Edema (ºÎ±â, ºÎÁ¾)

The Root of Ambulatory Care
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- Ãâ ÆÇ : ±ºÀÚÃâÆÇ»ç
- ÆäÀÌÁö¼ö: 543¸é
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KEYWORDS:
..ºÎÁ¾Àº Á¶Á÷°£¾×ÀÌ ºñÁ¤»óÀûÀ¸·Î ÃàÀûµÇ¾î ÀÖ´Â »óŸ¦ ¸»Çϸç, ÈçÈ÷ ½Åü
Áß dependent partÀÎ legs¿¡ È£¹ßÇÑ´Ù.
1. Onset?
Measured in hours to days :
Acute onset - eg. Celluitis, DVT, Compartment syndrome etc
Chronic onset - eg. Systemic process, Medication, Chronic venous insufficiency,
Lymphedema
2. Clinical course?
Intermittent vs constant
3. Pain?
Painful - eg. Cellulitis, Ruptured gastronemius, Ruptured Baker¡¯s cyst, Compartment
syndrome, DVT
Painless - eg. Systemic causes, Lymphedema
4. Associated systemic Symptoms?
Fever and chills - Cellulitis, Lymphangitis, or Venous thrombosis
Dyspnea, orthopnea, paroxysmal noctural dyspnea - Cardiac origin
Recent streptococcal sore throat, recurrent cystitis, hypertension, changes in
ocular fundi, U/A, BUN/Cr and Albumin abnormality - Renal pathogenesis
Hepatitis, alcoholism, axillary hair loss, palmar erythema,
Icterus, spider telangiectasia, Hepatomegaly, splenomegaly, Ascites,
abnormal LFT - Hepatic origin
5. Medications?
Antidepressants - Monoamine oxidase inhibitors
Anti-hypertensive drugs - ¥âblocker, CCB, Clonidine, Diazoxide, Guanethidine,
Hydralazine, Methyldopa, Minoxidil, Reserpine
Hormone agent - Corticosteroids, Estrogen, Progesterone, Testosterone
NSAIDs
Edema
Key Questions
6. Endocrine diseases?
- Cushing¡¯s syndrome,Thyroid dysfunction (pretibial myxedema)
7. Other conditions?
- Pregnancy, Salt overload, Sudden cessation of laxative, Diuretic abuse etc
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ºÐ¿¡ Àß »ý±ä´Ù.
..The distribution of edema (generalized/localized) is useful in diagnosis.
Common causes of generalized edema
- ½ÉÀåÁúȯ
Congestive heart failure
Constrictive pericarditis
Restrictive cardiomyopathy
- °£°æÈ
- ½ÅÀåÁúȯ
Renal failure
Nephrotic syndrome
Common causes of Localized edema
- Inflammatory disease
- Injury : thermal, immune, infectious, mechanical
- Occlusion of localized vein or lymphatic drainage
1. Chest radiograph
2. U/A (including microscopic)
3. Biochemistry profile (LFT, albumin, total protein, BUN/Cr)
7
The Root of ambulatory care
Key tests
Key treatments
Edema
Fig 1. Diagnostic approach to edema
1. Removal of underlying disease
2. Restriction of sodium intake : < 500mg/day
3. Diuretics : Weight loss by diuretics should be limited to 1~1.5kg/day
..Diuretics´Â ´ÜÁö ¹Ì¿ëÀûÀÎ ¸ñÀûÀ¸·Î »ç¿ëÇØ¼´Â ¾ÈµÈ´Ù. ÀÌ´¢Á¦´Â aldosteroneÀÇ
»ý¼ºÀ» ÀÚ±ØÇÏ¸ç ¿©¼ºÀÇ ÁÖ±âÀû ºÎÁ¾À» ¾ÇȽÃų ¼ö ÀÖ´Ù.
..AlbuminÅõ¿©´Â Áõ»ó°³¼±ÀÇ È¿°ú°¡ ÀϽÃÀûÀÌ¾î¼ Ä¡·á·Î¼ÀÇ Àǹ̴ ¹Ì¾à
ÇÏ´Ù.
