leads to a noticeable momentary indentation. ·Kidney disease. The decrease in sodium and water excretion can result in fluid retention and overload. ·Thyroid or liver disease. These conditions can change the concentration of protein in the blood, affecting fluid movement in and out of the tissues. In advanced liver disease, the liver is enlarged and fluid may build up in the abdomen. ·Malnutrition. Protein levels are decreased in the blood, and in an effort to maintain a balance of concentrations, fluid shifts out of the vessels and causes edema in tissue spaces. ·Diabetes

Some conditions that may cause swelling in just one leg include:

·Blood clots. Clots can cause pooling of fluid and may be accompanied by discoloration and pain. In some instances, clots may cause no pain. ·Weakened veins. Varicose veins, or veins whose walls or valves are weak, can allow blood to pool in the legs. This is a common condition. ·Infection and inflammation. Infection in leg tissues can cause inflammation and increasing blood flow to the area. Inflammatory diseases, such as gout or arthritis, can also result in swelling. ·Lymphedema. Blocked lymph channels may be caused by infection, scar tissue, or hereditary conditions. Lymph that can't drain properly results in edema. Lymphedema may also occur after cancer treatments, when the lymph system is impaired by surgery, radiation, or chemotherapy. ·Tumor. Abnormal masses can compress leg vessels and lymph channels, affecting the rate of fluid movement.

Symptoms vary depending on the cause of edema. In general, weight gain, puffy eyelids, and swelling of the legs may occur as a result of excess fluid volume. Pulse rate and blood pressure may be elevated. Hand and neck veins may be observed as fuller.

Diagnosis

Edema is a sign of an underlying problem, rather than a disease unto itself. A diagnostic explanation should be sought. Patient history and presenting symptoms, along with laboratory blood studies, if indicated, assist the health professional in determining the cause of the edema.

Edema

Medline Plus

What Is It

Edema is swelling of both legs from an accumulation of excess fluid. Edema has many possible causes:

·Prolonged standing or sitting, especially in hot weather, can cause excess fluid to accumulate in the feet, ankles and lower legs. ·Venous insufficiency is a common problem caused by weakened valves in the veins of the legs. This makes it more difficult for the veins to pump blood back to the heart, and leads to varicose veins and buildup of fluid. ·Severe chronic lung diseases, including emphysema and chronic bronchitis, increase the pressure in the blood vessels that lead from the heart to the lungs. This pressure backs up in the right side of the heart and the higher pressure causes swelling in the legs and feet. ·Congestive heart failure, a condition in which the heart can no longer pump efficiently, causes fluid buildup in the lungs and other parts of the body. The swelling is often most visible in the feet and ankles. ·Edema in the legs can occur during pregnancy because the pregnant uterus puts pressure on the vena cava, a major blood vessel that returns blood to the heart from the legs.

Fluid retention during pregnancy also can be caused by a more serious condition called preeclampsia.

·Low protein levels in the blood that can be seen in malnutrition, kidney and liver disease can cause edema. The proteins in the blood help to hold salt and water inside the blood vessels so fluid does not leak out into the tissues. If the most abundant blood protein, called albumin, gets too low, fluid is retained and edema occurs, especially in the feet, ankles and lower legs.

Symptoms

Symptoms vary according to the type of edema and its location. In general, skin covering the swollen area will be stretched and shiny.

Diagnosis

To check for edema that is not obvious, you can gently press your thumb over the foot, ankle or leg with slow, steady pressure. If edema is present, an indentation will show on the skin. You should see a doctor to determine the cause of leg swelling. If both legs are swollen, your doctor will ask about other symptoms and do a physical examination. A urine test will show if you are losing protein from the kidneys. Blood tests, a chest X-ray and an electrocardiogram (EKG) also may be ordered.

Expected Duration

Edema can be temporary or permanent. Also, it can come and go depending on the cause.

Prevention

The only way to prevent edema is to prevent the cause. Smoking is the main cause of chronic lung disease. Congestive heart failure most often is caused by coronary artery disease, high blood pressure, or excessive alcohol use. To avoid leg swelling on long trips, stand up and walk around often. Ideally, you should get up once an hour. If that's not possible, then exercise your feet and lower legs while sitting. This will help the veins move blood back toward the heart.

