Anasarka: what is it, causes, symptoms, treatment, prognosis

What is anasarka?

AnasarkaIs total edema. Edema is defined as a palpable swelling on the body caused by an increase in the volume of intercellular fluid. This accumulation of fluid in the interstitial space occurs when capillary filtration exceeds the amount of fluid being removed by lymphatic drainage. When the edema is massive and generalized, it is called anasarca. Anasarca is caused by a variety of clinical conditions such as heart failure, renal failure, liver failure or problems with the lymphatic system. Clinically, edema usually occurs when the volume of the interstitial space exceeds 2.5–3 liters.

Sign and symptoms

In most cases, swelling affects 1 or 2 areas of the body (for example, one or both of the lower limbs). Anasarca affects the entire body and is more severe than normal edema. With anasarka, the entire body of a person - from head to toe - will look very swollen.

Anasarka symptoms include:

• skin that will appear dimpled after pressing on it with your finger for a few seconds;
• high or low blood pressure;
• slow or fast heart rate;
• organ failure, especially liver and kidney.

Anasarka can be debilitating. The disorder can render the patient immobile, since the tumor makes it almost impossible to walk or move the limbs. Swelling on the face can also impair vision by making it difficult to open your eyes.

In some cases, anasarca may require emergency care. If the above symptoms are observed, and dyspnea, shortness of breath, or chest pain, seek emergency help immediately. These may be signs of pulmonary edema, i.e. congestion fluid in the lungs. The condition can quickly become life-threatening.

Causes and risk factors

The most common causes of anasarca seen by a doctor are heart failure, cirrhosis of the liver, renal failure and pregnancy. Other causes of anasarca are venous obstruction, burns, trauma, malignant neoplasms, etc.

Epidemiology

The epidemiology of the anasarka has not yet been studied, but this is one of the frequent complaints of patients admitted to the hospital. Anasarca is often seen in patients with organ dysfunction, especially with multiple organ failure.

Pathophysiology

Edema develops as a reaction to an increase in hydrostatic pressure in the capillaries, an increase in capillary permeability, a decrease in plasma oncotic pressure, or a combination of these changes. Edema can also be secondary to lymphatic obstruction, resulting in fluid retention in the intercellular space. Below are the clinical conditions for the various mechanisms described.

• Increasing the hydrostatic pressure of the capillaries:
  • Heart failure, kidney disease, early cirrhosis of the liver, pregnancy, medications.
  • Venous obstruction or insufficiency conditions such as deep vein thrombosis, venous stasis in the liver.
• Increased capillary permeability:
  • Burns, injuries, sepsis, allergic reactions, malignant ascites.
• Lymphatic obstruction:
  • Malignant neoplasms, lymph node dissection after the lymph node.
• Hypoalbuminemia:
  • Nephrotic syndrome, liver disease, improper nutrition.

In the first stage, when fluid moves from the vascular space to the interstitium, it reduces the plasma volume. This reduces tissue perfusion. Poor tissue perfusion causes sodium and water retention by the kidneys. Some of the excess fluid generated will be retained in the intravascular compartment. However, a change in capillary hemodynamics leads to the fact that most of the retained fluid enters the interstitium and, ultimately, manifests itself in the form of edema.

Diagnostics

The history should include the timing of edema and changes in position, unilateral or bilateral, as well as a history of medication and assessment of systemic disease.

A physical examination can help make a diagnosis. The examination should be aimed at determining the nature of the edema - peripheral edema versus pulmonary edema, pinpoint edema versus non-jugular edema, and the presence of distended jugular veins. Below are the results of an examination of typical clinical conditions that can cause anasarca.

Patients with pulmonary edema complain primarily of exertional dyspnea and orthopnea. Physical examination usually reveals wet wheezing, possible diastolic gallop, and heart murmur. Heart disease and kidney problems are common causes of pulmonary edema. Peripheral edema is usually detected by the presence of pits after pressure is applied to the edematous area for at least 5 seconds. Pitting reflects the movement of excess interstitial fluid in response to pressure. It is commonly seen in dependent areas such as the lower limbs in outpatients and above the sacrum in bedridden patients. Scrotal edema is also common in men. Pitted edema suggests lymphatic obstruction or hypothyroidism. Acute onset of unexplained unilateral leg edema should increase the likelihood of deep vein thrombosis (DVT). Patients with cirrhosis may develop ascites followed by swelling of the lower extremities due to increased venous pressure below the affected liver. The presence of other signs of portal hypertension, such as distension of the veins in the abdominal wall and enlarged spleenalso indicates primary liver disease.

The cause of the swelling can be determined by observing changes in skin temperature, color, and texture. Acute DVT and cellulite can cause increased heat in the affected area. Deposition of hemosiderin or chronic venous insufficiency often results in a muscular, reddish tinge of the skin and usually affects the medial malleolus. As venous insufficiency progresses, this can lead to lipodermatosclerosis, which is associated with severe sclerotic and hyperpigmented tissue and is characterized by fibrosis and hemosiderin deposition, which can lead to venous ulcers over the medial ankle. Ulcers can progress to deep, weeping erosions. Myxedema from hypothyroidism presents with generalized, dry, thick skin with periorbital edema no pits and discoloration of the knees, elbows, palms and soles from yellow to orange colors. Pretibial myxedema occurs in patients with thyroid disease and is characterized by bilateral, asymmetric, pitting, scaly thickening and thickening of the skin. These sores can be purple or slightly pigmented (yellow-brown) and often have an orange peel appearance. The most common localization of the pretibial myxedema is above the shins, especially in the pretibial regions or the dorsum of the foot.

