Diff Diagnosis of Edema
Peripheric swelling is an important manifestation of chronic heart failure. Pathogenetic factors of edema are:
activation of the renin-angiotensin-aldosterone system and enhanced reabsorption of sodium and water in the renal tubules;
progressive increase in hydrostatic pressure in the venous bed and capillaries;
decreased oncotic pressure due toviolations of protein synthesis in the liver and a significant increase in hydrostatic pressure over the oncotic, which is accompanied by the release of the liquid part of the blood from the vessels into the tissues;
drop in glomerular filtration due to impaired blood supply to the kidneys;
increased vascular wall permeability.
Edema is initially determined in the areaankle joints, ankles, feet, shins, and as the progression of heart failure progresses, they are located in the region of the hips, anterior abdominal wall, scrotum, sacrum, lumbar region (edema of the lumbar-sacral region is more characteristic of "recumbent" patients).
With severe heart failure developsanasarka - ie, massive, widespread swelling, not only completely capturing the lower extremities, the lumbosacral region, the anterior wall of the abdomen, but even the thorax region. Anasarca is usually accompanied by the appearance of ascites and hydrothorax.
Edema, which appear with heart failure ("cardiac" edema) have very characteristic features:
first appear in the areas with the highest hydrostatic pressure in the veins (in the distal parts of the lower extremities);
edema in the early stages of heart failure expressed slightly, appear at the end of the working day and per night disappear;
leave a deep hole after pressing the finger, which is then gradually smoothed (this is especially noticeable when the edema is localized in the region of the lower leg, lower back);
the skin in the region of the edema is smooth, shiny, at first soft, with prolonged existence of edema the skin becomes dense, and the depression after pressing is formed with difficulty;
massive edema in the lower extremities can be complicated by the formation of blisters that open and drain out of them;
edema on the legs combined with acrocyanosis and skin cold;
the location of edema can vary under the influence ofgravity - when positioned on the back they are localized mainly in the sacrum, with the position on the side located on the side on which the patient lies.
With prolonged existence of edema developtrophic skin changes - it becomes thinner, becomes dry, often hyperpigmented, flakes, it is possible to develop foci of necrosis. With pronounced swelling in the subcutaneous tissue of the abdomen, tearing of the skin with leakage of fluid and the subsequent formation of skin scars resembling scars after pregnancy are possible.
To judge the decrease or increase in edema,especially pronounced (anasarca), combined with ascites, it is necessary not only to assess the severity of edema during a daily medical examination, but also to monitor diuresis, the amount of liquid drunk per day, to perform daily weighing of patients and to note the dynamics of body weight.
After identifying the presence of peripheral edema, it is necessary to immediately differential diagnosis of edematous syndrome .
The most common swelling in chronic heartInsufficiency should be differentiated with local edema in the lower extremities, kidney edema, hypoproteinemic edema, and edema with cirrhosis and severe hypothyroidism (myxedema edema).
Local edema are caused by local disorders of the hemo- orlymphodynamics and permeability of capillaries. Local edema in the lower extremities often develop with phlebitis, thrombophlebitis, varicose veins, and lymph flow disorders.
Inflammatory swellings at phlebitis, thrombophlebitis are characterized byhyperemia of the skin, local fever (skin in the projection of the inflamed vein hot to the touch), pronounced soreness in palpation, the inflamed vein is dense, along the veins can be probed knots (thrombi). Thrombophlebitis often develops on one limb.
With varicose veins edema is also usually asymmetric, located on one of the lower extremities, soft or moderately dense, the skin in the area of the bluish cyanosis, the usual temperature, the enlarged, convoluted veins are clearly visible.
Lymphatic edema In the area of the lower extremities are oftensecondary and develop due to lymphangitis (eg, with recurrent erysipelas) or when lymphatic drainage is suppressed by enlarged lymph nodes and tumors. Secondary lymphatic edema usually develops after 40 years. Primary lymphatic edema is less common, occurs early (appear at the age after 10 years) and late (appear after 30 years) and is caused by congenital defects in the development of lymphatic vessels (hypoplasia or aplasia).
