KEYWORDS: ..부종은 조직간액이 비정상적으로 축적되어 있는 상태를 말하며, 흔히 신체 중 dependent part인 legs에 호발한다. 1. Onset? Measured in hours to days : Acute onset - eg. Celluitis, DVT, Compartment syndrome etc Chronic onset - eg. Systemic process, Medication, Chronic venous insufficiency, Lymphedema 2. Clinical course? Intermittent vs constant 3. Pain? Painful - eg. Cellulitis, Ruptured gastronemius, Ruptured Baker’s cyst, Compartment syndrome, DVT Painless - eg. Systemic causes, Lymphedema 4. Associated systemic Symptoms? Fever and chills - Cellulitis, Lymphangitis, or Venous thrombosis Dyspnea, orthopnea, paroxysmal noctural dyspnea - Cardiac origin Recent streptococcal sore throat, recurrent cystitis, hypertension, changes in ocular fundi, U/A, BUN/Cr and Albumin abnormality - Renal pathogenesis Hepatitis, alcoholism, axillary hair loss, palmar erythema, Icterus, spider telangiectasia, Hepatomegaly, splenomegaly, Ascites, abnormal LFT - Hepatic origin 5. Medications? Antidepressants - Monoamine oxidase inhibitors Anti-hypertensive drugs - βblocker, CCB, Clonidine, Diazoxide, Guanethidine, Hydralazine, Methyldopa, Minoxidil, Reserpine Hormone agent - Corticosteroids, Estrogen, Progesterone, Testosterone NSAIDs Edema Key Questions 6. Endocrine diseases? - Cushing’s syndrome,Thyroid dysfunction (pretibial myxedema) 7. Other conditions? - Pregnancy, Salt overload, Sudden cessation of laxative, Diuretic abuse etc ..전신적 부종은 걸을 수 있는 경우는 하지에, 침상 생활만 하는 경우는 천골부 분에 잘 생긴다. ..The distribution of edema (generalized/localized) is useful in diagnosis. Common causes of generalized edema - 심장질환 Congestive heart failure Constrictive pericarditis Restrictive cardiomyopathy - 간경화 - 신장질환 Renal failure Nephrotic syndrome Common causes of Localized edema - Inflammatory disease - Injury : thermal, immune, infectious, mechanical - Occlusion of localized vein or lymphatic drainage 1. Chest radiograph 2. U/A (including microscopic) 3. Biochemistry profile (LFT, albumin, total protein, BUN/Cr) 7 The Root of ambulatory care Key tests Key treatments Edema Fig 1. Diagnostic approach to edema 1. Removal of underlying disease 2. Restriction of sodium intake : < 500mg/day 3. Diuretics : Weight loss by diuretics should be limited to 1~1.5kg/day ..Diuretics는 단지 미용적인 목적으로 사용해서는 안된다. 이뇨제는 aldosterone의 생성을 자극하며 여성의 주기적 부종을 악화시킬 수 있다. ..Albumin투여는 증상개선의 효과가 일시적이어서 치료로서의 의미는 미약 하다. ..보고자에 따라 이견은 있으나, idiopathic cyclic edema치료에 있어 ACE inhibitors가 때때로 효과적이다. (e.g,Captopril 25~50mg bid-tid) Diuretics 처방예 - 울혈성 심부전 1. Furosemide 40mg 1/2T-1T qd or bid Spironolactone 25mg 1/2T-1T qd Edema Localized edema? Albumin < 2.5g/dL Heart failure Renal failure Severe malnutrition Cirrhosis Nephrotic syndrome Azotemia Active urine sediment Increased JVD (jugular venous distension) Decreased CO (cardiac output) Consider : Drug-induced : Steroids, Estrogens, Vasodilators, Hypothyroidism Inflammatory disease/Local Injury (thermal, lmmune, infectious, mechanical) Occlusion of localized vein or lymphatic drainage No No No No Yes Yes Yes Yes 9 The Root of ambulatory care Diuretics 처방예 - 신증후군 1. Furosemide 40mg 1/2T-1T & Spironolactone 25mg 1/2T-1T qd or bid (정상신 기능시) 2. Furosemide 40mg 1T-2T qd or bid (신부전시) Diuretics 처방예 - 간경변 1. Spironolactione 25mg 1/2T-1T bid or tid Overdiuresis may result in hyponatremia, hypokalemia, and alkalosis, which may worsen hepatic encephalopathy. Common ▶ Volume depletion ▶ Prerenal azotemia ▶ Potassium depletion ▶ Hyponatremia-thiazide ▶ Metabolic alkalosis ▶ Hypercholesterolemia ▶ Hyperglycemia-thiazides ▶ Hyperkalemia-K＋ sparing ▶ Hypomagnesemia ▶ Hyperuricemia ▶ Hypercalcemia-thiazides ▶ GI complaints ▶ Rash-thiazides Uncommon ▶ Interstitial nephritis-thiazides, furosemide ▶ Pancreatitis-thiazides ▶ Loss of hearing-loop diuretics ▶ Anemia,leukopenia, thrombocytopeniathiazides 참고 문헌 Ralph Weber : Leg edema,in Saunders Manual of Medical Practice, 2nd ed, Robert E. Rakel(ed). Philadelphia, Saunders, 2000, P 287-289 최지호 : 부종, in 가정의학 임상편. 서울, 계측문화사, 2002, P 614-618 Joshua H. Barash,M.D. : Edema, in A Lange clinical manual Family Medicine Ambulatory Care & Prevention, 4th ed, Mark B. Mengel, M.D., L. Peter Schwiebert M.D.(ed).United States of America, The McGrwa-Hill Companies, Inc., 2005, P 132-136 Glenn Chertow, M.D. : Edema, in Harrison's Manual of Medicine, 16th ed, Dennis L. Kasper, M.D., M.A., Eugene Braunwald, M.D., M.A., M.D., ScD., Anthony S. Fauci, M.D., ScD., Stephen L. Hauser, M.D., Dan L. Longo, M.D., J. Larry Jameson, M.D., PhD. (ed). United States of America, The McGrwa-Hill Companies, Inc., 2005, P 194-196 Martin S. Lipsky,M.D.,Mitchell S. King,M.D. : Edema, in Blueprints in Family Medicine. Massachusetts, Blackwell Publishing, 2003, P 94-96