Treatment

Treatment of edema focuses on correcting the underlying cause of the fluid accumulation. In addition, a low-salt diet and avoiding excess fluid intake usually helps. If you are not short of breath, elevating your legs above the level of your heart also will keep swelling down. Your doctor might suggest that you take a low dose of a diuretic (water pill).

For swollen ankles and feet caused by pregnancy, you can elevate your legs and avoid lying on your back to help improve blood flow and decrease swelling.

If your have mild leg edema caused by venous insufficiency, you can elevate your legs periodically and wear support (compression) stockings. Sometimes surgery is needed to improve the flow of blood through the leg veins.

No matter what the cause of edema, any swollen area of the body should be protected from pressure, injury and extreme temperatures. The skin over swollen legs becomes more fragile over time. Cuts, scrapes and burns in areas that have edema take much longer to heal and are more prone to infection.

When To Call A Professional

Call your doctor immediately if you have pain, redness or heat in a swollen area, an open sore, shortness of breath or swelling of only one limb.

Prognosis

The prognosis for edema of the legs depends on the cause. For most people with edema, the prognosis is excellent.

Additional Info

National Library of Medicine (NLM) 8600 Rockville Pike Bethesda, MD 20894 Phone: (301) 594-5983 Toll-Free: (888) FIND-NLM (346-3656) Fax: (301) 496-4450 National Institutes of Health

NIH

CONDITIONS CAUSING EDEMA VERSUS LYMPHEDEMA

Not all swelling is lymphedema, some is edema caused by an underlying medical condition.

Below is a list of medical conditions that cause or are involved with edema:

Causes of Edema

Premenstrual syndrome; Pregnancy; Heart failure; Kidney conditions; Glomerulonephritis; Nephrotic syndrome; Kidney failure; Liver condition; Cirrhosis of the liver; Varicose veins; Protein deficiency (type of Nutritional deficiency); Thyroid condition; Certain medications; Capillary Leak Syndrome Puffy Hand Syndrome Thrombophlebitis Venous Pooling Chronic Venous Insufficiency Diabetes

Edema as a complication

Aortic coarctation; Cor pulmonale; Exfoliative dermatitis; Hodgkin's Disease; Pericarditis; Post-Thrombotic Syndrome

Edema as a symptom

Acute rheumatic fever; Angioedema; Anaphylaxis; Aortic coarctation; Cardiomyopathy; Chronic kidney failure; Cirrhosis of the liver; Common migraine; Eclampsia; Edema; Glomerular Disease; Glomerulonephritis; Goodpasture syndrome; Hemolytic disease of the newborn; Hemolytic uremic syndrome; Hepatitis; Hodgkin's Disease; Liver cancer; Nephritis; Nephrotic syndrome; Polyarteritis nodosa; Preeclampsia; Premenstrual syndrome; Primary biliary cirrhosis; Pulmonary valve stenosis; Restrictive cardiomyopathy; Rheumatic fever; Trichinosis; Vitamin E deficiency Diabetes

CONDITIONS RELATED TO THE LYMPHATIC SYSTEM

Kawasaki Disease; Duncan's Syndrome; Lymphoproliferative Disorders; Toxoplasmosis; Sarcoidosis; Infectious mononucleosis; Lymphogranuloma venerum; Lyme Disease; Cutaneous Anthrax; Acrodermatitis

ICD9 Codes Associated with Edema

Updates to continue

260 NutritionaL edema; 276.6 Fluid Rentention; 277.6 Angioneurotic edema hereditary; 348.5 Cerebral edema; 362.01 Diabetic edema; 362.07 Diabetic macular edema; 362.83 Other; 425.8 Cardiomyopathy; 511.9 Pleueral effusion; 514.0 Pulomnary edema; 782.3 Edema, Edmatous,Anarsca, Dropsy, Localized edema NOS, Peripheral; 729.81 Swelling of limb; 778.5 Edema Newborn NOS;

ARM EDEMA

Breast cancer presenting as unilateral arm edema

J Gen Intern Med. 2007 May

Department of Surgery, Mayo Clinic, Rochester, Minnesota 55905, USA.

CONTEXT: Symptomatic arm lymphedema as the presenting symptom of invasive breast carcinoma is a rare occurrence.

