Edema And Ascites

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Edema is a common symptom or finding in patients with right- or left-sided heart failure. Fluid retention in heart failure results from increased venous pressure and abnormal activity of salt-retaining hormones (see Chap. 20). In an average-sized person, 5 to 10 lb of excess fluid is required for edema to become apparent; a history of recent weight gain often will correlate with a deterioration in clinical status. The amount of weight loss in response to treatment for heart failure in the past will relate to the severity of the problem. Minor degrees of edema are evident only after a period of dependency of the legs and will decrease after rest. Presacral edema may be most obvious when the patient has been at bed rest. Although edema of cardiac origin may progress to anasarca, cardiac edema rarely involves the face or upper extremities. Edema mainly affecting the face and arms is more likely to be due to venous or lymphatic obstruction by clot or neoplasm. Facial edema is a feature of the nephrotic syndrome, angioneurotic edema, and glomerulonephritis. Swelling or "puffiness" of the hands and fingers is not usually a symptom of cardiac disease. Persistent edema in the legs from which veins were harvested at the time of bypass surgery is common. Other causes of edema-such as varicosities, obesity, tight girdle, renal insufficiency, or cirrhosis with hypoproteinemia-must be considered.1 A patient with chronic congestive heart failure may detect edema of the ankles and lower legs during the day and note that it diminishes during the night. It is important to ascertain whether edema of the extremities preceded or followed dyspnea on effort. The calcium antagonists may produce bilateral edema of the lower legs. Edema may occur in one or both legs following the harvesting of veins for conduits in patients undergoing coronary artery bypass graft (CABG) surgery.

Patients will be aware of ascites because of increased abdominal girth. Previously comfortable trousers or skirts may no longer fit. Bending at the waist is uncomfortable, with ill-defined abdominal fullness. Patients with severe edema due to congestive heart failure may develop ascites; however, ascites is particularly common in patients with constrictive pericardial disease, sometimes occurring before peripheral edema becomes obvious (see Chap. 72). Ascitic fluid is formed when elevated venous pressure leads to transudation of fluids from the serosal surfaces. Other causes of ascites-such as cirrhosis, nephrosis, and tumor-must be excluded.

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