Anasarca: Difference between revisions

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__NOTOC__
{{Infobox_Disease |
{{Infobox_Disease |
   Name        = Anasarca |
   Name        = Anasarca |
Line 6: Line 7:
   ICD9        = {{ICD9|782.3}} |
   ICD9        = {{ICD9|782.3}} |
}}
}}
{{Template:Anasarca}}
{{CMG}}
{{CMG}}
{{JFS}}
{{AE}} {{MSJ}}
 
{{SI}}


{{SK}} Generalized edema, generalized swelling, leucophlegmatia
{{SK}} Generalized edema, generalized swelling, leucophlegmatia


==Overview==
==Overview==
'''Anasarca''' is a [[list of medical symptoms|medical symptom]] characterized by widespread swelling of the [[skin]] due to effusion of fluid into the [[extracellular space]]. Anasarca is often due to either congestive [[cardiac failure]], [[liver failure]] ([[cirrhosis]] of the liver), [[renal failure]]/disease, or the other diseases listed below.  Plant-derived anticancer [[chemotherapy|chemotherapeutic]] agents, such as [[docetaxel]], cause anasarca through a poorly understood [[capillary leak syndrome]].
[[Edema]] is characterized by the collection of excess [[fluid]] in the [[interstitial space]]. [[Anasarca]] is severe edema characterized by generalized swelling throughout the body. The main underlying cause of [[edema]] is an imbalance in the hemodynamic status of the [[Capillary|capillaries]] resulting in excess filtration of fluid in the [[intercellular space]] due to increased hydrostatic pressure, increased permeability of the [[Capillary|capillaries]] and decreased [[oncotic pressure]]. It exceeds the absorptive capacity of [[lymph]] [[vessel]]<nowiki/>s. It can be caused by systemic diseases including [[Congestive heart failure|chronic heart failure]], [[liver cirrhosis]], [[Hypersensitivity|hypersensitivity reaction]], and [[chronic renal failure]].
 
==Classification==
The edema is classified in different types depending upon the severity of fluid accumulation assessed clinically:<ref name="pmid101016/j.cardfail.2013.06.276">{{cite journal| author=Stoltz JF, Nicolas A| title=Study of amino groups of the human platelet membrane. | journal=Acta Haematol | year= 1978 | volume= 60 | issue= 5 | pages= 304-9 | pmid=101016/j.cardfail.2013.06.276 | doi=10.1159/000207727 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=101016  }} </ref>
 
{| class="wikitable"
 
|-


==Complete Differential Diagnosis of the Underlying Causes of Anasarca ==
!Grade


(In alphabetical order)
!Visibility of edema


*[[Acute renal failure]], especially oliguric renal failure with fluid retention
!Pitting over tibia
*[[Allergic reactions]], only systemic severe allergic reactions with associated capillary leak
     
*[[Angioedema]], rarely, when it is severe and generalized
!Level of edema
*[[Burns]] (generalized severe burns can result in [[Hypoalbuminemia]] and capillary leak)
*[[Calcium channel blockers]] usually cause localized edma and not anasarca
*[[Capillary leak syndrome]]
*[[Cardiac tamponade ]] resulting in heart failure and generalized edema
*[[Chronic kidney disease]] (advanced stages with fluid retention)
*[[Constrictive pericarditis]] with associated heart failure
*[[Cor pulmonale]] resulting in right heart failure
*[[Diazoxide]] usually cause localized edma and not anasarca
*Corticosteriods
*[[Dilated cardiomyopathy]]
*[[Docetaxel]] usually cause localized edma and not anasarca
*[[Eclampsia]] (severe eclampsia)
*[[Effusive-constrictive pericarditis]] with associated heart failure
*[[Estrogens]]
*[[Fludrocortisone]]
*[[Glomerulonephritis]]
*[[Haemolytic disease of the newborn]]
*[[Heart failure]]
*Hepatic [[cirrhosis]]
**[[Alcoholic liver disease]]
**[[Alpha-1-antitrypsin deficiency]]
**[[Autoimmune hepatitis]]
**Chronic [[hepatitis B]]
**Chronic [[hepatitis C]]
**Hepatic venous obstruction
**[[Hereditary hemochromatosis]]
**[[Primary biliary cirrhosis]]
**[[Primary sclerosing cholangitis]]
**[[Non-alcoholic fatty liver disease|Nonalcoholic fatty liver disease]]
**[[Wilson's disease]]
*[[Hereditary angioedema]] in severe cases
*[[Hypertrophic cardiomyopathy]]
*[[Hypoalbuminemia]]
*[[Hypoproteinemia]]
*[[Hypothyroidism]] (advanced untreated hypothyroidism)
*Idiopathic [[edema]]
*[[Increased capillary permeability]]
*Increased interstitial oncotic pressure
*[[Interleukin-2]] therapy
*[[Kwashiorkor]]
*Lymphatic obstruction usually cause localized limb [[edema]] unless very proximal
*[[Malnutrition]]
*[[Malignant ascites]] is usually associated with lower extremities edema
*[[Minoxidil]] usually causes localized edema to the lower extremities
*[[Nephrotic syndrome]]
*[[Nonsteroidal antiinflammatory drug]] causes localized edma
*[[Ovarian hyperstimulation syndrome]]
*[[POEMS syndrome]]
*[[Portal thrombosis]] causes lower extremities edema
*[[Pramipexole]]
*[[Pregnancy]]
*Protein loss
*[[Protein-losing enteropathy]]
*Reduced [[albumin]] synthesis
*[[Refeeding]] edema
*[[Restrictive cardiomyopathy]]
*Severe inflammation or [[sepsis]]
*Sodium overload
*[[Thiazolidinediones]]
*[[Trauma]] (severe trauma)
*[[Tricuspid stenosis]]
*[[Tropical sprue]]
*Venous obstruction usually causes localized edema in the limb
*[[Water overload]]
*[[Yellow nail syndrome]]


