Edema (부기, 부종)

The Root of Ambulatory Care
- 저 자 : 이진우
- 출 판 : 군자출판사
- 페이지수: 543면
이진우 선생님, 군자출판사와 제휴를 통해 책 내용 및 그림을 제공합니다.
무단 복제/배포 금지.
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)
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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
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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