DEFINITION — Edema means swelling in the small spaces that surround the body

tissues and organs. Edema can occur nearly anywhere in the body. The location of
the edema will depend, in part, on the underlying cause. Some of the most common
sites are:

• Lungs (also called pulmonary edema)

• Abdomen (also called ascites)
• Extremities such as the lower legs (also called peripheral edema)

Pulmonary edema can be life-threatening. In comparison, ascites and peripheral

edema can produce some discomfort and cosmetic concerns, but are generally not
serious although the underlying cause of edema may be.

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 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 worst at the end of the day. Pushing on the
swollen area for a few seconds will leave a dimple in the skin.

• Increased size of the abdomen (with ascites)

• Shortness of breath or difficulty breathing (with pulmonary edema)

CAUSES — In most cases, the process of edema formation begins when fluid leaks
from the body's smallest blood vessels, called capillaries, into the surrounding
tissues. The leakage can occur because of changes in pressure in the capillaries,
weakening of the capillary wall from disease, or other factors.

Usually, the leakage itself is not enough to cause noticeable edema. However, when
the body senses that fluid is being lost from the capillaries, it signals the kidneys to
hold on to sodium and water. This results in an increase in the volume of fluid
circulating in the blood vessels, which, in turn, leads to additional leakage of fluid
from the capillaries. It is typically at this point that edema can be seen.

CONDITIONS ASSOCIATED WITH EDEMA — A number of different problems can

cause edema. Some of the most common are unrelated to any specific disease. For
example, damage to the veins in the legs (venous insufficiency) can cause abnormal
pooling or clotting of blood in these vessels, leading to edema. Pregnancy, drug
effects, and problems with drainage in the lymphatic system can also cause
peripheral edema. Diseases commonly associated with edema include kidney
disease, heart failure, and cirrhosis of the liver.

Venous insufficiency — A common cause of peripheral edema in clinical practice is

venous insufficiency, one cause of which is a syndrome that may occur after an
episode of venous blood clots (called deep vein thrombosis). In this case, the edema
is usually limited to the lower extremities (feet or ankles) and may affect only one
side (the left or right); other conditions that cause edema usually cause swelling of
both extremities.

Pregnancy — Pregnant women retain a significant amount of sodium and water.

Some of this excess fluid is required by the fetus and placenta. Edema of the hands,
feet, and face is commonly seen.

Premenstrual syndrome — Edema that appears in a cyclic pattern (usually once

per month) may occur due to premenstrual syndrome (PMS). Diuretics are of no
benefit for edema related to PMS. (See "Patient information: Premenstrual syndrome
(PMS) and premenstrual dysphoric disorder (PMDD)").

Drugs — Edema can be a side effect of a wide variety of medications.

Kidney disease — The edema of kidney disease causes swelling in the legs and
around the eyes. It is caused by an increase in pressure in the blood vessels; this
occurs when the kidneys excrete an insufficient amount of sodium and fluid. The
extra fluid increases pressure on the blood vessel walls, which allows fluids to move
from inside the blood vessel to the space around the vessel. Low levels of protein
(albumin) in the blood may also contribute to the movement of fluid from the
capillaries.

Heart failure — In heart failure, also called congestive heart failure, the heart is
weakened and its pumping action is impaired. It can affect the right heart chambers,
which receive blood from the body and pump it to the lungs to be filled with oxygen;
or it can affect the left heart chambers, which pump oxygenated blood to the rest of
the body. (See "Patient information: Heart failure causes, symptoms, and
diagnosis").

Heart failure develops as a result of other conditions that damage the heart. These
include heart attacks due to coronary heart disease, diseases of the heart valves,
and hypertension (high blood pressure).
In right heart failure, pressure builds in the right chambers because they fail to pump
blood efficiently. The pressure is reflected back to the blood vessels in the body that
lead to the right chambers, frequently causing peripheral edema and, sometimes,
ascites. The patient therefore notices swelling in the legs and abdomen, as well as
other symptoms.

In left heart failure, pressure builds in the left chambers because they are failing to
pump blood efficiently. The increased pressure affects the large blood vessels that
connect the left side of the heart with the lungs. This causes edema in the lungs, or
pulmonary edema, causing shortness of breath.