..º¸°íÀÚ¿¡ µû¶ó À̰ßÀº ÀÖÀ¸³ª, idiopathic cyclic edemaÄ¡·á¿¡ ÀÖ¾î ACE
inhibitors°¡ ¶§¶§·Î È¿°úÀûÀÌ´Ù. (e.g,Captopril 25~50mg bid-tid)
Diuretics ó¹æ¿¹ - ¿ïÇ÷¼º ½ÉºÎÀü
1. Furosemide 40mg 1/2T-1T qd or bid Spironolactone 25mg 1/2T-1T qd
Edema
Localized edema?
Albumin < 2.5g/dL
Heart failure
Renal failure
Severe malnutrition
Cirrhosis
Nephrotic syndrome
Azotemia
Active urine sediment
Increased JVD (jugular venous distension)
Decreased CO (cardiac output)
Consider : Drug-induced : Steroids, Estrogens,
Vasodilators, Hypothyroidism
Inflammatory disease/Local Injury (thermal,
lmmune, infectious, mechanical)
Occlusion of localized vein or lymphatic drainage
No
No
No
No
Yes
Yes
Yes
Yes
9
The Root of ambulatory care
Diuretics ó¹æ¿¹ - ½ÅÁõÈıº
1. Furosemide 40mg 1/2T-1T & Spironolactone 25mg 1/2T-1T qd or bid (Á¤»ó½Å
±â´É½Ã)
2. Furosemide 40mg 1T-2T qd or bid (½ÅºÎÀü½Ã)
Diuretics ó¹æ¿¹ - °£°æº¯
1. Spironolactione 25mg 1/2T-1T bid or tid
Overdiuresis may result in hyponatremia, hypokalemia, and alkalosis, which may
worsen hepatic encephalopathy.
Common
¢º Volume depletion
¢º Prerenal azotemia
¢º Potassium depletion
¢º Hyponatremia-thiazide
¢º Metabolic alkalosis
¢º Hypercholesterolemia
¢º Hyperglycemia-thiazides
¢º Hyperkalemia-K£« sparing
¢º Hypomagnesemia
¢º Hyperuricemia
¢º Hypercalcemia-thiazides
¢º GI complaints
¢º Rash-thiazides
Uncommon
¢º Interstitial nephritis-thiazides, furosemide
¢º Pancreatitis-thiazides
¢º Loss of hearing-loop diuretics
¢º Anemia,leukopenia, thrombocytopeniathiazides
Âü°í ¹®Çå
Ralph Weber : Leg edema,in Saunders Manual of Medical Practice, 2nd ed, Robert E. Rakel(ed).
Philadelphia, Saunders, 2000, P 287-289
ÃÖÁöÈ£ : ºÎÁ¾, in °¡Á¤ÀÇÇÐ ÀÓ»óÆí. ¼¿ï, °èÃø¹®È»ç, 2002, P 614-618
Joshua H. Barash,M.D. : Edema, in A Lange clinical manual Family Medicine Ambulatory Care &
Prevention, 4th ed, Mark B. Mengel, M.D., L. Peter Schwiebert M.D.(ed).United States of America, The
McGrwa-Hill Companies, Inc., 2005, P 132-136
Glenn Chertow, M.D. : Edema, in Harrison's Manual of Medicine, 16th ed, Dennis L. Kasper, M.D., M.A.,
Eugene Braunwald, M.D., M.A., M.D., ScD., Anthony S. Fauci, M.D., ScD., Stephen L. Hauser, M.D., Dan
L. Longo, M.D., J. Larry Jameson, M.D., PhD. (ed). United States of America, The McGrwa-Hill Companies,
Inc., 2005, P 194-196
Martin S. Lipsky,M.D.,Mitchell S. King,M.D. : Edema, in Blueprints in Family Medicine. Massachusetts,
Blackwell Publishing, 2003, P 94-96