== '''Complete Differential Diagnosis of the Causes of Anasarca''': ==
(By organ system)
{|style="width:75%; height:100px" border="1"
|style="height:100px"; style="width:25%" border="1" bgcolor="LightSteelBlue" | '''Cardiovascular'''
|style="height:100px"; style="width:75%" border="1" bgcolor="Beige" | [[Cardiac tamponade ]], [[Constrictive pericarditis]], [[Cor pulmonale]], [[Dilated cardiomyopathy]], [[Effusive-constrictive pericarditis]], [[Heart failure]], [[Hypertrophic cardiomyopathy]], [[Restrictive cardiomyopathy]], [[Tricuspid stenosis]]
|-
|-
|-bgcolor="LightSteelBlue"
 
| '''Chemical / poisoning'''
|0+
|bgcolor="Beige"| No underlying causes
 
|No
 
|Absent
 
|Cannot assess
 
|-
|-
|-bgcolor="LightSteelBlue"
 
| '''Dermatologic'''
|1+
|bgcolor="Beige"| No underlying causes
 
|Yes
 
|Slight
 
|Cannot assess
 
|-
|-
|-bgcolor="LightSteelBlue"
 
| '''Drug Side Effect'''
|2+
|bgcolor="Beige"| [[Calcium channel blockers]], [[Diazoxide]], [[Docetaxel]], [[Estrogens]]
 
[[Fludrocortisone]], Interleukin-2 therapy, [[Minoxidil]], Nonsteroidal antiinflammatory drugs, Corticosteriods
|Yes
 
|Moderate
 
|Below knee
 
|-
|-
|-bgcolor="LightSteelBlue"
 
| '''Ear Nose Throat'''
|3+
|bgcolor="Beige"| No underlying causes
 
|-
|Yes
|-bgcolor="LightSteelBlue"
 
| '''Endocrine'''
|Moderate
|bgcolor="Beige"| Corticosteriods
 
|-
|Above knee
|-bgcolor="LightSteelBlue"
 
| '''Environmental'''
|bgcolor="Beige"| [[Water intoxication]]
|-
|-
|-bgcolor="LightSteelBlue"
| '''Gastroenterologic'''
|bgcolor="Beige"| [[Alcoholic liver disease ]], [[Autoimmune hepatitis]], [[Chronic hepatitis B]], [[Chronic hepatitis C]], [[Hepatic cirrhosis]], [[Hepatic venous obstruction]], [[Hereditary hemochromatosis]], [[Portal thrombosis]], [[Primary biliary cirrhosis]], [[Primary sclerosing cholangitis]], [[Wilson's disease]]


