水肿EDEMA知识讲座

EDEMA1水肿EDEMA知识讲座5/9/2024DEFINITIONExpansionoftheinterstitial（间质）fluidvolume.WeightgainprecedesovertedemaMassiveandgeneralizededemaiscalledanasarca（全身性水肿）Pitting(压凹性)andnon-pitting(非压凹性)edemaSchrothBE,JAAPA2005112水肿EDEMA知识讲座5/9/2024EdemaPittingedemaNon-pittingedema3水肿EDEMA知识讲座5/9/2024Anatomyandpathophysilolgy1/3oftotalbodywaterisextracellularspace,and2/3isintracellularspace;Extracellularspaceiscomposedoftheintravascularplasmavolume(25%)andtheextravascularinterstitialspaces(75%);4水肿EDEMA知识讲座5/9/2024Starling’slaw:Extravascularandintravascularhydrostaticpressurs;Differencesinoncoticpressureswithintheinterstitialspaceandplasma;Thepermeabilityofthebloodvesselwall.AnatomyandpathophysilolgyVascularsystemInterstitialspaceHydrostaticpressure（流体静水压）

HydrostaticpressureColloidoncoticpressure(tissuetension)（胶体渗透压）

Colloidoncoticpressure5水肿EDEMA知识讲座5/9/2024ReducedPlasmaOsmoticPressureAlbuminis

theserum

proteinMOSTresponsibleforthemaintenanceofcolloidosmoticpressureAdecreaseinosmoticpressurecanresultfromincreasedproteinlossordecreasedproteinsynthesis6水肿EDEMA知识讲座5/9/20247水肿EDEMA知识讲座5/9/2024CapillaryDamageDamagetothecapillaryendotheliumIncreaseitspermeabilityandpermitsthetransferofproteinintointerstitialcompartment

Injuryagents

DrugsViral/bacterialagentsThermal/mechanicaltraumaImmuneResponsibleforinflammatoryedema

Nonpittinglocalizedrednessandtenderness8水肿EDEMA知识讲座5/9/2024ClinicalCausesofEdemaSystemicedemaCongestiveheartfailureCirrhosisNephroticsyndrome/otherhypoalbuminemiaDrug-inducedIdiopathic

LocalizededemaVenous/lymphaticobstruction9水肿EDEMA知识讲座5/9/2024SystemicEdema

Congestiveheartfailure10水肿EDEMA知识讲座5/9/2024Congestiveheartfailure

Left-sidedheartfailure:shortnessofbreathwithexertionandwhenlyingdownatnight(orthophea,端坐呼吸)－－pulmonaryedemaRight-sidedheartfailure:swellinginthelegsandfeet－－peripheraledemaThephysicianexaminingapatientwhohascongestiveheartfailurewithfluidretentionlooksforcertainsigns:pittingedema;ralesinthelungs,agalloprhythmanddistendedneckveins.11水肿EDEMA知识讲座5/9/2024SystemicEdema12水肿EDEMA知识讲座5/9/2024NephroticSyndrome/HypoalbuminemicstatesTheprimaryalteration:decreasedcolloidoncoticpressureproteinlossintheurine

severenutritionaldeficiencyproteinlossenteropathycongenitalhypoalbuminemialivercirrhosisPromotesfluidmoveintotheinterstitiumCauseshypovolemia

salt/waterretentionactivationRAAaxisetc13水肿EDEMA知识讲座5/9/2024IdiopathicEdemaDiurnalalterationsinweightoccurringwithorthostaticretentionofsodiumandwaterIncreaseincapillarypermeability

fluctuateinseverityaggravatedbyhotweatherReductioninplasmavolumeinthisconditionwithsecondaryactivationoftheRAAsystem14水肿EDEMA知识讲座5/9/2024Drug-inducededemaNonsteroidalanti-inflammatorydrugsAntihypertensiveagents

Directarterial/arteriolarvasodilatorsCalciumchannelantagonistsa-AdrenergicantagonistsSteroidhormones

GlucocorticoidsAnabolicsteroidsEstrogensProgestinesCyclosporineGrowthhormoneImmunotherapies

Interleukin2OKT3monoclonalantibody15水肿EDEMA知识讲座5/9/2024LocalizededemaInflammationVenous/lymphaticobstructionChroniclymphangitisResectionofregionallymphnodesFilariasis(丝虫病)16水肿EDEMA知识讲座5/9/2024DiagnosisOfparticularimportanceisexcludingmajororgansystemdysfunction,especiallycardiac,liver,andrenaldysfunction.Askquestionssuchasthefollowing:Dotheringsonyourfingersgettight?Haveyouhadtoletyourbeltout?Haveyourclothesorshoesgottentootight?Payspecialattentiontothepatient’smedications;Also,obtainathoroughdietaryhistory,payingcarefulattentiontothepatient’sdietarysodiumintake,totaldailyfluidintake;17水肿EDEMA知识讲座5/9/2024Physicalexamination&Diagnostictesting

Inadditiontothestandardphysicalexamination,chartthepatient’sweightandnotegeneralappearance,payingspecialattentiontotheedemawithrespecttolocation,symmetry,pittingornonpittingappearance,tenderness,andassociatedskinchanges.Assesstheseverityofedemawithamethodsuchasthefour-pointscale(+1,slight,to+4,verymarked);Includingachemistrypanelandurinalysistoevaluaterenalandliverfunctionandalbuminlevelstoassessnutritionalstatus.Considermeasuringthethyrotropinleveltoruleouthypothyroidism.Incaseswherescreeningforacardiacetiologyisrequired,anECGandchestradiographmaybehelpfulinassessingcardiacfunction.18水肿EDEMA知识讲座5/9/2024DifferentialdiagnosisHeartfailureRenaldiseasesCirrhosisNutritionaloriginIdiopathicOthers19水肿EDEMA知识讲座5/9/2024Differentialdiagnosis

HeartFailureEdemainitiallyoccursatlowerpartofthebody(lowerextremities)symmetriclocationThepresenceofheartdiseasescardiacenlargementgalloprhythmdyspneabasilarralesvenousdistentionhepatomegalyNoninvasivetestsmaybehelpful

echocardiographyradionuclideangiography20水肿EDEMA知识讲座5/9/2024Differentialdiagnosis

RenaldiseasesMainlyduetohypoabluminemiaandsalt/waterretentionAssociatedwithhematuria,proteinuria,

hypertentionandimpairedrenalfunctionalCharacteriasticofedemaofrenalorigin:

puffinessofthefaceprominentintheperiorbitalareas21水肿EDEMA知识讲座5/9/2024Differentialdiagnosis

Cardiac/Renaldisease

Renal

CardiacLocationonsetfromtheface,onsetfromthelowerperiobitalareaspartofthebodyProgressionprogressquicklyprogressslowlyIdentitysoftandmobilerelativelysolid,lessmobileOthersignsproteinuriasignsofheartfailure:hypertensioncardiacenlargementimpairedrenalvenousdistentionfunctionaltesthepatomegaly

22水肿EDEMA知识讲座5/9/2024Differentialdiagnosis

Liverdiseases(cirrhosis)Clinicalevidenceofhepaticdisease

jaundicespiderangiomasascitesAscites