Edema – Physical Examination

Synonyms: Oedema

Definition of Edema

Accumulation of excessive amount of fluid in the extravascular interstitial space of the body. Interstitial space is the extravascular compartment of the extracellular fluid and surrounds the cells of a given tissue. Anasarca is a severe and generalized edema with profound subcutaneous tissue swelling. Further reading about basics of fluid compartment and fluid therapy: Basics of fluid therapy.

Body fluid spaces
Fluid compartment of human body

Some related terms:

  1. Swelling: Transient abnormal enlargement of a body part or area not due to cell proliferation (not necessarily edema).
  2. Effusion: Accumulation of excessive fluid in the body cavities.

Pathophysiology of Edema

Starling forces edemaStarling forces determine fluid movement through capillary membranes:

  1. Pc = capillary hydrostatic pressure
  2. Pi = interstitial fluid hydrostatic pressure
  3. πc = plasma oncotic pressure
  4. πi = interstitial fluid oncotic pressure

Note: The hydrostatic pressure pushes fluid out and the oncotic pressure pulls fluid into the respective compartments.

Thus, net fluid flow = Pnet = Kf [(Pc − Pi) − (πc − πi)].
Kf = filtration constant (capillary permeability).

Edema—excess fluid outflow into interstitium commonly caused by:

  1. ↑ capillary hydrostatic pressure (↑ Pc; heart failure)
  2. ↓ plasma proteins (↓ πc; nephrotic syndrome, liver failure)
  3. ↑ capillary permeability (↑ Kf; toxins, infections, burns)
  4. ↑ interstitial fluid oncotic pressure (↑ πi; lymphatic blockage)

Demonstration of edema clinically

A. Inspection:

  1. The overlying skin may be smooth, shiny, taut and even hairless.
  2. Observe for puffiness of eyelids and face and also the scrotal edema.
  3. Observe for signs of inflammation if any.

B. Palpation:

Press with your right thumb over the following bony backgrounds for 30 seconds (atleast 5 seconds) – to allow a depression to form (pitting edema) and wait for 15 seconds to allow the pit (if formed) to disappear:

  1. Medial malleouls
  2. 5 cm above medial malleolus
  3. Shin of tibia
  4. Sacrum
  5. Rib or sternum
  6. Forehead (In case of anasacra)
Pitting edema
Demonstrate with the tip of thumb

Pitting recovery time:

  1. Press down firmly all the way to the bone. Start the stopwatch.
  2. Shine a light at a tangent across the pit and do not call the pit recovery time until there is no shadow remaining anywhere in the area of the pit.
  3. Interpretation: In acute edema (< 3 months duration) associated with hypoalbuminemia, pitting recovery time is < 40 seconds

Note: Fluids accumulated in the dependent part of the body, hence the sign can often be elicited in the legs in sitting patients and sacrum in bedridden patients.

C. Examine for parietal edema: Press over or pinch the skin of abdominal wall for atleast 5 seconds and look for pitting edema.

D. Test for Lymphedema (Stemmer’s Sign):

Attempt to pinch and lift skinfold at the base of the second toe (or middle finger) – the test is negative if you are able to pinch skin and positive if you are unable to pinch skin.

  1. Negative: Suggestive of other cause of edema
    • No swelling at base of digit: suggestive of chronic Venous Insufficiency
    • Pitting swelling of the base of digit: suggestive of CHF, Nephrotic Syndrome, Cirrhosis, etc.
  2. Positive: Lymphedema

E. Percussion (For Ascites):

  1. Puddle sign: 120-250 ml (Mild ascites)
  2. Fullness of flanks: > 500 ml fluid
  3. Shifting dullness: > 1000-1500 ml fluid (Moderate ascites)
  4. Fluid thrill: >2000 ml fluid (Tense ascites)

Grading of Edema

A) Based on Pitting depth and Duration:

1+ :  ≤ 2mm pitting that disappears rapidly
2+ : 2-4 mm pitting that disappears in 10-15 seconds
3+ : 4-6 mm pitting that may last more than 1 minute; dependent extremity looks fuller
4+ : 6-8 mm pitting that may last more than 2 minute; dependent extremity is grossly distorted

