APPROACH TO A CASE OF ANASARCA Presented By Prof. Arvind Mishra Department of Medicine

Anasarca Defined as gross generalised edema Edema is defined as a clinically apparent increase in the interstitial fluid volume, which may expand by several liters before the abnormality is evident

Causes of anasarca Cardiac -cardiac failure, -pericardial effusion, -constrictive pericarditis Renal -chronic renal failure -nephrotic syndrome Hepatic- cirrhosis

Malnutrition/malabsorption(i.e. celiac disease,crohn’s disease etc) Drug-induced Thyroid disorder

Clinical feature Puffiness of face Pedal edema(pitting/non-pitting) Abdominal wall edema(by pressing with palm) Sacral edema

STARLING FORCES IN SHIFTING THE FLUID IN DIFFERENT COMPARTMENTS The hydrostatic pressure within the vascular system and the colloid oncotic pressure in the interstitial fluid tend to promote movement of fluid from the vascular to the extravascular space. By contrast, the colloid oncotic pressure contributed by plasma proteins and the hydrostatic pressure within the interstitial fluid promote the movement of fluid into the vascular compartment.

Mechanism of anasarca Decreased plasma oncotic pressure Lymphatic obstruction Increased capillary permeability Increased hydrostatic pressure

Drugs causing edema

HYPOTHYROIDISM

INVESTIGATIONS Serum protein & albumin Urine analysis -protein, sugar -cast Kidney function test -s.urea -s.creatinine

Liver function test -SGOT/SGPT -ALP -S.bilirubin Fecal fat estimation -to rule out malabsorption Thyroid function test ECG and echocardiography -LVEF -Valvular lesion -Regional wall motion abnormality

Treatment Treatment of the underlying cause(cardiac, renal, hepatic, thyroid abnormality) Stop and replace the drug causing edema Diuretics Restricting salt and fluid intake and monitoring input-output Protein rich diet (in hypoalbuminemic state)

MCQs

1)Causes of non pitting edema are all except a)Myxoedema b)Filariasis c)Angioneurotic edema d)Nephrotic syndrome

2)Pattern of edema(Legs ->face ->ascitis) in the given manner occurs in a)Cirrhosis b)Cardiac failure c)Nephrotic syndrome e)Nutritional edema

3)Drugs causing edema are all except a)Cilnidipine b)Hydralazine c)Amlodipine d)Clonidine

4)Milroy’s disease refers to a)Absence of thymus b)Congenital hypoplasia of lymphatics c)Post mastectomy lymphedema of upper limb d)Chylous pleural effusion

5)Angioneurotic edema is due to deficiency of a)C1 esterase inhibitor deficiency b) C5 convertase (C3bBbC3b) c)C1 esterase deficiency d) Factor H–related protein 1 (CFHR1)