Edema

Overview

Definition

Edema (also known as dropsy or fluid retention) is the accumulation of excessive amounts of fluid in the interstitial space due to imbalance between hydrostatic and oncotic pressure. It is a symptom caused by an underlying disease or disorder. Edema may either be localized due to venous/lymphatic obstruction or increased vascular permeability, or systemic due to organ failure. It may be mild and cyclical, as in fluid retention associated with menses, or severe and life-threatening, as in angioneurotic or cerebral edema. Types of edema include the following.

• Angioneurotic edema (angioedema/Quincke's disease): recurrent swelling of skin, mucous membranes, viscera, or brain with sudden onset lasting from hours to days
• Blue edema: cyanosis of swollen extremity
• Brown edema: associated with chronic, passive congestion of the lungs
• Cardiac edema: associated with congestive heart failure
• Cerebral edema: affecting the neuropile and white matter—often associated with diabetic ketoacidosis (DKA)
• Corneal edema: swelling of the cornea
• Cystoid macular: swelling in posterior pole of the eye
• High Altitude Pulmonary Edema (HAPE): potentially life-threatening non-cardiogenic altitude illness
• Idiopathic leg edema: swollen legs with no apparent cause
• Lipedema edema: fat/fluid accumulation in legs
• Lymphedema: abnormal accumulation of lymph fluid
• Malignant edema: anthrax
• Menstrual edema: associated with hormonal cycle
• Nutritional edema: from excess fluid and salt intake and insufficient protein intake
• Pulmonary edema: affecting the lungs and most commonly due to cardiac disorders

Etiology

Vary according to age, gender, underlying disorders.

Cyclical/generally non-life-threatening disorders, often evident in lower extremities only, include the following causes.

• Sitting or standing for extended periods: reduces blood flow so blood "pools" in veins, inhibiting oncotic movement
• Heat: expands blood vessels, allowing greater hydrostatic effusion
• Medications (steroids, NSAIDs antidepressants, HRT): increased hydrostatic movement
• Menstruation/pregnancy: hormonal changes affect hydrostatic/oncotic pressure gradients
• Damage to lymphatic system
• Infection/injury: vein damage impairs fluid movement
• Obesity
• High salt intake
• Allergies (food, insect bites)
• Hypoalbuminemia
• Proteinuria

Chronic and/or potentially life-threatening underlying disorders, include the following causes.

• Renal, cardiac, hepatic, thyroid diseases
• Hypothyroidism
• High/low blood pressure
• Pregnancy
• Vascular and arterial diseases
• Thrombosis
• Weakened venous system/varicose veins
• Infection/inflammation
• Tumors
• Short-term exposure to altitude combined with heavy physical exertion
• DKA, head trauma, anoxia, exposure to toxic substances

Risk Factors

The underlying cause of life-threatening conditions must be identified. At higher risk are those with the following.

• Radiation to surgical sites following lymphadenectomy increases lymphedema risk
• Genetic lymphatic abnormalities
• Obesity
• High salt intake

Signs and Symptoms

Will vary according to disorder.

• Swollen extremities (possibly accompanied by pain, redness, heat, and open sores)
• Facial puffiness
• Abdominal bloating
• Shortness of breath, extreme difficulty breathing, coughing up blood (pulmonary/HAPE)
• Sudden change in mental status/abnormal neurological signs, respiratory arrest (cerebral edema associated with DKA)
• Muscular pain due to bloating and swelling

Differential Diagnosis

• Inflammatory diseases (gout, rheumatoid arthritis)
• Preeclampsia (toxemia)

Diagnosis

Physical Examination

Varies according to underlying disorder; may include the following.

• Swelling in face, limbs, extremities, and/or trunk; weight gain
• Dermatological lesions may be present
• Pulmonary edema: fluid accumulation in pleural cavity
• Cerebral edema: intracellular (cytotoxic)—cellular swelling in grey matter; extracellular (vasogenic)—white matter moist and swollen; microscopically—micro-vacuolization/halos surrounding nuclei

Laboratory Tests

Reduced serum albumin; increased fecal loss of antiprotease

Pathological Findings

Excess fluid in intercellular tissue spaces due to the following.