|4+
|Yes
|Severe (cannot reach tibia)
|Above knee
|}
==Causes==
===Life-threatening Causes===
Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated.
*[[Burns]]
*[[Anaphylaxis]]
===Common Causes===
Common causes of [[anasarca]] may include the following:<ref name="pmid23939641">{{cite journal| author=Trayes KP, Studdiford JS, Pickle S, Tully AS| title=Edema: diagnosis and management. | journal=Am Fam Physician | year= 2013 | volume= 88 | issue= 2 | pages= 102-10 | pmid=23939641 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23939641  }} </ref><ref name="pmid15952439">{{cite journal| author=O'Brien JG, Chennubhotla SA, Chennubhotla RV| title=Treatment of edema. | journal=Am Fam Physician | year= 2005 | volume= 71 | issue= 11 | pages= 2111-7 | pmid=15952439 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15952439  }} </ref><ref name="pmid12459405">{{cite journal| author=Cho S, Atwood JE| title=Peripheral edema. | journal=Am J Med | year= 2002 | volume= 113 | issue= 7 | pages= 580-6 | pmid=12459405 | doi=10.1016/s0002-9343(02)01322-0 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12459405  }} </ref><ref name="pmid11569326">{{cite journal| author=Yale SH, Mazza JJ| title=Approach to diagnosing lower extremity edema. | journal=Compr Ther | year= 2001 | volume= 27 | issue= 3 | pages= 242-52 | pmid=11569326 | doi=10.1007/s12019-001-0021-5 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11569326  }} </ref>
*[[Congestive heart failure|Congestive cardiac failure]]
*[[Urticaria]]
*[[Liver|Hepatic]] [[cirrhosis]]
*[[Renal failure]]
*[[Kwashiorkor disease]]
*[[Obstructive sleep apnea]]
*[[Pregnancy]]
*[[Nephrotic syndrome]]
*Use of certain medications ([[Beta blockers]], [[Calcium channel blocker|calcium channel blockers]], [[clonidine]], [[methyldopa]], [[hydralazine]], [[androgen]], [[corticosteroid]])
==Differential Diagnosis==
On the basis of onset of symptoms, [[ascities]], and [[hypertension]], [[anasarca]] must be differentiated from [[congestive heart failure]], [[chronic kidney disease]], [[liver]] [[cirrhosis]], [[anaphylaxis]], [[nephrotic syndrome]], and protein-calorie [[malnutrition]].<ref name="pmid29939653">{{cite journal| author=| title=StatPearls | journal= | year= 2020 | volume=  | issue=  | pages=  | pmid=29939653 | doi= | pmc= | url= }} </ref><ref name="pmid27935768">{{cite journal| author=Yap FY, Skalski MR, Patel DB, Schein AJ, White EA, Tomasian A | display-authors=etal| title=Hypertrophic Osteoarthropathy: Clinical and Imaging Features. | journal=Radiographics | year= 2017 | volume= 37 | issue= 1 | pages= 157-195 | pmid=27935768 | doi=10.1148/rg.2017160052 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27935768  }} </ref><ref name="pmid28505213">{{cite journal| author=Auld T, Werntz JR| title=Dupuytren's disease: How to recognize its early signs. | journal=J Fam Pract | year= 2017 | volume= 66 | issue= 3 | pages= E5-E10 | pmid=28505213 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28505213  }} </ref><ref name="pmid11225711">{{cite journal| author=Carmelli D, Swan GE, Bliwise DL| title=Relationship of 30-year changes in obesity to sleep-disordered breathing in the Western Collaborative Group Study. | journal=Obes Res | year= 2000 | volume= 8 | issue= 9 | pages= 632-7 | pmid=11225711 | doi=10.1038/oby.2000.81 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11225711  }} </ref><ref name="pmid27367736">{{cite journal| author=Inamdar AA, Inamdar AC| title=Heart Failure: Diagnosis, Management and Utilization. | journal=J Clin Med | year= 2016 | volume= 5 | issue= 7 | pages=  | pmid=27367736 | doi=10.3390/jcm5070062 | pmc=4961993 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27367736  }} </ref><ref name="pmid26708193">{{cite journal| author=Levey AS, Inker LA| title=GFR as the "Gold Standard": Estimated, Measured, and True. | journal=Am J Kidney Dis | year= 2016 | volume= 67 | issue= 1 | pages= 9-12 | pmid=26708193 | doi=10.1053/j.ajkd.2015.09.014 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26708193  }} </ref><ref name="pmid26838799">{{cite journal| author=Hansen KL, Nielsen MB, Ewertsen C| title=Ultrasonography of the Kidney: A Pictorial Review. | journal=Diagnostics (Basel) | year= 2015 | volume= 6 | issue= 1 | pages=  | pmid=26838799 | doi=10.3390/diagnostics6010002 | pmc=4808817 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26838799  }} </ref><ref name="pmid23040367">{{cite journal| author=Vadas P, Perelman B, Liss G| title=Platelet-activating factor, histamine, and tryptase levels in human anaphylaxis. | journal=J Allergy Clin Immunol | year= 2013 | volume= 131 | issue= 1 | pages= 144-9 | pmid=23040367 | doi=10.1016/j.jaci.2012.08.