Too much of a good thing: intracellular, extracellular, extravascular fluid excess
Water is one of the key components of the milieu interior: when disbalanced in quantity and location, a diseased state is inevitable. Naturally confined in optimum quantities inside body cells and key to maintaining flow inside the vascular network, increased hydrostatic pressure (cardiac failure, inflammation, vascular compression or obstruction), reduced colloid oncotic pressure (hypoproteinemia: nutritional, decreased synthesis or excessive loss) or poor lymphatic drainage (block or interruption by surgery) are the salient etiologies for fluids to leave vessels. The clinical sign of edema – pitting – elicited most often in dependent parts of the body is ominous. This external sign when slow to manifest still conceals serious organ disease and morbidity due to functional compromise of internal organs. In rapid accumulations, it can be life threatening!
Insights and Impact
- Clinical detection of peripheral edema – localized or generalized – is an important sign demanding early diagnosis and intervention
- Even smaller quantities of fluid – excess in deeper tissues/cavities/confined spaces, when the peripheral sign maybe absent, is critical to suspect and confirm by imaging e.g. head injury, acute left ventricular failure, angioedema
- In chronic fluid collections a comprehensive clinical workup needs corroboration by
- imaging which displays fluid location, quantity and identifies underlying local organ disease
- biochemical workup which evaluates liver and kidney function
- haematological tests e.g. for prothrombotic conditions
- other specific tests appropriate to pinpoint specific diseases e.g. blockage of lymphatics by cancer cells or filarial worms.
- Principles of therapy are directed to improve fluid excretion, remove fluid in confined spaces for symptomatic and functional relief and, in all cases, identify and treat the etiology.
- Note: a history of major lymph node group dissection for cancer may make the diagnosis without any additional investigation…
Rhythm ’n rhyme
Fluids need to be contained
Have you ever given a thought why a compliment makes you blush?
Or your foot gets all swollen when tight socks your ankle crush;
You will learn soon enough it’s an arterial or venous phenomenon
That causes hyperemia, congestion, edema that can sometimes life threaten;
Compression, calibre-change or obstruction of vessels are some of edema’s local causes,
It’s a serious business to tackle when systemic disturbances create onward flow pauses;
Heart, liver or kidney diseases cause fluids from vessels to leak
In malnutrition-struck patients, albumin-rich diet you need to tweak;
Water filled body cavities and potential spaces expand like a balloon
Tissues hapless, compressed: medical intervention must be soon;
Sustained extravascular, extracellular fluid in subcutaneous locations, predisposes to infection
Skin suffers ischemia: non-healing ulcers deserve special mention;
Organs that get waterlogged enlarge and carry a heavy weight
Lungs can barely breathe, brain through the foramen magnum may herniate;
A chronically congested liver looks quite like a nutmeg
And when fluid slowly fills the abdomen it appears like a keg;
Rapid accumulations need emergency medical and surgical decompression
For chronic collections target the etiology, the reward is patient satisfaction;
Water is life giving, of cellular processes and blood flow the master
When in excess, deficient or misplaced, is a recipe for disaster…
Deep Dive
A. Cerebral edema (a medical emergency)
Acknowledgement of Image:
https://neuroradiologyteachingfiles.com/diffuse%20cerebral%20edemaB.jpg
Q. List etiologies for cerebral edema (localized and generalized)
B. Peripheral edema (pitting) – carefully search the etiology for management
Acknowledgement of Image:
https://www.medicalnewstoday.com/articles/321773
Q. Recap the key investigative modalities that will help you arrive at the underlying organ disease which leads to the clinical sign illustrated in Image B.
Read on:
https://www.ajronline.org/doi/full/10.2214/AJR.11.8081 https://www.ncbi.nlm.nih.gov/books/NBK537272/#_ncbi_dlg_citbx_NBK537272 https://www.osmosis.org/answers/pitting-edema
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