Anasarca is generalized swelling of subcutaneous fat in combination with the accumulation of fluid in the body cavities. The disease is manifested by swelling and pastyness of the whole body, abdominal enlargement, shortness of breath. Laboratory techniques (blood and urine tests, liver tests), instrumental studies (EchoCG, ultrasound of the abdominal cavity and retroperitoneal organs) are used for diagnosis. Treatment includes the removal of excess fluid by diuretics, the introduction of protein solutions and drugs for the treatment of the leading disease. If necessary, laparocentesis, pericardiocentesis, pleural puncture are performed.
R60.1 Generalized edema
Anasarca is not allocated to a separate nosological unit, it is part of the edematous syndrome. The condition develops with decompensation of the underlying pathology and serious hemodynamic disorders. The disease can occur in patients of any age. It is believed that women are more predisposed to generalized edema, which is due to the peculiarities of the hormonal background. The frequency of anasarca is 1-2% of all patients suffering from edematous syndrome.
Causes of anasarca
Edema is one of the most common symptoms in therapeutic practice, it occurs with a large number of diseases and pathological conditions. Generalized swelling, which includes anasarca, is noted in severe systemic diseases accompanied by circulatory disorders and water-electrolyte imbalance. The main causes of anasarca:
- Heart diseases. More than a third of cases are caused by the decompensated course of chronic heart failure (CHF) on the background of arterial hypertension, myocarditis. A low cardiac output is characteristic, as a result of which the blood stagnates in the venous bed, from where it quickly sweats into the intercellular space.
- Nephrotic syndrome. Generalized edema is formed in renal pathology, which causes massive loss of protein in the urine. Nephrotic syndrome is manifested in patients suffering from membranous nephropathy, chronic glomerulonephritis, systemic pathologies (diabetic nephropathy, SLE).
- Liver diseases. Anasarca occurs with long-term lesions of the hepatic parenchyma (cirrhosis, chronic hepatitis), which lead to a decrease in protein synthesis function. This etiology is characterized by the predominance of ascites over peripheral edema.
- Protein loss. The condition occurs in primary or secondary exudative enteropathy, when protein molecules enter the intestine from lymphatic vessels and are excreted from the body with feces. At the same time, there is a rapid progression of edematous syndrome with the appearance of anasarca and the accumulation of fluid in the serous cavities.
- Malignant neoplasms. Anasarca is possible in patients with cancerous cachexia due to protein starvation and progressive disruption of all internal organs. Sometimes the condition is determined when the lymphatic system is affected by tumor metastases, peritoneal carcinomatosis.
Pathogenetic mechanisms include changes in hydrostatic and oncotic pressure indicators, as well as electrolyte metabolism disorders. With an increase in the hydrostatic pressure of the blood, the transition of the liquid part of the plasma from the vessels to the tissues is observed. Excess fluid accumulates in the intercellular space. In pathogenesis, the concentration of sodium is of great importance — with an increase in the content of Na ions in the fiber, edema occurs.
Oncotic pressure is caused by blood proteins, therefore, with hypoproteinemia, intravascular fluid passes into peripheral tissues with a higher protein content. The condition is aggravated by damage to the endothelium of the vascular wall, which contributes to increased protein loss and increases edema. Secondary mechanisms of occurrence are represented by discoordination of the work of the RAAS, stimulation of the sympathetic nervous system.
In clinical practice, anasarca is not divided into separate types, but this syndrome includes several clinical manifestations, each of which has its own name. In addition to generalized edema of subcutaneous tissue (actually anasarca), in a pathological condition, local accumulations of transudate are determined in separate cavities of the body:
- ascites – in the peritoneal cavity;
- hydropericardium — between the leaves of the pericardium;
- hydrothorax – in the pleural cavity.
The congenital anasarca, which neonatologists face with severe hemolytic disease of the fetus, is considered separately.
Symptoms of anasarca
Pathology is characterized by gradual development. First, local peripheral edema appears, the localization of which is determined by the etiology of the syndrome. Then they increase and become generalized. With cardiac causes, patients notice swelling on the legs and pasty tissues. The skin is pale bluish in color, cold to the touch. Renal edema is noticeable in the morning and is localized mainly on the face.
With the progression of the process, total swelling and pasty of soft tissues are observed, the contours of the body are smoothed. Due to the swelling of the fingers, it becomes difficult to put on or take off the rings. When pressing on the skin, a “hole” remains, which straightens very slowly. There is an increase in body weight, in severe cases — 0.5-1 kg per day or more. Men have severe swelling of the scrotum, women have labia and perineum.