Lymphatic edema is more common in women,usually asymmetric, dense, do not leave a depression with pressure, the skin color and its temperature do not change. Usually there is a clear boundary between edematous and non-swollen areas of the lower limb. A characteristic feature of lymphatic edema is the inefficiency of diuretic therapy. With far-reaching lymphatic edema, the extremities sharply thicken, become formless, this condition is called elephantiasis.
In rare cases, local edema of one or bothlower limbs can develop with hemiplegia, vegetative polyneuropathies. Such edema is caused by a violation of local vegetative innervation and capillary permeability and is always accompanied by neurologic symptoms.
In women, swelling in the ankle,stop can be a manifestation of premenstrual tension syndrome. Edema appears usually in the second phase of the menstrual cycle and becomes most pronounced on the eve of menstruation. Premenstrual edema especially clearly manifested in hot weather. The development of premenstrual edema is due to the insufficient function of the yellow body.
Young women, especially those who are overweight and suffer from autonomic dysfunction, sometimes develop idiopathic edema. usually they appear mainly in hot weather, by the end of the day and are localized in the area of the ankles, lower third of the shins, when examining the internal organs of pathology is not revealed.
Renal edema most often develop with acute andchronic glomerulonephritis, amyloidosis of the kidneys, with kidney damage in systemic connective tissue diseases (systemic lupus erythematosus, rheumatoid arthritis, scleroderma), systemic vasculitis, diabetes mellitus (diabetic nephropathy). Diagnosing kidney genesis of swelling is usually not difficult. It is necessary to take into account the symptoms of the above diseases, leading to kidney damage, as well as the characteristic features of renal edema:
the initial location of edema usually in the face area followed by the appearance of puffiness in the area of the feet, shins, thighs;
appearance of puffiness of the face mainly in the morning and decrease in the evening;
the presence of pronounced changes in the analysis of urine: significant proteinuria, cylindruria, microhematuria;
Pale, and not cyanotic shade of distal edematous limbs;
high blood pressure in most patients with renal edema.
In severe parenchymal diseases of the kidneys (glomerulonephritis, lupus-nephritis, etc.), a nephrotic syndrome characterized by:
generalized edema (possibly the development of ascites, hydrothorax), while the consistency of edema is loose, dough-like;
massive proteinuria (more than 3-3.5 g / day or more than 50 mg protein per day per 1 kg of body weight);
Unlike generalized "cardiac" edema, nephrotic edema is not accompanied by acrocyanosis and pronounced dyspnea.
Hypoproteinemic edema develop with a massive loss of protein in the urine, andalso with the syndrome of impaired absorption in the intestine (sprout syndrome, Whipple's disease, gluten and other enteropathies, etc.). Usually, in this case, patients experience diarrhea, increased protein secretion with calves, hypoproteinemia, progressive weight loss, preceded by the appearance of edema.
Hepatic swelling occur more often with cirrhosis of the liver, usually inlate stages of the disease. As a rule, they appear against the background of the existing portal hypertension, ascites. To distinguish "cardiac" swelling from edema with decompensated liver cirrhosis, as a rule, is not difficult. Always present are the classic signs of liver cirrhosis (jaundice, "liver palm", "spider veins" carmine red lips, gynecomastia, hemorrhagic syndrome, pronounced disorders liver function tests, signs of portal hypertension by ultrasound and others.). It is also necessary to take into account the anamnestic data on previous viral hepatitis, repeated episodes of jaundice. However, one should also remember the possibility of developing cirrhosis due to long-term heart failure ("cardiogenic liver cirrhosis").
With a pronounced, decompensated hypothyroidism (myxedeme), the pronouncedswelling of the subcutaneous tissue, caused by the accumulation of glycosaminoglycans, mainly glucuronic acid, which increases the hydrophilicity of tissues. Edema with myxdeum localized primarily in the area of the dorsum of the hands, feet, but can be common, typical of the pastosity of the face. Myxedema edema have distinctive features:
when pressing on the edematous skin there is no dimple;
skin in the swollen region is dry, cold;
no effect on diuretics;
decrease in edema and even complete disappearance of edema on the background of substitution therapy with thyroid hormone preparations.
