Due to swollen feet, doctors can sometimes make the decision to treat a patient with diuretics, drugs that eliminate water from the body.
Edema can be treated only by stimulating the evacuation of fluids in the urine by the kidneys.
Applications with vinegar – alternation, one hot, another cold is an alternative treatment for leg swelling. Often when a person is experiencing swollen ankles, especially because of the pain, may avoid exercise. Please send me your treatment for swollen legs and feet,is hot and cold water good for this?
This is one of the reason why you really need to take care of your health so you won’t come to a point that you will experience all this. For localized edema, if the cause is known (eg varicose veins), edema may reflect changes in maldie ie a stage of greater severity. Mechanisms of edema are variables to achieve the same effect: the abnormal presence of fluid outside the vessels.
The causes of the occurrence of edema are different according to the mechanism: increased pressure in the veins, increased blood volume, increased permeability of veins, lymphatic insufficiency. If the pressure in the venous capillary increases, the liquid will leave the capillaries and cause edema. This is the case of malfunction of the heart, cuts or cancellations of the veins (phlebitis), blood reflux in superficial and deep veins (varicose veins, post-phlebitis). Circulating blood volume may increase in case of kidney disease, liver, in the last trimester of pregnancy, and sometimes in the days before menstruation (premenstrual syndrome). Certain medications such as steroids can also cause this phenomenon. If the capillary filtration capacity is increased, the liquid can emerge more easily from the blood circulation and edema appears. This is the case when taking a particular family of antihypertensives (calcium channel blockers), on the occasion of certain diseases of the kidney and in the very malnourished.
It is also the mechanism of idiopathic cyclic edema leading to outbreaks of diffuse edema, predominantly in the lower limbs in the evening, and which meets exclusively in women before menopause. Outbreaks of edema are often punctuated by the hormonal cycle or stress. When the lymphatic circulatory return can not be done properly, will stagnate in the lymph tissues, causing swelling. Of large proteins present in tissues that are normally removed by the lymph, can not reach the venous circulation and will behave like a sponge, drawing water around them.
Lymph stasis and protein will alter the immune system and promote the local risk of infection (lymphangitis). This stasis will also cause changes in tissues, which will thicken and harden (fibrosis). Generalized edema formation involves different mechanisms that lead to an increase in the volume of liquid in the tissues.
Under the effect of blood pressure, the water leaves the capillary arterial vessels to the interstitial space and is reabsorbed by the venous capillaries by pressure exerted by the presence of albumin in the blood (oncotic pressure) and low pressure venous pressure in the area. The lymphatic vessels are also involved in interstitial fluid drainage. Idiopathic edema, mainly found in women are very common, harmless, but they can be accompanied by a real psychological impact and significant functional impairment. They affect the face, especially the eyelids in the morning and move to the lower part of the body at the end of the day (ankle, calf, abdomen, breasts sometimes). Considerable swelling may require to come off or unbutton his clothes. These swellings are often accompanied by irritation, depression, obsession. These people just urinate during the day but can get up at night to do so. A number of simple measures can greatly improve edema and often enough, especially in the case of idiopathic edema. The low elastic restraint are very useful for women to stand still. They improve venous return and increase pore pressure, favoring the elimination and prevention of limb edema.
Caloric restriction is indicated in cases of obesity or overweight. Being overweight interferes with venous and lymphatic return, gene walking and exercise. Stop smoking stimulates antidiuretic hormone that opposes the removal of water by the kidney. Stop diuretics in some cases, idiopathic edema that will maintain and exacerbate the decline in blood volume (hypovolaemia) stimulates water retention by the kidneys. Attention to self-medicate. Stop that laxatives, such as diuretics, exacerbate the decline in blood volume (hypovolaemia). Diuretics are the core of this treatment. They reduce the reabsorption of salt filtered by the kidney and thus increase its elimination in the urine. Low doses are sufficient in normal individuals. Higher doses are required in patients with heart failure, renal failure and cirrhosis.
In the presence of edema associated with drug taking will be necessary to validate the conditions under which it will evolve treatment. Copyright © 2012 Rayur, All trademarks are the property of the respective trademark owners. The junior doc pops along and the patient tells her that she feels as though there is a lump in her throat and there is discomfort when breathing. Symptoms have been developing over the last 4 hours but the feeling of difficulty with breathing has been developing quickly over the last hour. Menstrual cycles are irregular and she has been previously investigated for possible endometriosis, evidence of which was found on laparoscopy the previous year.
Current medication: NSAID for analgesia prn (recent use) uses salbutamol intermittently when chest feels tight as is presumed mild asthma. Working on the assumption that this is allergy related, the Junior Doc has given antihistamine (Chlorphenamine 4mg oral) about 2 hours ago as well as 200mg IV Hydrocortisone. Since there has been no improvement, she comes to ask if she should give adrenaline in view of the feeling of discomfort with breathing.
It has also been associated with URTI and often a lip swelling closely predates a cold sore eruption. A feeling of swelling in the back of the pharynx and discomfort with breathing is the reason for attendance today.
In this patient, antihistamines have not had an effect and if adrenaline was given would we expect any improvement?