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23040367  }} </ref><ref name="pmid19960649">{{cite journal| author=Epstein LJ, Kristo D, Strollo PJ, Friedman N, Malhotra A, Patil SP | display-authors=etal| title=Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. | journal=J Clin Sleep Med | year= 2009 | volume= 5 | issue= 3 | pages= 263-76 | pmid=19960649 | doi= | pmc=2699173 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19960649  }} </ref><ref name="pmid9448172">{{cite journal| author=Sheth SG, Flamm SL, Gordon FD, Chopra S| title=AST/ALT ratio predicts cirrhosis in patients with chronic hepatitis C virus infection. | journal=Am J Gastroenterol | year= 1998 | volume= 93 | issue= 1 | pages= 44-8 | pmid=9448172 | doi=10.1111/j.1572-0241.1998.044_c.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9448172  }} </ref><ref name="pmid10498635">{{cite journal| author=Krzeski P, Zych W, Kraszewska E, Milewski B, Butruk E, Habior A| title=Is serum bilirubin concentration the only valid prognostic marker in primary biliary cirrhosis? | journal=Hepatology | year= 1999 | volume= 30 | issue= 4 | pages= 865-9 | pmid=10498635 | doi=10.1002/hep.510300415 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10498635  }} </ref><ref name="pmid16931288">{{cite journal| author=Schwartz LB| title=Diagnostic value of tryptase in anaphylaxis and mastocytosis. | journal=Immunol Allergy Clin North Am | year= 2006 | volume= 26 | issue= 3 | pages= 451-63 | pmid=16931288 | doi=10.1016/j.iac.2006.05.010 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16931288  }} </ref>
{|
! rowspan="2" style="background: #4479BA; color: #FFFFFF; text-align: center;" |Diseases
! colspan="6" style="background: #4479BA; color: #FFFFFF; text-align: center;" |Clinical manifestation
! colspan="2" style="background: #4479BA; color: #FFFFFF; text-align: center;" |Para-clinical findings
! rowspan="2" style="background: #4479BA; color: #FFFFFF; text-align: center;" |Gold Standard
|-
|-
|-bgcolor="LightSteelBlue"
! style="background: #4479BA; color: #FFFFFF; text-align: center;" |Onset
| '''Genetic'''
! style="background: #4479BA; color: #FFFFFF; text-align: center;" |Abdominal distention due to ascities
|bgcolor="Beige"| [[Angioedema]], [[Alpha-1-antitrypsin deficiency]], [[Hereditary angioedema]]
! style="background: #4479BA; color: #FFFFFF; text-align: center;" |Associated symptoms
[[Hereditary hemochromatosis]], [[Hypertrophic cardiomyopathy]], [[Wilson's disease]], [[Yellow nail syndrome]]
! style="background: #4479BA; color: #FFFFFF; text-align: center;" |Blood pressure
|-
! style="background: #4479BA; color: #FFFFFF; text-align: center;" |Tachycardia
|-bgcolor="LightSteelBlue"
! style="background: #4479BA; color: #FFFFFF; text-align: center;" |Physical examination findings
| '''Hematologic'''
! style="background: #4479BA; color: #FFFFFF; text-align: center;" |Lab findings
|bgcolor="Beige"| No underlying causes
! style="background: #4479BA; color: #FFFFFF; text-align: center;" |Imaging
|-
|-
|-bgcolor="LightSteelBlue"
! style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Congestive heart failure|Congestive Cardiac Failure]]
| '''Iatrogenic'''
| align="center" style="background:#F5F5F5;" |Chronic
|bgcolor="Beige"| [[Water intoxication]], excess intravenous fluids
| align="center" style="background:#F5F5F5;" | +
| align="left" style="background:#F5F5F5;" |[[Dyspnea]],[[Orthopnea]], [[Proxysmal nocturnal dyspnea]]
| align="center" style="background:#F5F5F5;" |&darr; /&uarr;
| align="center" style="background:#F5F5F5;" | +
| align="left" style="background:#F5F5F5;" |[[Tachypnea]], [[Jugular venous pressure|jugular venous distention]], elevated [[Central venous pressure|CVP]], S3, decreased [[Breathing|breath]] sounds in lower [[lung]] fields, [[hepatojugular reflex]]
| align="center" style="background:#F5F5F5;" |Elevated [[Brain natriuretic peptide|BNP]]
| align="left" style="background:#F5F5F5;" |
*[[Chest X-ray]]: [[Cardiomegaly]], [[pleural effusion]], Berkley lines
*Cardiac ECHO: Reduced [[Ejection fraction]]
| align="left" style="background:#F5F5F5;" |[[Ejection fraction|LVEF]] on echocardiography
|-
|-
|-bgcolor="LightSteelBlue"
! style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Liver]] [[cirrhosis]]
| '''Infectious Disease'''
| align="center" style="background:#F5F5F5;" |Chronic
|bgcolor="Beige"| [[Tropical sprue]]
