Clinical studyPeripheral edema
Section snippets
Pathophysiology
Total body water is divided between the intracellular and extracellular spaces. The extracellular space, which comprises about one third of total body water, is composed of the intravascular plasma volume (25%) and the extravascular interstitial space (75%) (1). Starling defined the physiologic forces involved in maintaining the balance of water between these two compartments 2, 3, which include the gradient between intravascular and extravascular hydrostatic pressures, differences in oncotic
Heart failure
In heart failure, an elevation in venous pressure caused by ventricular systolic or diastolic dysfunction increases capillary hydrostatic pressure (Table 1). The resulting low-output state activates the aforementioned neurohumoral mechanisms that maintain arterial perfusion. If the resulting extravasation of fluid outpaces the ability of the lymphatic system to return this fluid to the vascular space, edema will result. With left ventricular failure, this manifests as pulmonary edema; whereas
Clinical approach
Initial efforts in the work-up should focus on excluding major organ system failure as the underlying cause. However, given the ubiquity and often benign causes of peripheral edema, a rational approach is necessary to minimize patients’ exposure to unnecessary tests and to contain costs. A thorough history and physical examination are critical. Examination of the lower extremities should document more than the presence or absence of pitting. Comparisons of one foot and leg with those on the
Conclusion
Peripheral edema is a common manifestation of many disease states. Its proper diagnosis and management mandates an understanding of the physiologic principles governing its formation. By directing specific therapy at correcting the underlying capillary hemodynamic disturbance, development of edema may be halted or reversed. Lifestyle and dietary modification in conjunction with pharmacotherapy are also useful in long-term management.
Acknowledgements
We are indebted to Drs. Paul Heidenreich, Victor Froelicher, and Timothy Meyer for their thoughtful review of this manuscript. We also thank Ms. Belinda Byrne for assistance with the artwork.
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