DESIGN: We report a case of invasive breast cancer presenting with unilateral arm swelling. The patient was initially thought to have venous thrombosis. A thorough physical examination and a mammogram revealed the presence of breast cancer and associated subclinical axillary lymphadenopathy.

CONCLUSION: Failure to recognize this presentation can lead to misdiagnosis or a significant delay in diagnosis and treatment.

PMID: 17443377 [PubMed - in process]

PubMed

LEG EDEMA

Leg Edema

Related Terms:

Edema, Oedema, Fluid Retention, Water Retention, Swollen Leg, Lymphedema, Lymphoedema Leg Swelling

Leg swelling is not uncommon and has been experienced by many many people. Usually, this swelling is temporary and goes away after the underlying condition is healed.

Temporary Leg Swelling

This temporary leg swelling may be caused by an infection, burn or sunburn, insect bites, an injury to the leg such as a sprain, surgery, or even medications such a hormone drugs, steroids, blood pressure drugs. This may also be an part of the inflammatory response your body goes through it trying to protect and heal the leg from the cause of the trauma.

Long Term Leg Swelling.

Long term leg swelling is referred to as edema. This is usually related to specific medical conditions. These conditions may include diabetes, congestive heart failure, blood clot, varicose veins, kidney failure, liver failure or a number of cardio-vascular problems.

Treatment for this long term swelling is in conjunction with the treatment for the condition that caused it. Usually diuretics are also used to relieve the swelling or water-retention.

Permanent Leg Swelling

In the situation of any permanent leg swelling whether the cause is known or unknown, the diagnoses of lymphedema must be considered

There are several groups of people who experience leg swelling from known causes, but it doesn't go away or unknown causes where the swelling can actually get worse as time goes by.

Group One

This group includes those who have had the injuries, infections, insect bites, trauma to the leg, surgeries or reaction to a medication. When this swelling does not go away, and becomes permanent it is called secondary lymphedema.

Group Two

Another extremely large group that experiences permanent leg swelling are cancer patients, people who are morbidly obese, or those with the condition called lipedema. What causes the swelling to remain permanent is that the lymph system has been so damaged that it can no longer operate normally in removing the body's waste fluid.

In cancer patients this is the result of either removal of the lymph nodes for cancer biopsy, radiation damage to the lymph system, or damage from tumor/cancer surgeries.

This is also referred to as secondary lymphedema.

Group Three

Group three consists of people who have leg swelling from seemingly unknown reasons. There may be no injury, no cancer, no trauma, but for some reason the leg simply is swollen all the time.

The swelling may start at birth, it may begin at puberty, or may begin in the 3rd, 4th or even 5th decade of life or sometimes later.

This type of leg swelling is called primary lymphedema. It can be caused by a genetic defect, malformation or damage to the lymph system while in the womb or at birth or be part of another birth condition that also effects the lymph system.

This is an extremely serious medical condition that must be diagnosed early, and treated quickly so as to avoid painful, debilitating and even life threatening complications. Treatment should NOT include the use of diuretics.

What is Lymphedema?

Lymphedema is defined simply as an accumulation of excessive protein rich fluid in the tissues of the leg. The accumulation of fluid causes the permanent swelling caused by a defective lymph system.

A conservative estimate is that there may be 1-2 million people in the United States with some form of primary lymphedema and two to three million with secondary lymphedema.

For extensive information on lymphedema, please visit our home page:

Lymphedema People

© Copyright 2005 by Pat O'Connor and Lymphedema People. Use of this information for educational purpose is encouraged and permitted. It must be available free and without charge and not used for financial renumeration or gain. Please include an acknowledgement to the author and a link to Lymphedema People.

Edema in the lower limb of patients operated on for proximal femoral fractures

Mar 2007

BACKGROUND: Patients with proximal femoral fracture (PFF) often develop postoperative edema in the operated limb. This may lead to reduced mobilization, increasing the length of hospitalization. It is therefore relevant to gain information about the extent and pathogenesis of this edema formation.

METHODS: Forty-one patients with PFF (30 women and 11 men) were studied pre- and postoperatively. Patients were grouped into pertrochanteric fractures and femoral cervical fractures, according to the AO/ASIF classification of PFF. Thigh and calf volumes were calculated in both fractured and contralateral limbs preoperatively and on postoperative days 3, 5, 7, and 30.