| align="center" style="background:#F5F5F5;" | +
| align="left" style="background:#F5F5F5;" |[[Nausea and vomiting|Nausea]],[[Nausea and vomiting|vomitting]], [[jaundice]], [[Telangiactesia|telangiactesia,]] [[palmar erythema]], [[hematemsis]],  anorectal varicies
| align="center" style="background:#F5F5F5;" |&darr;
| align="center" style="background:#F5F5F5;" | -
| align="left" style="background:#F5F5F5;" |[[Jaundice]], [[pallor]], [[caput meducae]], [[splenomegaly]], inintially [[hepatomegaly]], [[clubbing]], [[Dupuytrens contracture|Dupuytren's contracture]]
| align="left" style="background:#F5F5F5;" |Elevated [[ALP]], [[AST]], [[Alanine transaminase|ALT]], [[Gamma-glutamyl transpeptidase|GGT]], [[bilirubin]], hypoalbuminemia, prolonged [[prothrombin time]]
| align="left" style="background:#F5F5F5;" |USG [[liver]] will show [[Cirrhosis|cirrhotic]], irregular nodular [[liver]] with increased echogenicity.
| align="left" style="background:#F5F5F5;" |[[Liver]] [[biopsy]]
|-
|-
|-bgcolor="LightSteelBlue"
! style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Chronic kidney disease]]
| '''Musculoskeletal / Ortho'''
| align="center" style="background:#F5F5F5;" |Chronic
|bgcolor="Beige"| No underlying causes
| align="center" style="background:#F5F5F5;" | +
| align="left" style="background:#F5F5F5;" |[[Anorexia]], [[Nausea and vomiting|Nausea]], [[bleeding]], [[Fatigue|fatigue,]] [[weakness]]
| align="center" style="background:#F5F5F5;" |&uarr;
| align="center" style="background:#F5F5F5;" | +
| align="left" style="background:#F5F5F5;" |[[Pallor]], [[tachypnea]], [[pericardial friction rub]], crackles on chest ascultation, uremic fetor
| align="left" style="background:#F5F5F5;" |Elevated [[Blood urea nitrogen|BUN]],[[creatinine]], decrease [[hemoglobin]], [[acidosis]], [[hyperkalemia]], elevated [[Triglyceride|TAG]]
| align="left" style="background:#F5F5F5;" |[[Ultrasound|USG]] [[kidney]] will show atrophied [[kidney]] with cortical thinning and increased echogenecity.
| align="left" style="background:#F5F5F5;" |[[Glomerular filtration rate|GFR]]
|-
|-
|-bgcolor="LightSteelBlue"
! style="background: #DCDCDC; padding: 5px; text-align: center;" |Protein losing [[nephropathy]]
| '''Neurologic'''
| align="center" style="background:#F5F5F5;" |Chronic
|bgcolor="Beige"| No underlying causes
| align="center" style="background:#F5F5F5;" | +
| align="left" style="background:#F5F5F5;" |[[Dyspnea]], [[headache]], irratibility, [[bacteria]]<nowiki/>l or [[Virus|viral]] infections, recent H/O of [[Upper respiratory tract infection|URTI]]
| align="center" style="background:#F5F5F5;" |&uarr; /N
| align="center" style="background:#F5F5F5;" | +/-
| align="left" style="background:#F5F5F5;" |[[Hematuria]] in some patients, Facial [[malar rash]] in [[SLE]] [[patient]]<nowiki/>s.
| align="left" style="background:#F5F5F5;" |[[Hypoalbuminemia]], 24 hour [[urine]] [[protein]] excretion>3.5g, Elevated [[Triglyceride|TAG]] and [[cholesterol]].
| align="left" style="background:#F5F5F5;" |[[Ultrasound|USG]] [[kidney]] may show increased echogenecity.
| align="left" style="background:#F5F5F5;" |[[Kidney|Renal]] [[biopsy]]
|-
|-
|-bgcolor="LightSteelBlue"
! style="background: #DCDCDC; padding: 5px; text-align: center;" |Protein Calorie [[malnutrition]]
| '''Nutritional / Metabolic'''
| align="center" style="background:#F5F5F5;" |Chronic
|bgcolor="Beige"| [[Hypoalbuminemia]], Hypoproteinaemia, [[Kwashiorkor]], [[Malnutrition]]
| align="center" style="background:#F5F5F5;" | +
Protein loss, [[Protein-losing enteropathy]], Reduced albumin synthesis, Refeeding edema, Sodium overload, [[Tropical sprue]], Water overload
| align="left" style="background:#F5F5F5;" |[[Muscle wasting]], stunted [[growth]], swollen [[face]], dry [[skin]], brittle [[hair]]
| align="center" style="background:#F5F5F5;" |&darr; /N
| align="center" style="background:#F5F5F5;" | +
| align="left" style="background:#F5F5F5;" |[[Hepatomegaly]], [[Scaling skin|Scaling]], [[hyperpigmentation]] and [[hypopigmentation]] of [[skin]]
| align="left" style="background:#F5F5F5;" |[[Hypoalbuminemia]]
| align="left" style="background:#F5F5F5;" |NA
| align="left" style="background:#F5F5F5;" |NA
|-
|-
|-bgcolor="LightSteelBlue"
! style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Allergic Reaction|Allergic reactions]]
| '''Obstetric/Gynecologic'''
| align="center" style="background:#F5F5F5;" |Acute
|bgcolor="Beige"|[[Eclampsia]], [[Estrogens]], [[Haemolytic disease of the newborn]], [[Ovarian hyperstimulation syndrome]], [[Pregnancy ]]
