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  Swelling

Swelling or edema formerly known as dropsy or hydropsy is accumulation of excess lymph fluid or interstitial fluid in any organ or tissue without an increase of the number of cells in the affected tissue. This buildup of excessive fluid can lead to a rapid increase in weight over a short period of time (days or weeks). Swelling can occur throughout the body or it may be localized or limited to a specific body part. Most common sites of edema are the feet and ankles.

Swelling Joint pain
Swelling


The pathophysiology of edema lies on the impairment of balance between the secretion and removal of fluid in the interstitium. This is regulated by Starling equation of Tissue Fluid which states that the balance is maintained by oncotic pressure and of hydrostatic pressure across the capillary walls. Any condition that increases or reduces the oncotic pressure (low plasma osmolality) will cause edema. Increased hydrostatic pressure will likewise have the same effect. Obstruction of the lymphatic system, a subsystem of the circulatory system, may result to abnormal removal of the interstitial fluid and will also lead to edema.

The following are types of edema:

1. Peripheral/dependent edema – accumulation of fluid in parts of the body that are most affected by gravity such as the legs, feet and ankles in an ambulatory patient. For bedridden patients, sacral edema maybe the first manifestation. Usually this is a pitting type of edema (pressing down the swollen area with a finger for 5 seconds then remove it will lead to a formation of a small pit that resolves over seconds).
2. Anasarca – a generalized type of edema due to progression of peripheral edema, involving the abdominal and thoracic cavities.
3. Periorbital edema – around the eyes, which is often present in nephritic syndrome.
4. Lymphedema – a form of edema that develops around obstructed lymph vessels. This belongs to the non-pitting type of edema.

The causes of peripheral edema are:

1. high hydrostatic pressure of the veins (poor reabsorption of fluid)
a. deep venous obstruction (DVT) – usually one-sided
b. congestive heart failure
c. varicose veins
d. asymmetric compression of thigh and leg (e.g. knee pads, tight jeans, pregnancy)
e. too much salt or sodium intake

2. low oncotic pressure
a. malnutrition (poor protein intake)
b. cirrhosis (hypoalbuminemia- too little albumin which is the most abundant plasma protein that maintains plasma osmolality)
c. nephrotic syndrome (heavy renal protein loss); acute glomerulonephritis
d. epidemic dropsy

3. lymphatic drainage obstruction
a. infection
b. cancer
c. fibrosis after surgery
d. filariasis (infiltration of the lymphatic vessels by the filarial worm also known as elephantiasis)

4. inflammation (increasing capillary membrane permeability by chemical mediators leading to active fluid secretion into the interstitium)
a. allergic conditions (e.g. angioedema, urticaria)
b. any other form of inflammation

Organ-specific edema may also occur with similar principle as the peripheral edema. Examples are cerebral edema, pulmonary edema, pleural effusions, macular edema, cutaneous edema (mosquito bites). Another type of edema is due to endocrine disorders such as Cushing syndrome and thyroid disease specifically hypothyroidism which causes myxedema. In Cushing syndrome, aside from deposition of fats more on the trunk (truncal obesity), buffalo hump, the patient has also the characteristic feature of moon facies (facial edema). The most frequent cause of Cushing syndrome is prolonged intake of steroids (self-medication). Myxedema is also facial swelling occurring in an adult-onset form of hypothyroidism, a thyroid disorder.

The treatment of edema or swelling will largely depend on its underlying cause. Management is geared towards the precipitating cause and reducing the edema by giving diuretics. Diuretics will promote urine formation and helps in getting rid of the excess tissue fluid. The following are the classes of diuretics used: loop diuretics, thiazide, potassium-sparers and carbonic anhydrase inhibitors.

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