B) Based on Pitting depth and Rebound time:

1+ : 2 mm pit that rebounds immediately
2+ : 4 mm pit that rebounds after few seconds
3+ : 6 mm pit that rebounds after 10-12 seconds
4+ : 8 mm pit that rebounds after > 20 seconds

C) Severity of Bilateral pitting edema:

1+ (mild): Both feet/ankles
2+ (moderate): Both feet + lower legs, hands or lower arms
3+ (severe): Generalized bilateral pitting edema, including both feet, legs, arms and face

Types of Edema fluid

Protein-poor (< 3 g/dl)
Protein-rich (>3 g/dl)
Pitting edemaNon-pitting edemaNon-pitting edema

Classification and Causes of Edema

1) Non-pitting/Solid/Brawny Edema

  • Myxedema: Generalized (Hypothyroidism) and Pretibial (Grave’s disease)
  • Lymphedema: Primary or secondary
  • Angioneurotic/Qincke’s edema and urticaria
  • Scleroderma

Note: Non-pitting edema are usually localized type of edema but generalized type may be seen in cases of generalized myxedema and generalized urticaria (hypersensitivity to drugs).

Differentials for Lymphedema

By etiology:

  1. Primary lymphedema: Alteration or deficiency with lymphatic collection or transportation system
    • Milroy disease (Hereditary lymphedema type I): Appears at or soon after birth
    • Meige disease (Hereditary lymphedema type II): Develops later
    • Lymphedema parecox: Another term for 2 syndromes described above, has an early onset upto 35 years
    • Lymphedema tardum: Similar to lymphedema parecox but has an onset after 35 years
    • Lymphangioms
  2. Secondary lymphedema:
    • Infection: Filariasis, Reccurent cellulitis, Lymphogranuloma venereum, Scrofula (TB lymph node)
    • Inflammation: SLE, Rheumatoid arthritis, Psoriatic arthritis, Retroperitoneal fibrosis, Chronic dermatitis
    • Malignancies
    • Surgeries: Lymphadenectomy, Surgery of prostate, uterus or cervix, Reconstructive arterial surgeries
    • Irradiation

By age:

  1. At Birth: Prematurity, amniotic bands, Milroy’s disease
  2. In childhood (Upto 10 years): Meige disease, Turner syndrome
  3. 10-30 years: Meige disease, rarely infection
  4. 30-50 years: Primary idiopathic lymphedema (Kinmonth)
  5. After 50 years: Malignancies

By site:

  1. Upper limbs: Breast cancer, surgery/irradiation for breast cancer, newborn baby, turner syndrome
  2. Lower limbs: Congenital lymphedema, parecox, tarda, other secondary causes of lymphedema


Males and females affectedExclusively females affected
Due to failure of lymphaticsDue to abnormal fat deposition
No increased bruisingEasy bruising
Brawny skin textureNormal skin texture
Involvement of feetSparing of feet
Kaposi-Stemmer’s sign positiveKaposi-Stemmer’s sign negative

Reasons why these edema don’t pit on pressure:

In general, this type of edema contains protein that osmotically attracts the fluid right back into the extracellular space.
In myxedema, there is infiltrative edema with deposition of mucinous materials under the skin.
In Lymphedema, there is also an obstruction to lymphatic drainage besides lymph being protein-rich fluid.

2) Pitting Edema:

Mnemonic: CHILD

  • Cardiac failure
  • Hypoalbuminemia
  • Insufficency (venous), Idiopathic
  • Liver disease
  • Drugs (Vasodilators, Androgenic)

a. Localized:

  1. Venous obstruction: Pregnancy, SVC syndrome, IVC syndrome, Varicose veins, Deep vein thrombosis, Prolonged recumbency, Neoplasm (pelvic tumor, lymphoma)
  2. Infection or inflammation: Cellulitis, Osteomyelitis, Gout
  3. Local trauma or injury: Bruise, sprain, fracture, insect bite, snake bite, frost bite, burn

b. Generalized:

 Generalized edema

  1. Hypoproteinemia:
    • Decreased intake: Malnutrition (Kwashiorkor)
    • Decreased absorption: Protein losing enteropathy
    • Decreased synthesis: Hepatic cirrhosis
    • Increased loss via: Skin (Burns), Urine (Nephrotic syndrome), Fecal (Bowel disease)
  2. Systemic venous hypertension:
    • Congestive heart failure
    • Pericardial diseases
    • Tricuspid valve diseases
  3. Some special types of generalized edema:
    • Cyclic edema of women (varies with menstrual cycle)
    • Vasodilators (Minoxidil and Hydralazine causes sodium retention while Nifedipine alters capillary permeability)
    • Other drugs: Corticosteroids, Estrogens
    • Edema of pregnancy
    • Capillary leak syndrome (In critically ill patients who are septic)

The 4 common causes of Anasarca are:

  1. Congestive cardiac failure
  2. Nephrotic syndrome
  3. Liver cirrhosis
  4. Malnutrition

Why edema is pitting: In general, this type of edema contains protein-poor transudate and the lymphatic drainage is not obstructed.

Types of edema
A. Periorbital edema in Nephrotic syndrome (Puffiness in morning)
B. Ascites in Liver cirrhosis
C. Pitting pedal edema in Congestive heart failure
D. Unilateral edema of lymphedema
Cardiac edemaHepatic edemaRenal edema
Dependent edema+++++++++
Facial edema+
EvolutionLegs → Face → AscitesAscites → Legs → FaceFace → Legs → Ascites
DyspneaPrecedes edemaFollows ascites
Clinical featuresOf cardiac failure
Raised JVP
Hepatomegaly may be present
Stigmata of Chronic liver diseases
Pale and waxy look

Edema with sudden onset (<72 hours): DVT, Cellulitis, Trauma, Acute nephritis, Allergic reactions

Dependent edema:

  1. Improves with limb elevation (Venous insufficiency)
  2. Doesn’t improve with limb elevation (Malnutrition, Cirrhosis, CHF, Nephrotic syndrome)

Asymmetrical/Unilateral edema

  1. Traumatic: Sprains and fractures
  2. Infective: Boils, carbuncles, cellulitis
  3. Thrombophlebitis: White leg following pregnancy
  4. Lymphedema
  5. Local effects of heat or cold: Frostbite, sunburns, burns
  6. General causes: Angioneurotic edema

Causes of Edema in Newborns:

A) Generalized:

  1. Hemolytic disease of newborn
  2. Congestive cardiac failure
  3. Cold injury
  4. Electrolyte imbalance (Overhydration, Hypernatremia, Hypokalemia)
  5. Nutritional edema (Anemia with hypoproteinemia, Vitamin E deficiency)
  6. Renal edema (Congenital nephrosis)
  7. Maternal diabetes

B) Localized:

  1. Head: Caput succedaneum (not to be confused with cephalhematoma)
  2. Face: Excessive crying, conjunctivitis, drug sensitivity
  3. Limbs: Arm presentation, cold, Milroy’s disease, Turner syndrome
  4. Genitalia: Physiological, Allergic, Insect bite, Cellulitis
  5. Abdominal wall: Peritonitis, Necrotizing enterocolitis, Appendicitis

General physical examination in Patient with Edema

  1. Built and nourishment: Poor in nutritional deficiency
  2. Pallor: Cardiac or Gastrointestinal cause
  3. Icterus: Hepatic cirrhosis
  4. Cyanosis and clubbing: Cardiac edema
  5. Lymphadenopathy: Filariasis

Clinical Tips:

  1. Minimally 10-15% increase in body weight is necessary for demonstrable pitting edema.
  2. Most reliable index of progression of treatment of edema is daily alteration of body weight.
  3. Bilateral pitting edema can occur in hyperthyroidism as a result of heart failure. However, cases with unilateral pitting edema have also been seen, the mechanism of which is not clearly understood but is responsive to the treatment.
  4. Complications of peripheral edema include cellulitis, venous thrombosis, impaired vision (periorbital edema), pain
  5. Complications of ascites include impaired intestinal absorption, esophageal reflux, dyspnea, umbilical and inguinal hernias, spontaneous bacterial peritonitis
  6. General measures for treatment of edema include management of primary disease, bed rest, Na+ restriction and Diuretic administration.

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