• Increased hydrostatic pressure gradient, or elevated extracellular fluid volume
• Decrease in overall osmotic pressure gradient, or increase in capillary permeability to plasma protein

Imaging

• CT, MRI, X ray as appropriate to aid in diagnosis

Other Diagnostic Procedures

Because certain forms of edema are life-threatening, treating immediate symptoms may be necessary before diagnosis of underlying disorder is established.

Medical history/interview to determine:

• Time frame/longevity of symptoms
• Whether continuous, intermittent, or cyclical (e.g., with menses)
• Diet
• History of cardiac/renal/hepatic/thyroid disease
• Exposure to toxic fumes
• Allergic reactions

Physical examination:

• Location
• Degree of pitting (indentation remaining following application of pressure with finger)
• Cutaneous wounds/sores
• Varicose veins
• Blood clots
• Shortness of breath
• Determine underlying cause (e.g., pregnancy; cardiac, renal, hepatic, thyroid disease)

Special tests:

• Serum electrolyte/albumin tests
• Urinalysis
• ECG
• Echocardiography
• Liver Function Test

Treatment Options

Treatment Strategy

Treatment will depend upon underlying disorder. In pulmonary edema or HAPE, immediate hospitalization and/or treatment with oxygen, diuretics and/or medications are necessary.

To reduce swelling:

• Salt reduction diet
• Daily exercise
• Periodic elevation of legs above heart level
• Diuretics
• Support hose
• Massage
• Complete Decongestive Therapy (CDT): compression physical therapy (including sleeves, pumps) to move fluid through alternate lymph channels for reabsorption by the body, compression bandaging, skin care/manipulation.

Drug Therapies

Diuretics effectively reduce fluid levels; however, they also deplete potassium, magnesium, B vitamins, and calcium, which results in loss of bone mass.

• Loop/thiazide diuretics (heart failure, cirrhosis, nephrosis, renal failure, hypertension)
• Potassium-sparing diuretics (hypokalemia caused by other diuretics, hypertension)
• Carbonic anhydrase inhibitors (glaucoma, HAPE, heart failure)
• Osmotic diuretic (Mannitol—1/gm/kg at onset of neurologic symptoms in DKA-related edema)
• Morphine (in pulmonary disease reduces congestion/anxiety)
• Corticosteroid/immunosuppressives
• Medications appropriate for underlying disorder

Surgical Procedures

• Surgical removal of fat and fluid deposits in lipedema
• Attempt to reestablish lymph/blood flow

Complementary and Alternative Therapies

While following nutritional and herbal support guidelines may help alleviate edema, it is essential that the underlying cause be addressed. Edema is multi-factorial. Choose the appropriate guidelines according to the underlying cause.

Nutrition

• Eliminating food allergens from the diet decreases inflammation edema secondary to inflammatory processes.
• A low-salt, high-protein diet may help resolve edema. High protein is contraindicated in renal involvement. Dietary intake of sugar and refined carbohydrates should also be reduced.
• Increase dietary potassium with diuretic use (e.g., bananas, apricots, and green leafy vegetables).
• Some foods are natural diuretics: asparagus, parsley, beets, grapes, green beans, leafy greens, pineapple, pumpkin, onion, leeks, and garlic. These foods also support kidney and liver function.
• Vitamin B₆ (50 to 100 mg/day) induces diuresis. Thiamine may be depleted with Lasix and should be supplemented (200 mg/day).
• Vitamins C (1,000 to 1,500 mg tid), E (400-800 IU/day), and coenzyme Q10 (50 to 100 mg bid) protect and strengthen blood vessels.
• Potassium aspartate (20 mg/day) may need to be supplemented if using diuretics.
• Magnesium (200 mg bid to tid) and calcium (1,000 mg/day) influence intra- and inter-cellular fluid exchange and may be depleted with diuretic use.

Herbs

Herbs are generally a safe way to strengthen and tone the body's systems. As with any therapy, it is important to ascertain a diagnosis before pursuing treatment. Herbs may be used as dried extracts (capsules, powders, teas), glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless otherwise indicated, teas should be made with 1 tsp. herb per cup of hot water. Steep covered 5 to 10 minutes for leaf or flowers, and 10 to 20 minutes for roots. Drink 2 to 4 cups/day. Tinctures may be used singly or in combination as noted.

