Patient information: Edema (swelling)

EDEMA OVERVIEW

Edema is the medical term for swelling caused by a collection of fluid in the small spaces that surround the body tissues and organs. Edema can occur nearly anywhere in the body. Some of the most common sites are:

• The lower legs or hands (also called peripheral edema)
• Abdomen (also called ascites)
• Chest (called pulmonary edema if in the lungs and pleural effusion if in the space surrounding the lungs)

Ascites and peripheral edema can be uncomfortable, and can be a sign of a more serious condition. Pulmonary edema, which can be life-threatening, is a symptom of heart failure and is discussed in more detail separately. (See "Patient information: Heart failure causes, symptoms, and diagnosis".)

EDEMA SYMPTOMS

Symptoms of edema depend upon the cause, but may include:

• Swelling or puffiness of the skin, causing it to appear stretched and shiny. This is typically seen in the lower legs (called peripheral edema) or lower back (called sacral edema, frequently seen in those with edema who have been in bed for long periods).

Swelling is often worst after sitting or standing for a period of time (due to gravity), and may be worse at the end of the day. Pushing on the swollen area for a few seconds will leave a dimple in the skin (picture 1).

• Increased size of the abdomen (with ascites)
• Shortness of breath (with edema in the chest)

CONDITIONS ASSOCIATED WITH EDEMA

A number of different problems can cause edema.

Chronic venous disease — A common cause of edema in the lower legs is chronic venous disease, a condition in which the veins in the legs cannot pump enough blood back up to the heart because the valves in the veins are damaged. This can lead to fluid collecting in the lower legs, thinning of the skin, and in some cases, development of skin sores (ulcers) (picture 2). (See "Patient information: Chronic venous disease".)

Edema can also develop as a result of a blood clot in the deep veins of the lower leg (called deep vein thrombosis). In this case, the edema is usually limited to the feet or ankles and may affect only one side (the left or right); other conditions that cause edema usually cause swelling of both legs. (See "Patient information: Deep vein thrombosis (DVT)".)

Pregnancy — Pregnant women retain extra fluid. Swelling commonly develops in the hands, feet, and face, especially near the end of pregnancy. Swelling during pregnancy is not necessarily a sign of preeclampsia (sometimes called toxemia). (See "Patient information: Preeclampsia".)

Monthly menstrual periods — Edema is women that occurs in a cyclic pattern (usually once per month) can develop as a result of hormonal changes related to the menstrual cycle. This type of edema is common, but does not require treatment because it resolves on its own.

Drugs — Edema can be a side effect of a variety of medications, including some oral diabetes medications, high blood pressure medications, non-prescription pain relievers (such as ibuprofen), and estrogens.

Kidney disease — The edema of kidney disease can cause swelling in the lower legs and around the eyes. (See "Patient information: Chronic kidney disease".)

Heart failure — In heart failure, also called congestive heart failure, the heart is weakened and its pumping action is impaired. Heart failure can cause swelling to develop in the legs and abdomen, as well as other symptoms. Heart failure can also cause fluid to accumulate in the lungs (pulmonary edema), causing shortness of breath. (See "Patient information: Heart failure causes, symptoms, and diagnosis".)

Cirrhosis — Cirrhosis is scarring of the liver from various causes, which can obstruct blood flow through the liver. People with cirrhosis can develop pronounced swelling in the abdomen (ascites) or in the lower legs (peripheral edema). (See "Patient information: Cirrhosis".)

Travel — Sitting for prolonged periods, such as during air travel, can cause swelling in the lower legs. This is common and is not usually a sign of a problem. Table 1 provides tips to minimize leg swelling during travel (table 1).

If your leg(s) remain swollen or you develop pain hours or days after the flight, contact your healthcare provider. Continued swelling and pain can be signs of a blood clot (deep vein thrombosis or DVT). (See "Patient information: Deep vein thrombosis (DVT)".)

DIAGNOSING THE CAUSE OF EDEMA

If you develop new swelling in one or both of your legs, hands, in your abdomen, or around your eyes, you should be call your healthcare provider to determine if you need to be evaluated. (See "Clinical manifestations and diagnosis of edema in adults".)

