Diagnosis of Edema

The diagnosis of edema includes history, physical examination and lab investigations to find out the cause and rule out other important conditions.

History

Site and distribution

Enquiries should be made regarding the site of edema as localized and demarcated sites of edema are usually due to trauma or infection. Oedema may be confined to both lower limbs, for example wit IVC obstruction and pregnancy or affect only a single limb such as the leg with unilateral DVT, or arm following axillary lymph node clearance.

Precipitating factors

Precipitating factors such as trauma and infection may be obvious from the history, and should be excluded. Angio-edema may be precipitated by a known allergen. Lymphedema may result as a complication of infection with filarial nematodes while travelling in endemic areas such as Africa, Asia and Australia. Lymphoedema may also be congenital occurring shortly after birth (Milroy’s disease) or at puberty (lymphedema praecox) or in the third decade (lymphedema trada)

Past medical and drug history

Interruption to lymphatic drainage may result as a complication of irradiation or surgery, especially in the region of the axilla and groin. Obstruction of lymphatic flow can also result from direct involvement of the lymph nodes by lymphoma or secondary to metastatic lymphatic infiltration from tumors. A detailed drug history will identify any offending drug.

Associated symptoms

If there is no obvious precipitating factor in the history, then specific enquiries should be undertaken for each system. Symptoms suggestive of malignancy, in particular should be sought. In addition, it is important to exclude the following conditions:

Cardiac failure

Lethargy, dyspnea, paroxysmal nocturnal ayspnea, cough, ankle edema and abdominal distension from ascities may be some symptoms experienced by patients with cardiac failure

Liver disease

Symptoms of jaundice, pruritus, ankle edema, abdominal distension, haematemesis and confusion (encephalopathy) should be sought to determine the presence of liver disease.

Renal disease -nephrotic syndrome

Severe generalized oedema is the prominent feature with nephrotic syndrome. Patients may also complain of frothy urine due to protenuria

Malabsorption

Wight loss, diarrhoea and steatorrhoea may be some of the features associated with malabsorption

Venous thrombosis

Unilateral leg swelling and pain are the main symptoms of DVT occasionally with iliofemoral vein thrombosis, the entire leg may appear blue (phlegmasia cerulean dolens) or white (phlegmasia alba dolens) bilateral leg edema with the onset of dilated superficial collateral veins on the trunk and abdomen is suggestive of IVC obstruction.

Examination

Inspection

Assessment of the distribution of edema may narrow the differential diagnosis. Generalized causes tend to present with dependent edema, with fluid accumulating in the ankles in ambulant patients with the sacrum in recumbent patients

Cardiovascular system

With cardiac failure, palation of the pulse may reveal tachycardia with pulsus alternans. The measured blood pressure may be low due to systolic failure. The JVP is elevated and a third heart sound with bilateral coarse pulmonary crepitations may be auscultated. Hepatomegaly due to liver congestion and ascites may also be present.

Abdominal examination

Generalized wasting from malabsorption or malignancy may be appreciated on inspection. Clubbing, palmar erythema, Dupuytren’s contracture, jaundice, spider naevi and gynaecomastia are signs of liver disease. Dilated collateral veins on the abdomen may be due to portal hypertension or IVC obstruction; therefore determine the direction of blood flow. Below the umbilicus the direction of blood flow is inferior with portal hypertension, and superior with IVC obstruction. Organomegaly due to carcinoma may be present and predispose to venous thrombosis. Pelvic malignancy may also result in venous outflow obstruction.

Legs

The legs are examined for the presence of tenderness and swelling Circumferences of both the thighs and calves are compared. Marked painful erythematous unilateral swelling may be indicative of DVT.

General investigations

Urinalysis

Heavy proteinuria with nephrotic syndrome

Free blood count (FBC)

WBC elevated infection, Hb decreased, Malabsorption and DVT

U&Es

Urea and creatinine elevated with renal failure

LFTs

Abnormal in liver disease

Serum albumin

Reduced with nephrotic syndrome, liver disease, malabsorption and malnutrition

Specific investigations

24 hour urine collection

>3.5 g of protein with nephrotic syndrome

Renal biopsy

To determine the cause of nephrotic syndrome in adults

Echocardiography

Ventricular dilatation and impaired function with cardiac failure

Liver biopsy

Liver cirrhosis

Faecal fat estimation

Malabsorption

Duplex Doppler deep veins of the leg

DVT of the leg

Venography

Below-knee DVT, IVC obstruction

Lymphangcography

Lymphatic obstruction of any cause

Pelvic ultrasound or CT

Pelvic tumours