A general diuretic should contain herbs that support circulation and lymphatic drainage. They are best administered in a cooled tea (four to six cups/day), although a tincture may also be used (30-60 drops qid). Drinking the tea cool will support circulation and lymphatic drainage without increasing vasodilation. Combine three of these herbs with equal parts of two to three additional herbs from the following categories, as indicated: cleavers (Gallium aparine), yarrow (Achillea millefolium), oatstraw (Avena sativa), elder (Sambucus canadensis), red clover (Trifolium pratense), and red root (Ceonothus americanus).

Cyclic edema and idiopathic orthostatic edema:

• Ginkgo (Ginkgo biloba) strengthens the integrity of the vasculature and its use has improved cyclical edema associated with hormonal changes.
• Bilberry (Vaccinium myrtillus) is a gentle diuretic as well as a tonic for the vasculature.
• Topical applications of creams containing one or more of the following may be helpful in increasing vascular integrity in orthostatic edema: horse chestnut (Aesculus hippocastanum), butcher's broom (Ruscus asuleatus), sweet clover (Melilotus officinalis), and rue (Ruta graveolens).

Renal insufficiency:

Use caution in administering diuretics with renal failure. Herbal options include parsley (Petrosilinum crispum), dandelion leaves (Taraxacum officinalis), buchu (Barosma betulina), couchgrass (Agropyron repens), horsetail (Euquisetum arvense), and goldenrod (Solidago virgaurea)

Cardiac and/or pulmonary involvement:

• Hawthorn (Crataegus oxyacantha), motherwort (Leonorus cardiaca), rosemary (Rosemariana officinalis), and linden (Tilia cordata)
• Lily of the valley (Convalleria majalus), night blooming cereus (Cactus grandiflorus), and broom (Sarothamnus scoparius) have toxic side effects but may be added to the cardiopulmonary formula under physician supervision

Hepatic involvement (may be used in conjunction with treatment for cyclic edema) may respond to milk thistle (Silybum marianum), dandelion root (Taraxacum officinalis), turmeric (Curcuma longa), and artichoke leaves (Cynara scolymus)

Homeopathy

Because of the many presentations of edema, remedies are best chosen by an experienced homeopath.

Physical Medicine

• Dry skin brushing. Before bathing, briskly brush the entire skin surface with a rough washcloth, loofa, or soft brush. Begin at the feet and work up. Always stroke in the direction of the heart. This helps facilitate lymphatic circulation. There is no need to press deeply as the lymph are superficial vessels.
• Cold compresses to the face or backs of the legs with yarrow tea may give temporary relief of edema.
• Contrast hydrotherapy involves alternating hot and cold application to bring nutrients to the site and to diffuse metabolic waste from inflammation. The overall effect is decreased inflammation, pain relief, and enhanced healing. Using this technique with hand and/or foot baths may help to improve circulation and lymphatic drainage. Alternate three minutes hot with one minute cold and repeat three times. This is one set. Do two to three sets/day. Use caution in areas of decreased sensation by ensuring that the hot application does not burn.

Acupuncture

Acupuncture may improve fluid balance and provide support in the treatment of underlying cause and improve circulation.

Massage

Therapeutic massage can assist with lymph drainage and improve circulation.

Patient Monitoring

Monitor for:

• Fluid input/outflow.
• Potassium levels, electrolyte balance, blood pressure, allergic reactions, GI bleeding, CNS effects, muscle cramps, and other side effects of diuretic use.

Other Considerations

Daily exercise is highly beneficial in general, unless contraindicated by underlying condition.

Prevention

• Pulmonary edema: reduce risk by treating cardiac disorder
• Lymphedema: keep skin clean/supple, protect surgical site from injury; drainage-promoting exercises, elevation of affected limb
• Idiopathic disease: reduce salt intake; avoid constrictive clothing around legs and wrists

Complications/Sequelae

• Hypertensive disease
• Pulmonary edema/HAPE/cerebral edema are life-threatening
• Infection/ulceration of cutaneous lesions

Prognosis

• Life-threatening edema treatable and often curable with prompt attention combined with treatment for underlying disorder
• Effective reduction of swelling attainable with diuretics and compression therapies

Pregnancy

Orthostatic edema is common in pregnancy and can be safely addressed with leg elevation, hawthorn tea, and topical applications. Edema may also be a sign of preeclampsia and should be monitored closely.

References

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