- Analyzes and visualization.

Routine laboratory tests, such as a comprehensive metabolic panel, can help evaluate kidney function, albumin, and liver function tests. All children with edema should have urinalysis. Urine test strips primarily detect albumin and require an additional Sulfosalicylic Acid Protein Precipitation Test to detect globulins and Bence Jones proteins. The urine protein / creatinine ratio or 24-hour urine protein content may obviate the need for sulfosalicylic acid testing. Finding an overtly positive protein test in combination with hypoalbuminemia and clinical edema is actually a diagnostic sign of nephrotic syndrome. Measuring natriuretic peptide in the brain may provide clues to the underlying cause of CHF. Albumin and liver function tests can help diagnose liver cirrhosis.

A chest x-ray is useful for detecting heart failure, pulmonary edema, and pleural effusion. For security reasons, ease of use and the information provided, the most common the X-ray method used in patients with renal failure is ultrasound kidney examination. Ultrasonography allows the doctor to determine the size of the kidneys and evaluate cystic kidney disease and hydronephrosis. Cardiac echocardiography can evaluate ventricular function, detect pericardial effusion, and help diagnose heart disease.

Echocardiography to assess pulmonary artery pressure is recommended in patients with obstructive sleep apnea syndrome and swelling. Vein ultrasound is the preferred imaging modality for suspected DVT. Duplex ultrasound can also be used to confirm chronic venous insufficiency. Magnetic resonance angiography with venography of the lower limb and pelvis can be used to evaluate internal or external DVT of the pelvis or hip. Compression of the left iliac vein by the right iliac artery (May-Turner syndrome) should be suspected in women aged 18 and 30 years with left lower extremity edema. Lymphoscintigraphy is the method of choice for assessing lymphedema when the diagnosis cannot be made clinically. MRI can help diagnose musculoskeletal etiology, such as a ruptured gastrocnemius muscle or popliteal cyst.

Treatment

When treating edema, one should be guided by their etiology. Causes usually include chronic venous insufficiency, lymphedema, DVT, and drug-induced edema. Pulmonary edema is the only life-threatening form of generalized edema that requires immediate treatment. For all other edematous conditions, the removal of excess fluid may be slower as it does not pose a serious threat to the patient's life. In patients with generalized edema caused by heart failure, nephrotic syndrome, or primary sodium retention, the edematous fluid may be rapidly mobilized.

In patients with anasarca, removal of 2 to 3 liters or more of edematous fluid within 24 hours can usually be performed without a clinically significant decrease in plasma volume. In patients with localized edema due to venous or lymphatic obstruction or malignant ascites, diuretic therapy may result in volume depletion. Diuretic therapy for generalized edematous conditions usually begins with loop diuretics such as furosemide.

In patients with cirrhosis of the liver, the combination of spironolactone and a loop diuretic is the preferred starting diuretic regimen for preventing hypokalemia. Because the hypokalemia predisposes to increased production of ammonia. Patients with nephrotic syndrome may require higher doses of diuretics. Some cases of idiopathic edema are caused by diuretics, and the initial approach to patients with idiopathic edema who are already taking diuretics, is to stop the diuretics for at least 2-3 weeks and stimulate sodium restriction in diet.

The mainstay of therapy for edema of the lower extremities due to venous insufficiency is mechanical methods of treatment, including compression stockings with elevation of the legs and a pressure of 20 to 30 mm Hg. Art. with mild edema and from 30 to 40 mm Hg. Art. with severe edema complicated by ulcers. Compression therapy is contraindicated in patients with peripheral arterial disease. Local care for the skin and wounds of venous ulcers is important to prevent secondary cellulite and dermatitis. Eczematous (congestive) dermatitis, characterized by dry, inflamed, flaky skin over superficial varicose veins, often occurs in patients with chronic venous failure. Treatments include daily moisturizing with emollients and short topical courses corticosteroids for severely inflamed skin.

Primary treatment for lymphedema includes comprehensive decongestant physiotherapy, including manual lymphatic massage and multi-layer dressings. The first goal is to improve fluid resorption and continue until the maximum therapeutic response is achieved. The maintenance phase of treatment includes compression stockings at 30-40 mm Hg. Art. Pneumatic compression devices can be used to supplement standard therapy. Surgical removal of the tumor or bypass procedures are limited to severe refractory cases. Diuretics have not been shown to be effective in treating lymphedema.

Forecast

The prognosis of anasarca depends on the underlying etiology. Reversible causes can have a favorable outcome, while irreversible etiology and malignant neoplasms have a poor prognosis. However, in most situations, by the time the anasarca develops, the underlying problem is no longer curable.

Complications

If the disease is left untreated, common complications include, but are not limited to, skin ulcers, skin infections, shortness of breath, congestive heart failure, and death.