EDEMA TREATMENT

Treatment of edema includes several components: treatment of the underlying cause (if possible), reducing the amount of salt (sodium) in your diet, and in many cases, use of a medication, called a diuretic, to eliminate excess fluid. Compression stocking and elevating the legs may also be recommended. (See "General principles of the treatment of edema in adults".)

Not all types of edema require treatment. Edema related to pregnancy or menstrual cycles is not usually treated. Peripheral edema and ascites is usually treated slowly to minimize the side effects of rapid fluid loss (such as low blood pressure).

Reduce salt (sodium) in your diet — Sodium, which is found in table salt, can worsen edema. Reducing the amount of salt you consume can help to reduce edema, especially if you also take a diuretic. Guidelines on how to reduce sodium are available separately. (See "Patient information: Low sodium diet".)

Diuretics — Diuretics are a type of medication that causes the kidneys to excrete more water and sodium, which can reduce edema. Diuretics must be used with care because removing to much fluid too quickly can lower the blood pressure and impair kidney function.

You may have to empty your bladder more frequently for several hours after taking a loop diuretic. However, other side effects are uncommon when diuretics are taken at the recommended dose.

Compression stockings — Leg edema can be prevented and treated with the use of compression stockings. Stockings are available in several heights, including knee-high, thigh-high, and pantyhose. Knee-high stockings are sufficient for most patients. Some stockings can cause skin irritation or pain, although proper measurement and fitting of the stockings can reduce the risk of discomfort. More detailed compression stocking tips are available in table 2 (table 2 and figure 1 and figure 2 and figure 3).

Effective compression stockings apply the greatest amount of pressure at the ankle and gradually decrease the pressure up the leg. These stockings are available with varying degrees of compression.

• Stockings with small amounts of compression can be purchased at pharmacies and surgical supply stores without a prescription.
• People with moderate to severe edema, those on their feet a lot, and those with ulcers usually require prescription stockings. A healthcare provider may take measurements for stockings, or may write a prescription for stockings and then have a surgical supply or specialty store take the necessary measurements.
• The white "antiembolism" stockings commonly given in the hospital do not apply enough pressure at the ankle and are not adequate treatment for edema.

Body positioning — Leg, ankle, and foot edema can be improved by elevating the legs above heart level for 30 minutes three or four times per day. Elevating the legs may be sufficient to reduce or eliminate edema for people with mild venous disease, but does not usually help in more severe cases. In addition, it may not be practical for those who work to elevate their legs several times per day.

WHERE TO GET MORE INFORMATION

Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two people are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.

This discussion will be updated as needed every four months on our web site (www.uptodate.com/patients). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.

Some of the most pertinent include:

Patient Level Information:
Patient information: Cirrhosis
Patient information: Heart failure causes, symptoms, and diagnosis
Patient information: Heart failure treatments
Patient information: Premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD)
Patient information: Chronic venous disease
Patient information: Deep vein thrombosis (DVT)
Patient information: Preeclampsia
Patient information: Chronic kidney disease
Patient information: Low sodium diet

Professional Level Information:
Clinical manifestations and diagnosis of edema in adults
Idiopathic edema
Lymphedema: Etiology, clinical manifestations, and diagnosis
Lymphedema: Prevention and treatment
Mechanism and treatment of edema in nephrotic syndrome
Mechanism of action of diuretics
Neurogenic pulmonary edema
Overview of heavy proteinuria and the nephrotic syndrome
Pathophysiology and etiology of edema in adults
Treatment of refractory edema
General principles of the treatment of edema in adults
Patient information: Heart failure treatments
Patient information: Premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD)

A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable.

• National Library of Medicine

      (www.nlm.nih.gov/medlineplus/edema.html, available in Spanish)

• National Institute of Diabetes and Digestive and Kidney Diseases

      (www.niddk.nih.gov)

• National Kidney Foundation

      (www.kidney.org)