| align="center" style="background:#F5F5F5;" | -
| align="left" style="background:#F5F5F5;" |[[Dyspnea]], difficulty [[breathing]], raised erythematous [[skin]] [[rash]]<nowiki/>es, [[abdominal cramping]]
| align="center" style="background:#F5F5F5;" |&darr;
| align="center" style="background:#F5F5F5;" | +
| align="left" style="background:#F5F5F5;" |[[Wheeze|Bronchial wheezing]] on [[chest]] ascultation
| align="left" style="background:#F5F5F5;" |Elevated [[tryptase]] and plasma [[histamine]] levels
| align="left" style="background:#F5F5F5;" |NA
| align="left" style="background:#F5F5F5;" |NA
|-
|-
|-bgcolor="LightSteelBlue"
! style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Pregnancy]]
| '''Oncologic'''
| align="center" style="background:#F5F5F5;" |Chronic
|bgcolor="Beige"| [[Malignant ascites]]
| align="center" style="background:#F5F5F5;" | -
| align="left" style="background:#F5F5F5;" |[[Amenorrhea]], morning sickness, [[Fatigue (physical)|fatigue]], [[Breast|breast tenderness]], [[constipation]], [[back pain]]
| align="center" style="background:#F5F5F5;" |&darr;
| align="center" style="background:#F5F5F5;" | +
| align="left" style="background:#F5F5F5;" |Fundal height of the [[fetus]], [[pallor]], [[melasma]]
| align="left" style="background:#F5F5F5;" |[[Urine]] [[Pregnancy|pregnanc]]<nowiki/>y test positive, increased serum beta [[Human chorionic gonadotropin|hcG]]
| align="left" style="background:#F5F5F5;" |[[Medical ultrasonography|USG]] [[Abdomen]] will show an intrauterine [[pregnancy]].
| align="left" style="background:#F5F5F5;" |Blood levels of [[Human chorionic gonadotropin|beta hcG]]
|-
|-
|-bgcolor="LightSteelBlue"
! style="background: #DCDCDC; padding: 5px; text-align: center;" |Medication-induced
| '''Opthalmologic'''
| align="center" style="background:#F5F5F5;" |Chronic
|bgcolor="Beige"| No underlying causes
| align="center" style="background:#F5F5F5;" | -
|-
| align="left" style="background:#F5F5F5;" |Temporal relation between [[medicine]] intake and appearance of symptoms
|-bgcolor="LightSteelBlue"
| align="center" style="background:#F5F5F5;" |N/ &darr;
| '''Overdose / Toxicity'''
| align="center" style="background:#F5F5F5;" | -
|bgcolor="Beige"| [[Water intoxication]]
| align="left" style="background:#F5F5F5;" |Specific to the medication
|-
| align="left" style="background:#F5F5F5;" |Resolution of symptoms after discontinuing medication
|-bgcolor="LightSteelBlue"
| align="left" style="background:#F5F5F5;" |NA
| '''Psychiatric'''
| align="left" style="background:#F5F5F5;" |NA
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Pulmonary'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Renal / Electrolyte'''
|bgcolor="Beige"| [[Nephrotic syndrome]]
|-
|-bgcolor="LightSteelBlue"
| '''Rheum / Immune / Allergy'''
|bgcolor="Beige"| [[Haemolytic disease of the newborn]], [[Autoimmune hepatitis]]
|-
|-bgcolor="LightSteelBlue"
| '''Sexual'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Trauma'''
|bgcolor="Beige"| [[Trauma]]
|-
|-bgcolor="LightSteelBlue"
| '''Urologic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Miscellaneous'''
|bgcolor="Beige"| No underlying causes
|-
|-
! style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Obstructive sleep apnea]]
| align="center" style="background:#F5F5F5;" |Chronic
| align="left" style="background:#F5F5F5;" |Due to obesity
| align="left" style="background:#F5F5F5;" |[[Snoring]], Frequent night-time awakening, daytime [[Somnolence|drowsiness]]
| align="center" style="background:#F5F5F5;" |&uarr;
| align="center" style="background:#F5F5F5;" | -
| align="left" style="background:#F5F5F5;" |High [[Body mass index|BMI]], increase [[neck]] size and waist circumference, enlarged [[tongue]], [[Hypertrophy (medical)|hypertrophy]] of [[tonsil]]<nowiki/>s, enlarged [[Palatine uvula|uvula]], [[Nasal polyp|nasal polyps]] and high arched [[palate]].
| align="left" style="background:#F5F5F5;" |[[Polysomnography]]
| align="left" style="background:#F5F5F5;" |NA
| align="left" style="background:#F5F5F5;" |[[Polysomnography]]
|}
|}
<br>
Abbreviations: CVP: Central venous pressure, BNP: Brain natriuretic peptide, LVEF: Left ventricular ejection fraction, ALP: Alkaline phosphatase, AST: Aspartate transferase, ALT: Alanine transferase, GGT: Gamma Glutamyl transferase, BUN: Blood urea nitrogen, N: Normal, TAG: Triglycerides, URTI: Upper respiratory tract infection, USG: Ultrasound, hcG: human chorionic gonadotropin, BMI: Body mass index, N/A: Not applicable.
<br>
==Treatment==
 