RESULTS: All patients with PFF developed edema in the operated limb. The greatest volume increase occurred on postoperative day 7

CONCLUSIONS: Postoperative edema in the thigh and leg of the operated limb was considerable. The magnitude of edema formation was related to the severity of primary trauma and the type of osteosynthesis. Therefore, the operation performed for PFF should be minimally traumatic.

PMID: 17414351

JTrauma

Approach to Leg Edema of Unclear Etiology

The Journal of the American Board of Family Medicine 19:148-160 (2006) Evidence-Based Clinical Medicine Approach to Leg Edema of Unclear Etiology John W. Ely, MD, MSPH, Jerome A. Osheroff, MD, M. Lee Chambliss, MD, MSPH and Mark H. Ebell, MD, MS

Department of Family Medicine, University of Iowa Carver College of Medicine, Iowa City, IA (JWE)Thomson MICROMEDEX, Greenwood Village, CO (JAO)Moses Cone Hospital Family Medicine Residency, Greensboro, NC (MLC)Department of Family Practice, Michigan State University, East Lansing, MI (MHE)

Correspondence: Corresponding author: John W. Ely, MD, MSPH, University of Iowa College of Medicine, Department of Family Medicine, 200 Hawkins Drive, 01291-D PFP, Iowa City, IA 52242 (E-mail: john-ely@uiowa.edu <mailto:john-ely@uiowa.edu>)

Abstract A common challenge for primary care physicians is to determine the cause and find an effective treatment for leg edema of unclear etiology. We were unable to find existing practice guidelines that address this problem in a comprehensive manner. This article provides clinically oriented recommendations for the management of leg edema in adults. We searched on-line resources, textbooks, and MEDLINE (using the MeSH term, “edema”) to find clinically relevant articles on leg edema. We then expanded the search by reviewing articles cited in the initial sources. Our goal was to write a brief, focused review that would answer questions about the management of leg edema. We organized the information to make it rapidly accessible to busy clinicians. The most common cause of leg edema in older adults is venous insufficiency. The most common cause in women between menarche and menopause is idiopathic edema, formerly known as “cyclic” edema.

A common but under-recognized cause of edema is pulmonary hypertension, which is often associated with sleep apnea. Venous insufficiency is treated with leg elevation, compressive stockings, and sometimes diuretics. The initial treatment of idiopathic edema is spironolactone. Patients who have findings consistent with sleep apnea, such as daytime somnolence, load snoring, or neck circumference >17 inches, should be evaluated for pulmonary hypertension with an echocardiogram. If time is limited, the physician must decide whether the evaluation can be delayed until a later appointment (eg, an asymptomatic patient with chronic bilateral edema) or must be completed at the current visit (eg, a patient with dyspnea or a patient with acute edema could be used as a guide. If the full evaluation could wait for a subsequent visit, the patient should be examined briefly to rule out an obvious systemic cause and basic laboratory tests should be ordered for later review (complete blood count, urinalysis, electrolytes, creatinine, blood sugar, thyroid stimulating hormone, and albumin).

Edema is defined as a palpable swelling caused by an increase in interstitial fluid volume. The most likely cause of leg edema in patients over age 50 is venous insufficiency. Venous insufficiency affects up to 30% of the population whereas heart failure affects only approximately 1The most likely cause of leg edema in women under age 50 is idiopathic edema, formerly known as cyclic edema. Most patients can be assumed to have one of these diseases unless another cause is suspected after a history and physical examination. However, there are at least 2 exceptions to this rule: pulmonary hypertension and early heart failure can both cause leg edema before they become clinically obvious in other ways.

