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Generalized Anasarca
1. 1. Fatma Ghoneim 768
2. Fatma Lotfy 769
3. Fatma Mahmoud 770
4. Fatma Al-zahraa Ahmed 772
Cairo University
Faculty of medicine
Internal Medicine Department
November 2016
2.
Anasarca is the gross and
generalized edema of the body
tissues with profound
subcutaneous swelling due to
accumulation of excess fluid in
the body tissue.
Anasarca is not a disease itself
but it is a symptom of an
underlying condition
What is anasarca ?
3.
Abnormal leak of
plasma fluid to
interstitial space
Increased
hydrostatic pressure
Reduced plasma
osmotic pressure
Sodium Retention
Pathophysiology
4. Main causes
•Liver
•Heart
•Kidney
•Nutritional
•Allergic
Others
•Eclampsia or Pre-eclampsia
•Hookworm
•Burns and sunburns
•Albumin deficiency
•Side effects of certain medications
•Hypothyroidism
•POEMS syndrome
•Idiopathic edema
•Systemic amyloidosis (abnormal
protein buildup in the organs)
•Systemic capillary leak syndrome
(also known as Clarkson
syndrome)
Causes
6.
Alcoholic liver disease.
Chronic hepatitis B or
C.
Autoimmune hepatitis.
Non alcoholic
steatohepatitis.
Causes
7.
Pathogenesis
•low protien production
low osmotic pressure
and fluid leak to the
interstitium
•Compression on the
portal vessels increase
hydrostatic pressure in
veins of abdominal
organs ascitis
compresses the inferior
vena cava lower limb
edema.
10.
Congestive heart failure.
Right heart failure.
The most common and most serious causes of anasarca .
Other causes include :
Constrictive pericarditis.
Venous obstructions.
Causes
12.
Edema:
Begins in the most dependent part ( feet and ankle)
Bilateral pitting
Progresses till it becomes generalised
Features of cardiac disease:
Ex in heart failure
Pulmonary edema
Clinical Picture
16.
Most important causes :
Nephrotic syndrome.
Renal failure.
Causes
17.
1. Reduced colloid osmotic pressure : loss of
protein in urine.
2. Salt and water retention in acute or chronic
renal failure, edema occurs if Na intake exceeds
kidney’s ability to excrete Na secondary to
marked reductions in glomerular filtration.
Pathogenesis
18.
Edema in nephrotic begins in
loose tissues around the eyes
causing puffiness in the eye
lids.
Gradually progresses to
anasarca when the plasma
protien level falls below 2.5
gm/100ml.
Clinical Picture
22.
Kwashiorkor is a severe form
of malnutrition, caused by a
deficiency in dietary protein.
The extreme lack of protein
causes an osmotic imbalance
in the gastro-intestinal system
causing swelling of the gut
diagnosed as an edema or
retention of water.
Causes
23.
blood protein falls to
abnormally low levels, water
leaks from your circulation
into your tissues, causing
swelling. With kwashiorkor,
the levels of sodium and
potassium in your
bloodstream become
unbalanced, further
contributing to tissue
swelling.
Pathogenesis
27.
Release of
inflammatory
mediators and
cytokines from mast
cells and basophils,
typically due to an
immunologic reaction.
But sometimes non-
immunologic
mechanism.
Pathogenesis
30.
History
General examination
Local examination
Diagnosis
Age
Complaint
Associated symptoms Similar condition
Chronic disease
Drug intake
Analysis of edema
32.
Liver
• Laboratory tests:
• Liver function.
• Kidney
function.
• Tests for
hepatitis B and
C.
• Clotting (INR) .
• Imaging;
• US
• MRE
• Other imaging
tests. MRI, CT.
• Biopsy.
Heart
•ECG
•Cardiac
enzymes
•Chest Xray
•Echo
Kidney
•Renal function
tests
•Urine analysis
•Blood
investigations:
• CBC
• Lipid profile
• Serum albumin
• Electrolytes
•Renal imaging
•Renal biopsy
33.
Plasma proteins:
low total proteins
low serum albumin
Glucose : hypoglycemia
Electrolytes:
low K
Low Na (dilutional hyponatremia) but increased total body
Na
low Mg
CBC: anemia, leukocytosis
Nutritional
36.