The abdomen increases in size, often an expanded network of venous vessels is visible on the skin. In the horizontal position of the patient, the stomach is flabby (“frog”), and in the vertical position it is saggy. Due to an increase in intra-abdominal pressure, the navel bulges out. Typical complaints of severe shortness of breath, inability to breathe deeply. Symptoms worsen in the supine position, so patients try to sit down, hanging their legs and leaning their hands on the edge of the bed.
Anasarca is accompanied by severe disorders of the cardiovascular and respiratory systems, the severity of which is superimposed on the symptoms of the underlying disease. Due to an increase in hydrostatic pressure in the pulmonary capillaries, congestive pneumonia develops, and with a rapid increase in clinical symptoms, there is a risk of pulmonary edema. Hydropericardium can be complicated by cardiac tamponade and acute heart failure.
Violation of blood flow and blood thickening contributes to the formation of blood clots in the veins of the lower extremities. With the separation of thrombotic clots, there is a possibility of PE, myocardial infarction, renal vascular infarctions. Severe anasarca is fraught with paradoxical hypovolemic shock, when the volume of circulating blood decreases to 50-60% of the norm, and the volume of edematous fluid reaches 20-25 liters.
Diagnosis of anasarca
Anasarca is an interdisciplinary condition, therefore, doctors of different specialties are engaged in examining the patient. Taking into account the most common causes of swelling, the primary examination is carried out by a nephrologist and a cardiologist therapist. If there are appropriate indications, other narrow specialists are involved. The presence of this disease can be established after a physical examination, a number of studies are prescribed to determine its etiology:
- Laboratory tests. In the biochemical analysis of blood, a decrease in the level of total protein and albumin fraction, an increase in sodium and chlorides are detected. To confirm the renal origin, a general urinalysis is performed, where proteinuria of more than 3 g / l is detected. With edematous syndrome, it is also necessary to make functional liver tests.
- Ultrasound examination. Be sure to recommend an echocardiogram to examine the contractility of the myocardium and identify the hydropericardium. To detect ascites and approximate the amount of free fluid, an ultrasound of the abdominal cavity is shown. For differential diagnosis, ultrasound of the liver and kidneys is performed.
- Radiography of abdominal area. The study helps to clarify the degree of increase in the size of the heart sac, which makes the diagnosis of CHF highly reliable. With anasarca, the cardiothoracic index increases by more than 50%. In the case of hydrothorax, the fluid in the pleural sinuses is visualized on the X-ray.
Treatment of anasarca
Usually, treatment is carried out in cardiology or nephrology departments, in severe cases — in intensive care wards, where modern equipment is available and constant medical supervision is provided. According to the indications, they perform correction of basic vital functions, provide oxygen support. The following medications are used for therapy:
- Diuretics. Drugs from the loop diuretic group for intravenous use are administered to remove fluid in the acute stage. They reduce the swelling of tissues and reduce the load on the heart, thereby improving the condition of patients. Thiazide and potassium-sparing diuretics are recommended for long-term use.
- Cardiac glycosides. They are indicated in the complex therapy of CHF to normalize the systolic function of the left ventricle and reduce venous congestion. An additional clinical effect is the regulation of heart rate.
- Protein solutions. With protein-free anasarca, it is advisable to carry out infusions of protein hydrolysates, albumins. The solutions normalize the oncotic blood pressure and prevent the transfer of plasma into the tissues of the body.
Laparocentesis is performed to quickly remove the transudate from the peritoneal cavity. The procedure is aimed at gradually reducing the severity of ascites and relieving the patient’s condition. Taking into account the amount of fluid in the abdominal cavity, 1-3 procedures are prescribed. Laparocentesis is a therapeutic and diagnostic method, since the study of the resulting transudate allows us to determine the cause of the edematous syndrome.
Increased CVD in hydropericardium also requires surgical treatment. The method of choice is a puncture (pericardiocentesis) with aspiration of 100-200 ml of edematous fluid, after which the function of the heart is restored. Less often, other operations are used — xiphoid or thoracoscopic pericardiostomy, thoracotomy. Removal of effusion from the pleural cavity is carried out by puncture.
Prognosis and prevention
After anasarca relief and stabilization of vital functions, clinical improvement occurs in most patients. Doctors give a relatively favorable prognosis, provided that the recommendations are followed and the complex treatment of the underlying pathology that caused the edema. Measures of primary prevention of anasarca have not been developed. Secondary prevention consists in early detection and therapy of edematous syndrome, correction of hemodynamics.