JABFM

Leg Edema and Obstructive Sleep Apnea

cross-sectional study ROBERT P. BLANKFIELD, MD, MS; STEPHEN J. ZYZANSKI, PHD Cleveland and Berea, Ohio

From the Department of Family Medicine, Case Western Reserve University School of Medicine, Cleveland, OH (R.P.B., S.J.Z.) and the University Hospitals Primary Care Physician Practice, Berea, OH (R.P.B.). This research was supported by the Pfizer Investigator in Practice Award administered through the North American Primary Care Research Group, and by SleepMed, Inc., Parma, OH. Address reprint requests to Robert P. Blankfield, MD, MS, 201 Front Street, Suite 101, Berea, OH 44017. E-mail: rblankmd@aol.com <mailto:rblankmd@aol.com

Key words Edema; obesity; pulmonary hypertension; obstructive sleep apnea. (J Fam Pract 2002; 51:561–564)

This study was undertaken to clarify whether pulmonary hypertension is a useful marker for underlying obstructive sleep apnea in patients with edema. Twenty-eight ambulatory adults with bilateral leg edema and a normal echocardiogram were enrolled. Sixteen subjects had pulmonary hypertension, and 12 subjects had normal pulmonary artery pressures. Spirometry, pulse oximetry on room air, and polysomnography were obtained for each subject. Ten of 16 (63%) pulmonary hypertension subjects and 9 of 12 (75%) nonpulmonary hypertension subjects had obstructive sleep apnea (P = .48). Eleven of 16 (69%) pulmonary hypertension subjects and 11 of 12 (92%) nonpulmonary hypertension subjects were obese (P = .20). If these results are generalizable, obstructive sleep apnea is frequently associated with bilateral leg edema and obesity, regardless of the presence of pulmonary hypertension. Thus, especially in obese patients, bilateral leg edema may be a useful clinical marker for underlying obstructive sleep apnea. We previously found an association between bilateral leg edema and pulmonary hypertension in primary care patients. After consideration of the differential diagnosis of pulmonary hypertension, obstructive sleep apnea was deemed the most likely explanation for the high frequency of pulmonary hypertension. Subsequently, we identified an association among leg edema, obesity, pulmonary hypertension, and obstructive sleep apnea in ambulatory patients with normal left ventricular function. Our earlier data failed to clarify whether leg edema, obesity, pulmonary hypertension, or a combination thereof is the most useful marker for obstructive sleep apnea. This cross-sectional study was undertaken to determine whether subjects with bilateral leg edema and pulmonary hypertension have a higher frequency of obstructive sleep apnea than edematous subjects with normal pulmonary artery pressures.

Methods

A single physician (R.P.B.) enrolled a convenience sample of subjects from an inner city group family practice in Cleveland OH, from July 1995 to September 1997, and from a 2-physician suburban family practice near Cleveland, OH, from October 1997 to July 2000. Ambulatory patients older than 18 years with bilateral pitting leg edema, no clinically overt lung disease, no echocardiographic evidence of a cardiac abnormality, and an echocardiogram that permitted an estimation of the pulmonary artery pressure were eligible to participate in the study. The methodology for estimating the pulmonary artery pressures has been described previously. For this study, pulmonary hypertension was defined as an estimated pulmonary artery systolic pressure > 30 mm Hg, whereas an estimated pulmonary artery systolic pressure 30 mm Hg was considered normal. Subjects were excluded if their echocardiogram revealed valvular heart disease, congenital heart disease, or left ventricular systolic or diastolic dysfunction; if they used dihydropyridine calcium antagonists; if they had a known pulmonary condition; or if pulmonary function evaluation indicated the presence of obstructive or restrictive lung disease. Individuals with asthma were included as long as the asthma was well controlled. The protocol was approved by the Institutional Review Board at the MetroHealth Medical Center (Cleveland, OH).

The medical history of each subject was reviewed for risk factors recognized as being associated with pulmonary hypertension,and subjects answered the Epworth sleepiness scale questions. The percent predicted forced vital capacity (FVC), the percent predicted forced expiratory volume in 1 second (FEV1), and the FEV1 in relation to the FVC were determined by spirometry (Brentwood Spiroscan 2000, Hoks Electronics, Inc, Japan). Oxygen saturations on room air were determined by oximetry (N-20, Nellcor, Inc, Hayward, CA). Polysomnography was performed on all subjects in a sleep laboratory, and the average number of episodes of apneas and hypopneas per hour of sleep (apnea-hypopnea index) was calculated.