==Diagnosis==
'''CT images demonstrate diffuse anasarca'''
<gallery>
Image:
 
Anasarca-001.jpg
 
Image:
 
Anasarca 002.jpg
 
Image:
 
Anasarca-003.jpg
 
</gallery>
 
=='''Treatment'''==
 
The treatment of anasraca depends on the underlying cause. It involves the use of [[diuretic]]s in cases related to [[heart failure]] or kidney disease. The latter may require [[hemodialysis]] especially if there are signs or symptoms of [[uremia]]. In cases of severe [[burns]] resulting in [[hypoalbuminemia]] and [[capillary leak]], admission to a burn unit, volume and [[electrolyte]] replacement, and adequate nutrition is of paramount. Withdrawal of the offending drug is critical in drug-induced anasarca. The use of diuretics, [[paracentesis]], and adequate nutritional supplementation is needed in anasarca secondary to [[hepatic cirrhosis]]. Profound [[hypothyroidism]] requires thyroid hormone replacement. Protein [[malabsorption]] syndromes require the identification of the underlying disease process and adequate protein supplementation. 


[[Category:Signs and symptoms]]
*To check the management of edema [[Edema resident survival guide|click here]].
[[Category: Physical examination]]


{{WH}}
==References==
{{WS}}
{{Reflist|2}}

Latest revision as of 20:29, 14 September 2020

Anasarca
CT scan showing generalized edema of skin
ICD-10 R60.1
ICD-9 782.3

Anasarca Microchapters

Home

Patient Information

Overview

Classification

Causes

Differential Diagnosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Mydah Sajid, MD[2]

Synonyms and keywords: Generalized edema, generalized swelling, leucophlegmatia

Overview

Edema is characterized by the collection of excess fluid in the interstitial space. Anasarca is severe edema characterized by generalized swelling throughout the body. The main underlying cause of edema is an imbalance in the hemodynamic status of the capillaries resulting in excess filtration of fluid in the intercellular space due to increased hydrostatic pressure, increased permeability of the capillaries and decreased oncotic pressure. It exceeds the absorptive capacity of lymph vessels. It can be caused by systemic diseases including chronic heart failure, liver cirrhosis, hypersensitivity reaction, and chronic renal failure.

Classification

The edema is classified in different types depending upon the severity of fluid accumulation assessed clinically:[1]

Grade Visibility of edema Pitting over tibia Level of edema
0+ No Absent Cannot assess
1+ Yes Slight Cannot assess
2+ Yes Moderate Below knee
3+ Yes Moderate Above knee
4+ Yes Severe (cannot reach tibia) Above knee

Causes

Life-threatening Causes

Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated.

Common Causes

Common causes of anasarca may include the following:[2][3][4][5]

Differential Diagnosis

On the basis of onset of symptoms, ascities, and hypertension, anasarca must be differentiated from congestive heart failure, chronic kidney disease, liver cirrhosis, anaphylaxis, nephrotic syndrome, and protein-calorie malnutrition.[6][7][8][9][10][11][12][13][14][15][16][17]

Diseases Clinical manifestation Para-clinical findings Gold Standard
Onset Abdominal distention due to ascities Associated symptoms Blood pressure Tachycardia Physical examination findings Lab findings Imaging
Congestive Cardiac Failure Chronic + Dyspnea,Orthopnea, Proxysmal nocturnal dyspnea ↓ /↑ + Tachypnea, jugular venous distention, elevated CVP, S3, decreased breath sounds in lower lung fields, hepatojugular reflex Elevated BNP LVEF on echocardiography
Liver cirrhosis Chronic + Nausea,vomitting, jaundice, telangiactesia, palmar erythema, hematemsis, anorectal varicies ↓ - Jaundice, pallor, caput meducae, splenomegaly, inintially hepatomegaly, clubbing, Dupuytren's contracture Elevated ALP, AST, ALT, GGT, bilirubin, hypoalbuminemia, prolonged prothrombin time USG liver will show cirrhotic, irregular nodular liver with increased echogenicity. Liver biopsy
Chronic kidney disease Chronic + Anorexia, Nausea, bleeding, fatigue, weakness ↑ + Pallor, tachypnea, pericardial friction rub, crackles on chest ascultation, uremic fetor Elevated BUN,creatinine, decrease hemoglobin, acidosis, hyperkalemia, elevated TAG USG kidney will show atrophied kidney with cortical thinning and increased echogenecity. GFR
Protein losing nephropathy Chronic + Dyspnea, headache, irratibility, bacterial or viral infections, recent H/O of URTI ↑ /N +/- Hematuria in some patients, Facial malar rash in SLE patients. Hypoalbuminemia, 24 hour urine protein excretion>3.5g, Elevated TAG and cholesterol. USG kidney may show increased echogenecity. Renal biopsy
Protein Calorie malnutrition Chronic + Muscle wasting, stunted growth, swollen face, dry skin, brittle hair ↓ /N + Hepatomegaly, Scaling, hyperpigmentation and hypopigmentation of skin Hypoalbuminemia NA NA
Allergic reactions Acute - Dyspnea, difficulty breathing, raised erythematous skin rashes, abdominal cramping ↓ + Bronchial wheezing on chest ascultation Elevated tryptase and plasma histamine levels NA NA
Pregnancy Chronic - Amenorrhea, morning sickness, fatigue, breast tenderness, constipation, back pain ↓ + Fundal height of the fetus, pallor, melasma Urine pregnancy test positive, increased serum beta hcG USG Abdomen will show an intrauterine pregnancy. Blood levels of beta hcG
Medication-induced Chronic - Temporal relation between medicine intake and appearance of symptoms N/ ↓ - Specific to the medication Resolution of symptoms after discontinuing medication NA NA
Obstructive sleep apnea Chronic Due to obesity Snoring, Frequent night-time awakening, daytime drowsiness ↑ - High BMI, increase neck size and waist circumference, enlarged tongue, hypertrophy of tonsils, enlarged uvula, nasal polyps and high arched palate. Polysomnography NA Polysomnography