Liver Cirrhosis
Ascites :
•A low-sodium diet.
•Diuretics and antibiotics.
•Paracentesis.
•Transjugular intrahepatic portosystemic shunt.
Variceal bleeding :
•Beta-blocker and vasoconstrictor.
•Endoscopic variceal banding or sclerotherapy.
•Balloon tamponade.
Encephalopathy :
•Limited amount of protein in diet.
•Lactulose.
•Avoid sedative medicines, such as sleeping pills, antianxiety
medicines, and narcotics.
37.
Lifestyle changes:
• Stop drinking alcohol.
• Drugs such
as acetaminophen, aspirin, ibuprofen and naproxen could
increase the risk of liver damage and bleeding.
• Immunization against hepatitis a and b.
• Low-sodium diet.
Follow-up visits:
• Regular checkups and lab tests.
• Periodic screening for varices and hepatocellular carcinoma.
Liver transplant:
• The only treatment that will restore normal liver function and
cure portal hypertension.
• Liver transplant is usually considered only when liver damage
is severe and threatening.
38.
Dietary Na restriction.
Bed rest enhances response to salt restriction.
Supportive stockings and elevation of edematous
lower extremities.
If severe hyponatremia is present, water intake
should also be reduced.
Diuretics are indicated for:
Marked peripheral edema.
Pulmonary edema.
CHF.
Inadequate dietary salt restriction.
Heart Failure
40.
Treatment of the cause.
Diet:
Sodium restriction
Protein restriction or heavy protein meals according to
the condition .
Water balance.
Choice of diuretics according to the condition.
Treatment of complications.
Dialysis.
Renal
43.
Hospitalization & management of complications:
-Shock & dehydration IV fluids
-Anemia blood or packed RBCs
-Hypothermia adequate clothing or radiant warmer
-Infection antibiotics
Nutritional management:
-Diet:
Milk ,animal protein, plant protein.
-Method:
Nasogastric tube, parenteral feeding.
Supportive:
Vit . A single dose (50000 IU < 6m - 100000 6m- 1y - 200000
>1y)
Vit. B, C, D, E - Folic acid, Iron.
Treatment of the cause: parasitic infestation if present.
Nutritional
44.
Resuscitation measures and close monitoring.
Administration of epinephrine is the treatment of
choice with antihistamines and steroids.
A period of in-hospital observation.
"Allergy action plan"
Use of epinephrine autoinjectors.
To wear a medical alert bracelet.
Avoidance of triggers.
Immunotherapy is available for certain triggers to
prevent future episodes of anaphylaxis.
Anaphylaxis
46. Rodríguez-Iturbe B, Herrera-Acosta J, Johnson RJ. Interstitial
inflammation, sodium retention, and the pathogenesis of
nephrotic edema: A unifying hypothesis. Kidney Int.
2002;62(4):1379–84.
Sabbadini DD, Peressutti R, Di Silvestre a., Lucchese F,
Margarit O, Macor D, et al. Systemic capillary leak syndrome:
Case report. Minerva Anestesiol. 2002;68(12):929–36.
Oczkowski SJ, Mazzetti I, Meade MO, Hamielec C. Furosemide
and albumin for diuresis of edema (FADE): a study protocol for
a randomized controlled trial. Trials [Internet]. 2014;15(1):222.
Hirosaki Y, Hayashidani S, Ouchi S, Ohshima T, Nakano R,
Yamamoto H. A fatal case of acute progression of generalized
edema and simultaneous flash pulmonary edema in a patient
with idiopathic systemic capillary leak syndrome: a case report.
J Med Case Rep [Internet]. 2015;9:90.
References
47.
C K. Nephrotic syndrome in adults : diagnosis and
management. Am Acad Fam physicians.
2009;80(10):1129–34, 1136.
Coulthard MG. Oedema in kwashiorkor is caused by
hypoalbuminaemia. Paediatr Int Child Health
[Internet]. 2015;35(2):83–9.
Robbins and Kotran 7/e pg 120- 121
Ganong 22/e pg 1
Guyton 11/e pg 303
O.P.Ghai 7/e pg 450, pg 67
Willson’s
www.webmd.com/heart-disease/heart-failure/edema-
overview