No universally accepted criteria exist for diagnosing obstructive sleep apnea.For this study, obstructive sleep apnea was defined as an apneahypopnea index of ≥ 20 events per hour,8 or a rapid eye movement-specific apnea-hypopnea index of ≥ 20 events per hour. Levels of serum albumin, antinuclear antibody, rheumatoid factor, and thyroid stimulating hormone were obtained on all subjects, as were sedimentation rate and results of liver function tests. Subjects were considered obese if they had a body mass index (weight in kg/height in m2) of more than 30 kg/m2.

Mean values between study groups were compared with Student’s t-test, and 2 statistics were used to compare differences between proportions. A final regression analysis was conducted to test whether controlling for potential confounding variables altered the univariate association observed. A hierarchical logistic regression analysis was performed by first regressing obstructive sleep apnea status on potential confounding variables as the first level, and then allowing pulmonary hypertension status to enter the equation as the second level. These analyses compared the extent to which pulmonary hypertension is associated with obstructive sleep apnea status before and after adjusting for confounding variables.

Results

Twenty-eight subjects enrolled in the study, 16 with pulmonary hypertension and 12 without. Findings regarding 15 of the 16 subjects with pulmonary hypertension were reported previously. The edema was mild (1+ or 2+ pitting) for most subjects, typically presenting as an incidental examination finding. Of the edematous patients recruited for enrollment, many more than the number who actually participated were ineligible because their echocardiograms did not allow an estimation of the pulmonary artery pressure. Demographic information on the subjects with and without pulmonary hypertension is shown in subjects with pulmonary hypertension were older (mean age 63.4 ± 13.6 years versus 52.2 ± 9.9 years, P = .02). Most subjects in both groups were obese. There were no differences between the 2 groups in sex, race, education, marital status, body mass indices, or duration of edema.

Ten of 16 (63%) subjects with pulmonary hypertension and 9 of 12 (75%) subjects without pulmonary hypertension had obstructive sleep apnea (P = .48). There were no differences between the 2 groups in apnea-hypopnea indices, spirometry measurements, oxygen saturation, asthma, systemic hypertension, previous use of appetite suppressants, use of prescription medications, or Epworth sleepiness scale scores. Because Epworth sleepiness scale scores of 9 to 10 or less are considered mild, the low Epworth sleepiness scale scores in both groups indicate that many individuals with obstructive sleep apnea and edema lack symptoms of excessive daytime sleepiness. In the hierarchical logistic regression analysis, the probability associated with the adjusted regression coefficient for pulmonary hypertension status was .71, indicating that even with adjustment for potential confounding variables (age, duration of edema), there was no association between pulmonary hypertension and obstructive sleep apnea.

Discussion

We found a high prevalence of obstructive sleep apnea (68%) in patients with bilateral leg edema, most of whom were obese. The proportion of obstructive sleep apnea was high whether or not pulmonary hypertension was present. Our findings suggest that bilateral leg edema, but not pulmonary hypertension, may be a useful marker for underlying obstructive sleep apnea, especially in obese patients. Moreover, if the data are generalizable, many individuals with bilateral leg edema and normal left ventricular systolic function may be misdiagnosed or underdiagnosed as having idiopathic edema, venous insufficiency

The finding that subjects with pulmonary hypertension were older than those with normal pulmonary artery pressures suggests that either patient age or the duration of the obstructive sleep apnea may be important variables in the development of pulmonary hypertension in edematous patients with obstructive sleep apnea.

Because of the small sample, a type II error might be the explanation for the lack of difference between the pulmonary hypertension and nonpulmonary hypertension groups. Because of the small sample size and the possibility of selection bias, the results of this study should be interpreted with caution. These findings need to be replicated with a larger sample to confirm the association. In addition, further research is necessary to clarify whether leg edema, obesity, or a combination thereof is the most useful marker for obstructive sleep apnea.

If our patients are typical of those in other practices, we estimate that leg edema associated with obstructive sleep apnea occurs frequently compared with other cardiovascular diseases. In both the inner city and suburban family practices of one of the authors (R.P.B.), leg edema associated with obstructive sleep apnea is the third most common cardiovascular condition, occurring less often than systemic hypertension and coronary artery disease but more frequently than congestive heart failure, cerebrovascular accidents, or cardiac arrhythmias.

Because our experience represents primary care rather than tertiary or specialty care, and because our experience is similar in inner city and suburban settings, we believe that our experience may be generalizable to a variety of practice settings. We now practice according to the clinical dictum that for patients without symptoms or signs of congestive heart failure and without overt lung disease, bilateral leg edema represents obstructive sleep apnea until proven otherwise.

