A Quick Review of AFP's "Edema: Diagnosis and Management"

Edema: Diagnosis and Management
KATHRYN P. TRAYES, MD, and JAMES S. STUDDIFORD, MD, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, SARAH PICKLE, MD, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, AMBER S. TULLY, MD, Cleveland Clinic, Cleveland, Ohio
http://www.aafp.org/afp/2013/0715/p102.pdf 

Am Fam Physician. 2013 Jul 15;88(2):102-110 

     Edema is the accumulation of fluid from the intravascular space to the intercellular space. This is caused by changes in the capillary hydrostatic pressure gradient and the oncotic pressure gradient. The history can help determine the management of the edema. Acute edema can be seen in a DVT, compartment syndrome, a ruptured popliteal cyst, or a new calcium channel blocker script. Chronic edema is seen with systemic conditions such as CHF, kidney, thyroid or liver diseases. Unilateral swelling can be seen in DVT, venous insufficiency, or obstruction. Certain medications such as MAOIs, BBLs, CCBs, NSAIDs, cytokines, and chemotherapeutics can also lead to edema.
     For diagnostic testing, labs such as BNP, creatinine, UA, albumin, D-dimer, and liver enzymes should be drawn.  Examination of the legs for pitting and the feet for Kaposi-Stemmer sign (inability of skin tenting during pinching of the top of the foot) is helpful for the diagnosis of lymphedema. Venous ultrasound is good for DVT. Duplex ultrasound is good for venous insufficiency. Additional imaging, such as an MRI with venography can help find a DVT or May-Turner syndrome (where the left iliac vein is compressing the right iliac artery).  An echo can be used to evaluate pulmonary arterial pressures in patients with obstructive sleep apnea.
     Management of edema usually focuses on treating the underlying condition. Patients with chronic venous insufficiency can use leg elevation and compression stockings. Pneumatic devices can be used if stockings are contraindicated (peripheral arterial disease). Wound care includes emollients and topical steroids. Patients with lymphedema may need manual lymphatic massage, multilayer bandages, compression stockings, or debulking/ bypass procedures if the lymphedema is severe refractory. DVT management consists of anticoagulation and compression stockings. Medication induced edema patients will need to discontinue the offending medication.  Obstructive sleep apnea patients will need positive pressure ventilation.