Cirrhosis — With cirrhosis, congestion in the liver leads to an increase in pressure

within the blood vessels in the liver and subsequently, in the blood vessels leading
into the liver, causing ascites. The patient may have pronounced swelling in the
abdomen, as well as edema in the feet or, if the patient is lying down most of the
day, swelling in the lower back (also called sacral edema). (See "Patient information:
Cirrhosis").

DIAGNOSING THE CAUSE — A healthcare provider may use a number of different

tools to determine the most likely cause for edema. For example, close examination
of the legs and veins in the neck provide valuable clues. By listening to the lungs
through a stethoscope or viewing the lungs on x-ray, providers can detect the
presence of fluid, which indicates pulmonary edema. Blood and urine tests give
information about possible kidney or liver disease.

TREATMENT — Treatment of edema is directed at the underlying cause; this may be

done by removing the excess fluid with diuretics, elevating the legs, or using
compression stockings.

Pulmonary edema is life-threatening and requires immediate treatment. Fluid in the

lungs interferes with the transfer of oxygen from the lungs to the bloodstream.
Pulmonary edema is treated according to its cause, and commonly requires
supplemental oxygen, mechanical ventilation (a respirator forces air into the lungs),
and several medications.

Other forms of edema can be treated more slowly since they are of less danger to
the patient. Slow removal is recommended for patients with cirrhosis (liver disease)
since rapidly changing fluid levels can cause serious illness.

Diuretics — Diuretics cause the kidneys to increase their excretion of water and
sodium, reducing fluid volume throughout the body. Diuretics must be used carefully
as fluid removal decreases the blood volume. In some patients, this can result in a
decrease in blood pressure.

There are several types of diuretics, and not all types are used to treat edema; the
two primary types used for edema are loop diuretics (eg, furosemide (Lasix®) and
potassium sparing diuretics (spironolactone)).

Although diuretics are beneficial in many types of edema, they are not appropriate in
every case. In particular, diuretics are generally not recommended for venous
insufficiency or for edema caused by pregnancy, where fluid retention is generally
normal.

Side effects — Side effects of loop and potassium sparing diuretics are uncommon
when taken at the recommended doses. Many patients must empty their bladder
more frequently for several hours after taking their diuretic. Although some
symptoms may result from the loss of sodium and potassium, most patients tolerate
diuretics very well.

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. Leg elevation alone
may be sufficient therapy for patients with mild venous insufficiency, but is usually
not adequate for more severe cases. In addition, it may not be practical for those
who work to elevate their legs several times per day.

Compression stockings — Leg edema can also be prevented and treated with the
use of compression stockings. Many types are available, including knee-high, thigh-
high, and pantyhose. Knee-high stockings are sufficient for most patients; thigh-high
stockings are less desirable because they tend to provide too much pressure behind
the knees, reducing blood flow in the veins and causing discomfort.

Compression stockings that have varying degrees of pressure are best; the greatest
pressure is applied at the ankle. The pressure should gradually decrease up to the
knee. The white "antiembolism" stockings commonly given to patients in the hospital
do not apply enough pressure at the ankle and are not adequate treatment for
venous insufficiency.

Proper measurement and fitting of the stockings are important for the patient's
comfort and safety. The following tips may also be helpful:

• Washing new compression stockings before wearing will reduce some of the
initial stiffness and difficulty in putting them on.
• The stockings should be put on as early as possible in the morning when
edema is minimal.

• Patients should lean against a firm back support (not on the bed) while
putting on the stockings.

• Knee-high stockings can be put on by turning the leg portion of the stocking
inside-out down to the heel. With the stocking stretched, the foot is slipped in
while pulling the stocking firmly onto the foot by its folded edge. As the
stocking is pulled on by the edge, it will turn right-side out and can be gently
worked up the leg. Some manufacturers recommend wearing rubber gloves to
slide the stocking up the leg rather than grasping and pulling the edge of the
stocking.

• Heavy compression stockings may go on more easily if a light silk hose is

worn under the compression garment, or if talcum powder is first applied to
the foot and leg. Some patients do not have the strength or mobility to pull
on compression stockings. Stockings are now available with a zippered back
or velcro attachment.