Page 25 - Clinical Pearls in Cardiology

History and General Examination 13

19. What are the important causes of generalized edema
or anasarca?
Hypoproteinemia (by decreasing capillary colloid oncotic
pressure) and fluid overload (by increasing capillary
filtration pressure) are the two important factors leading
onto generalized edema:

Causes of hypoproteinemia
• Inadequate protein intake or absorption (e.g. Starvation,
chronic pancreatitis)
• Inadequate protein production (e.g. Chronic liver disease)
• Excess protein loss (e.g. Nephrotic syndrome, protein-losing
enteropathy)
Causes of fluid overload
• Heart failure/renal failure/hepatic failure
• Iatrogenic (e.g. excessive IV fluid replacement)

20. How will you clinically distinguish generalized edema
due to fluid overload from that due to hypoproteinemia?
These two causes may be distinguished by examining
the jugular venous pulse (JVP). The jugular venous
pressure is usually elevated in fluid overload states
but not in hypoproteinemia. Another method is by
noting the time taken for the pitting behind the medial
malleolus to disappear after applying firm pressure.
Fluid overload states usually produce “slow” edema
(i.e the pitting formed on applying firm pressure takes
more than 1 minute to disappear after removing the
pressure). Hypoproteinemic states usually produce “fast”
edema (i.e the pitting disappears within 40 seconds after
removing the pressure).