Our data raise the question of a possible causal relationship between obstructive sleep apnea and leg edema. Most of the participants in our study have not used nasal continuous positive airway pressure (CPAP) for long. However, using nightly nasal CPAP, 4 edematous patients experienced reduced leg edema, and 3 have stopped using diuretic medication (Blankfield, unpublished data). This small subset of obstructive sleep apnea patients suggests that obstructive sleep apnea may be a cause of edema.

Making a diagnosis of obstructive sleep apnea does not necessarily mean that treatment is indicated. An abnormal apnea-hypopnea index without excessive daytime sleepiness does not warrant treatment. The results of this study have unclear clinical relevance for patients with obstructive sleep apnea and edema who lack symptoms of daytime somnolence because no study has evaluated whether treating obstructive sleep apnea alters morbidity or mortality in these individuals. Accordingly, it may be prudent for clinicians to refer edematous patients for polysomnography only if they have symptoms of excessive daytime sleepiness, desire a remedy for their edema, use diuretic medication, or develop complications of edema formation such as cellulitis, stasis dermatitis, or venous stasis ulcers.

However, if obstructive sleep apnea contributes to or causes pulmonary hypertension or edema, then it may be advisable to treat patients who have these cardiovascular complications, regardless of the presence or absence of symptoms of sleep-disordered breathing. Previous research is inconclusive regarding a causal relationship between obstructive sleep apnea and pulmonary hypertension. Most of the literature favors the premise that obstructive sleep apnea is not a cause of pulmonary hypertension but some studies suggest otherwise.

If subsequent research demonstrates that obstructive sleep apnea causes either pulmonary hypertension or edema, then clinical trials will be necessary to document whether morbidity and mortality rates improve after appropriate treatment of the obstructive sleep apnea. This information will be essential to determine if treatment is warranted for obstructive sleep apnea patients who have pulmonary hypertension or edema, but who lack symptoms of excessive daytime sleepiness.

· Acknowledgments · The authors appreciate data collection assistance by Louise Wiatrak, MA and Simone Powers, data entry assistance by Amy Tapolyai, MBA, and Gregory Zyzanski, and manuscript assistance by Kurt Stange, MD, PhD. Journal of Family Practice JPFOnline

HAND EDEMA

Puffy hand syndrome due to drug addiction: a case-control study of the pathogenesis

Authors: Andresz, Valérie1; Marcantoni, Nicolas1; Binder, Florence2; Velten, Michel2; Alt, Martine3; Weber, Jean-Christophe4; Stephan, Dominique

Source: Addiction, Volume 101, Number 9, September 2006, pp. 1347-1351(5) Publisher: Blackwell Publishing

Abstract: We studied the pathogenesis of puffy hand syndrome of intravenous drug use. We hypothesized that injections of high-dose sublingual buprenorphine, instead of the recommended sublingual administration, could play an important role in lymphatic obstruction and destruction. Design and participants Findings: We included 33 cases and 33 controls, mean age of 32 years. They were past heroin users, mainly methadone-substituted. In multivariate analysis, sex (women) injections in the hands injections in the feet and the absence of tourniquet were significant risk factors for puffy hand syndrome. In 69.7% of the cases and 59.4% of the controls, respectively, there was a high-dose sublingual buprenorphine misuse, although it appeared not to be a significant risk factor for puffy hand syndrome.

Conclusions: Injection practices are likely to cause puffy hands syndrome, but buprenorphine misuse should not be considered as a significant risk factor. However, intravenous drug users must still be warned of local and systemic complications of intravenous drug misuse. Keywords: Buprenorphine; intravenous drug use; puffy hand syndrome

Document Type: Research article DOI: 10.1111/j.1360-0443.2006.01521.x

Affiliations: 1: Hypertension Maladies vasculaires Pharmacologie clinique, Hôpitaux Universitaires, 2: Laboratoire d'épidémiologie et de Santé publique EA 1801, Faculté de Médecine, 3: Centre de Pharmacovigilance 4: and Médecine interne A, Hôpitaux Universitaires, Université Louis Pasteur, Strasbourg, France

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