Great value in differential diagnosticscardiac and hypothyroid (edema) edema has the presence of other symptoms characteristic of hypothyroidism: chilliness, drowsiness, bradycardia, constipation, hair loss, severe obesity, low body temperature, delayed speech, dryness and flaking of the skin and, of course, low blood levels of thyroxine and triiodothyroxine.
Along with this, it should be noted thathypothyroid myocardial dystrophy can lead to the development of heart failure, which is also facilitated by the accumulation of fluid in the pericardial cavity (sometimes in a significant amount). In this situation, swelling has a mixed genesis, but the true nature of edema is easily recognized, given the presence of signs of hypothyroidism.
When examining patients with chronic cardiacdeficiency can be seen cervical vein swelling - an important clinical sign due to increased central venous pressure, a violation of outflow of blood from the superior vena cava due to high pressure in the right atrium. Swelling of the cervical veins also reliably testifies to an increase in the wedge pressure (pulmonary-capillary pressure) above 18 mm Hg. Art. (in normals <18 mm Hg). The higher the central venous pressure, the more intense and longer the cervical veins swell.
The magnitude of central venous pressure can beapproximately judge by measuring the horizontal distance from the angle of Louis (the angle formed by the handle and the body of the sternum) in the horizontal position or in the reclining position (45 °) to the filling level of the cervical veins (usually on the right) and adding to it distance of 5 cm, since the angle of Louis is 5 cm above the right atrium.
Swollen cervical veins can pulsate (venouspulse). The pulse of the heart differs from the arterial pulse in magnitude and filling character (usually a larger pulse of the pulse, diffuse, biphasic and non-palpable). The viral pulse disappears when pressure is applied to the base of the neck, changes depending on the respiratory movements (pulsation decreases on inhalation) and the position of the body and shifts upward when pressure is applied to the abdomen.
Sometimes swelling of the cervical veins is expressed verysignificantly and even accompanied by swelling of the neck. In this case, there is a need for a differential diagnosis with a syndrome of the inferior vena cava, which suggests its occlusion or compression.
In the syndrome of the superior vena cava abruptlythe venous pressure of the upper half of the body increases with normal venous pressure of the lower half of the body. This syndrome is characterized by pronounced cyanosis and edema of the face, occiput, neck, shoulder area and hands. Cyanosis is pronounced in the prone position and somewhat decreases in an upright position. The veins in the neck region are sharply swollen, venous collaterals develop on the entire surface of the thorax.
The main reasons for the development ofsyndrome of the superior vena cava, lung cancer, aortic aneurysm, mediastinitis, an increase in the intrathoracic lymph nodes with lymphogranulomatosis, lymphocytic leukemia, lymphosarcoma, mediastinal tumor, pericarditis.
Differentiate heavy cardiacthe insufficiency proceeding with the swollen cervical veins and puffiness, from a syndrome of a compression of the top hollow vein it is possible on the basis of following signs. With heart failure, edema of the upper limbs is more pronounced on the side on which the patient lies, in the syndrome of the superior vena cava, the edema of the upper limbs is symmetrical. In severe heart failure, head edema can occur, but it does not extend to the occiput and the scalp, unlike the syndrome of the superior vena cava. In case of cardiac insufficiency, edema is localized first in the region of the lower limbs, then, as the disease progresses, on the upper part of the body, while in the upper vena cava syndrome edema is located in the neck, shoulder girdle, head, but not in the lower part of the body . In addition, with the syndrome of the superior vena cava, there are clinical and instrumental symptoms of the diseases that cause it.
Positive Plesca symptom (hepatic-yugulartest) is characteristic for severe biventricular or right ventricular failure, it is an indicator of venous congestion, high central venous pressure and volume overload. With quiet breathing of the patient for 10 s, the palm is pressed against the enlarged liver, which causes an increase in the central venous pressure by approximately 4-5 cm of water. Art. and increased swelling of the cervical veins. It is possible to carry out an abdominal-yugular test, while pressing the palm is carried out on the anterior abdominal wall in the peripodal region (the abdominal press should not be strained). The result of the test is evaluated in the same way as in the hepatic-yugular Ples test. If the expressed peripheral edema is caused not by cardiac insufficiency, but by other causes, hepatic-yugular or abdominal-nal-yugular samples are negative.
Submit date: 2015-02-06 | Views: | Copyright infringement