Chapter 36

Edema is defined as a clinically apparent increase in the interstitial fluid volume, which may expand by several liters before the abnormality is evident. Therefore, a weight gain of several kilograms usually precedes overt manifestations of edema, and a similar weight loss from diuresis can be induced in a slightly edematous patient before “dry weight” is achieved. Anasarca refers to gross, generalized edema. Ascites (Chap. 43) and hydrothorax refer to accumulation of excess fluid in the peritoneal and pleural cavities, respectively, and are considered special forms of edema.

Depending on its cause and mechanism, edema may be localized or have a generalized distribution. Edema is recognized in its generalized form by puffiness of the face, which is most readily apparent in the periorbital areas, and by the persistence of an indentation of the skin after pressure; this is known as “pitting” edema. In its more subtle form, edema may be detected by noting that after the stethoscope is removed from the chest wall, the rim of the bell leaves an indentation on the skin of the chest for a few minutes. When the ring on a finger fits more snugly than in the past or when a patient complains of difficulty putting on shoes, particularly in the evening, edema may be present.

### Pathogenesis

About one-third of total-body water is confined to the extracellular space. Approximately 75% of the latter is interstitial fluid, and the remainder is in the plasma compartment.

#### Starling Forces

The forces that regulate the disposition of fluid between these two components of the extracellular compartment frequently are referred to as the Starling forces. 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.

As a consequence of these forces, there is movement of water and diffusible solutes from the vascular space at the arteriolar end of the capillaries. Fluid is returned from the interstitial space into the vascular system at the venous end of the capillaries and by way of the lymphatics. Unless these channels are obstructed, lymph flow rises with increases in net movement of fluid from the vascular compartment to the interstitium. These flows are usually balanced so that there is a steady state in the sizes of the intravascular and interstitial compartments, yet a large exchange between them occurs. However, if either the hydrostatic or the oncotic pressure gradient is altered significantly, a further net movement of fluid between the two components of the extracellular space will take place. The development of edema then depends on one or more alterations in the Starling forces so that there is increased flow of fluid ...

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