Abbreviations: CVP: Central venous pressure, BNP: Brain natriuretic peptide, LVEF: Left ventricular ejection fraction, ALP: Alkaline phosphatase, AST: Aspartate transferase, ALT: Alanine transferase, GGT: Gamma Glutamyl transferase, BUN: Blood urea nitrogen, N: Normal, TAG: Triglycerides, URTI: Upper respiratory tract infection, USG: Ultrasound, hcG: human chorionic gonadotropin, BMI: Body mass index, N/A: Not applicable.

Treatment

References

  1. ↑ Stoltz JF, Nicolas A (1978). "Study of amino groups of the human platelet membrane". Acta Haematol. 60 (5): 304–9. doi:10.1159/000207727. PMID 101016/j.cardfail.2013.06.276 Check |pmid= value (help).
  2. ↑ Trayes KP, Studdiford JS, Pickle S, Tully AS (2013). "Edema: diagnosis and management". Am Fam Physician. 88 (2): 102–10. PMID 23939641.
  3. ↑ O'Brien JG, Chennubhotla SA, Chennubhotla RV (2005). "Treatment of edema". Am Fam Physician. 71 (11): 2111–7. PMID 15952439.
  4. ↑ Cho S, Atwood JE (2002). "Peripheral edema". Am J Med. 113 (7): 580–6. doi:10.1016/s0002-9343(02)01322-0. PMID 12459405.
  5. ↑ Yale SH, Mazza JJ (2001). "Approach to diagnosing lower extremity edema". Compr Ther. 27 (3): 242–52. doi:10.1007/s12019-001-0021-5. PMID 11569326.
  6. ↑ "StatPearls". 2020. PMID 29939653.
  7. ↑ Yap FY, Skalski MR, Patel DB, Schein AJ, White EA, Tomasian A; et al. (2017). "Hypertrophic Osteoarthropathy: Clinical and Imaging Features". Radiographics. 37 (1): 157–195. doi:10.1148/rg.2017160052. PMID 27935768.
  8. ↑ Auld T, Werntz JR (2017). "Dupuytren's disease: How to recognize its early signs". J Fam Pract. 66 (3): E5–E10. PMID 28505213.
  9. ↑ Carmelli D, Swan GE, Bliwise DL (2000). "Relationship of 30-year changes in obesity to sleep-disordered breathing in the Western Collaborative Group Study". Obes Res. 8 (9): 632–7. doi:10.1038/oby.2000.81. PMID 11225711.
  10. ↑ Inamdar AA, Inamdar AC (2016). "Heart Failure: Diagnosis, Management and Utilization". J Clin Med. 5 (7). doi:10.3390/jcm5070062. PMC 4961993. PMID 27367736.
  11. ↑ Levey AS, Inker LA (2016). "GFR as the "Gold Standard": Estimated, Measured, and True". Am J Kidney Dis. 67 (1): 9–12. doi:10.1053/j.ajkd.2015.09.014. PMID 26708193.
  12. ↑ Hansen KL, Nielsen MB, Ewertsen C (2015). "Ultrasonography of the Kidney: A Pictorial Review". Diagnostics (Basel). 6 (1). doi:10.3390/diagnostics6010002. PMC 4808817. PMID 26838799.
  13. ↑ Vadas P, Perelman B, Liss G (2013). "Platelet-activating factor, histamine, and tryptase levels in human anaphylaxis". J Allergy Clin Immunol. 131 (1): 144–9. doi:10.1016/j.jaci.2012.08.016. PMID 23040367.
  14. ↑ Epstein LJ, Kristo D, Strollo PJ, Friedman N, Malhotra A, Patil SP; et al. (2009). "Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults". J Clin Sleep Med. 5 (3): 263–76. PMC 2699173. PMID 19960649.
  15. ↑ Sheth SG, Flamm SL, Gordon FD, Chopra S (1998). "AST/ALT ratio predicts cirrhosis in patients with chronic hepatitis C virus infection". Am J Gastroenterol. 93 (1): 44–8. doi:10.1111/j.1572-0241.1998.044_c.x. PMID 9448172.
  16. ↑ Krzeski P, Zych W, Kraszewska E, Milewski B, Butruk E, Habior A (1999). "Is serum bilirubin concentration the only valid prognostic marker in primary biliary cirrhosis?". Hepatology. 30 (4): 865–9. doi:10.1002/hep.510300415. PMID 10498635.
  17. ↑ Schwartz LB (2006). "Diagnostic value of tryptase in anaphylaxis and mastocytosis". Immunol Allergy Clin North Am. 26 (3): 451–63. doi:10.1016/j.iac.2006.05.010. PMID 16931288.
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