Peripheral Edema

Case Presentation:

In our morning report at WCH, we discussed a case of a patient referred for evaluation of acute-on-chronic peripheral edema. Clinical assessment and investigations were supportive of a diagnosis of chronic venous insufficiency with superimposed acute edema related to recent initiation of amlodipine for the management of chronic hypertension. In relation to the case, we also discussed several useful acronyms that may help guide a systematic clinical assessment.

Learning Points:

1) Mechanisms underlying the development of edema

2) Differential diagnosis for development of edema

3) Useful acronyms to guide clinical assessment

4) Basic management of chronic venous insufficiency

 

Mechanisms underlying edema:

  • Local and systemic disorders lead to increased quantity of fluid in the interstitial space

  • Physiology parameters of relevance:

    • Increased hydrostatic pressure

    • Decreased oncotic pressure

    • Increased capillary leak

  • Any of the above in part or in unison may lead to the development of edema

 

Differential Diagnosis for peripheral edema:

DDx Edema

Useful Acronyms to Guide Clinical Assessment:

  • SOCRATES to guide HPI (applied to peripheral edema as a presenting complaint)

Table SOCRATES for EDEMA

  • Review of Symptoms for cardiac complaints (or symptoms that might be cardiac-related): PPPDOES

    • Pain, Palpitations, PND (Paroxysmal nocturnal dyspnea), Orthonpea, Edema, Syncope

  • Functional Status

    ADL and IADL table

 

Basic Management of Chronic Venous Insufficiency:

  • Avoid diuretics (unless indicated with respect to comorbidity)

  • Leg elevation (note: legs above the level of the heart TID for >30 minutes at a time)

  • Compression stockings (contraindicated in peripheral artery disease so must perform ABI-ankle-brachial index assessment first)

  • Horse Chestnut seed extract (active compound=escin)

    • Cochrane Review of 17 studies

      • Improved pain, pruritus, and edema with minimal toxicity

      • For those unable to wear (i.e. contraindicated) or intolerant of compression stockings

Helpful Review Article:

 

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