Attacks can effect the skin, the face and lips, the larynx and pharynx, the gastrointestinal or genito-urinary tracts. Facial and pharyngeal attacks are at best disfiguring, preventing the sufferer from working for several days, but they are potentially lethal with 30% of affected families describing airway obstruction deaths in affected family members, often associated with simple URTI. Triggers that are recognized are; direct trauma, such as dental work, intubation, and peripheral injuries, infections, exposure to oestrogens (HRT and Oral Contraceptives), Non steroidal analgesics and ACE inhibitors. In vivo this might be a viral or bacterial surface coat, or various altered proteins such as amyloid or Bence Jones protein as well as articular cartilage, endotoxins and heparin amongst other physiological auto-activation triggers.
Type 1, making up 85% of such cases, with a pathologically low level of C1 esterase inhibitor protein, and Type 2 (15%) where the protein concentration is near normal but it lacks function. Other known causes of “normal inhibitor” angioedema are those patients on ACE inhibitors (ACEI), where up to 2% can suffer from angioedema.
The traditional treatments we, in the ED, routinely use when airway appears compromised by swelling are adrenaline, antihistamines and steroids. Tranexamic acid has been used for decades as prophylaxis for HAE with some reduction in attack frequency and consequently is used in the acute event although studies suggest a slow response to treatment with 20+ hours before resolution.
Since the end organ trigger for angioedema appears to be bradykinin in at least three patient types of angioedema, it would seem logical to consider attempting blocking the Bradykinin receptor.
Known HAE cases need replacement of C1 esterase inhibitor, which now exists in purified form. There is also a new Bradykinin blocker which acts at the end organ directly and can be given as a subcutaneous injection. It is very probable that most angioedema attacks will prove to be due abnormally elevated bradykinin levels and so as an emergency treatment a selective blocker is a logical choice for these cases as well, although that would be currently out of license and so would need to be discussed as such with the patient.
Lastly, but most importantly. Although this case is hypothetical it is based on very real events and on events very close to the Volans family.
2010 International consensus algorithm for the diagnosis, therapy and management of hereditary angioedema Bowen et al.

Acute angioedema: recognition and management in the emergency department Thiagarajan Jaiganesh, Martin Wiese, John Hollingsworth, Chris Hughan, Mohamed Kamara, Philip Wood and Claire Bethune. Emerging concepts in the diagnosis and treatment of patients with undifferentiated angioedema Jonathan A Bernstein and Joseph Moellman Int J Emerg Med.
Factor XII mutations, estrogen-dependent inherited angioedema, and related conditions Binkley. Therapeutic efficacy of icatibant in angioedema induced by angiotensin-converting enzyme inhibitors: a case series. My experience with angioedema over the years, almost exclusively due to ACE, is that airway problems are rare. This case series describes using FFP but I didn’t find it particularly convincing from an efficacy perspective. In the paper from the European Journal they make a similar point about the ACE associated ones I.e. I think that’s why there is differentiation in the diagnostic pathway between the two groups.
A wonderful overview Simon of a poorly appreciated condition that most of us have seen and dealt with at some point.
I still frequently see many doctors give the knee-jerk H1 receptor blockers and steroids for non-histamine mediated angioedmea. Although I am not a fan of using the above stated medications in what I clinically suspect to be a non-histamine mediated angioedema (like you I am convinced bradykinin is usually the common final pathway and main guilty culprit for most of the symptoms) I am still cautious in completely dismissing the use of such medications when discussing this with my colleagues just to reinforce the point that patients with HAE (types I, II and III) or any cause of acquired angioedema could of course still suffer from histamine mediated allergic reactions, so I give leeway to physician judgement. Bradykinin receptor blocker use for ACE inhibitor induced angioedema may be off-licence but I agree it makes sense based on the putative patho-physiology. I am collecting our AE cases, since they seem quite common just now, so will try to present a case series. I know of a fatal case where angioedema occurred, probably Bradykinin related as nonresponsive to adrenaline, antihistamines. We have a family with HAE and its useful to see the rapid response to Berinert, factor concentrate as well as icatibant.
Sierra Leone has seen serious and grotesque human rights violations since 1991 when the civil war erupted. Als Quincke-Odem werden akut auftretende Schwellungen an der Unterhaut, gennant auch (Angioodeme) bezeichnet, die mehrmals auftreten konnen. Durch die angeborenen und vererbten Quincke-Odeme (hereditare) kann es zu Bauchschmerzen, Erbrechen und Durchfall kommen. Ein Quincke-Odem kann genau dann lebensgefahrlich werden, wenn es die Schleimhautedes Rachenraums und den Halsbereich angreift und so eine akute Atemnot ausgelost wird. In den meisten Fallen jedoch klingt so ein Odem meist nach wenigen Stunden wieder ab oder nach ein paar Tagen. Bei Beobachtung einer Schwellung im Gesichts und Halsbereich sollte sich es auf jeden Fall von einem Arzt angeschaut werden, da mogliche Folgen wie Atemnot auftreten konnten.
Durch eine Blutuntersuchung kann der Arzt feststellen, um welche Form es sich bei dem entsprechendem Patienten handelt. Bei dieser auftretenden Krankheit kann im Normalfall ein entzundungshemmendes Medikament eingesetzt werden.
Im Falle eines Allergie-Auslosers bekommt der Patient einen Allergiepass, indem festgehalten wird, welche Stoffe der Patient in Zukunft meiden sollte.
Andy Volans is consultant in Emergency Medicine in the seaside town of Scarborough, Yorkshire. You assign the case to one of the junior docs to see in the majors end whilst you are busy in resus.
She is on the oral contraceptive to try and suppress the Endometriosis and regularize the periods. It is after all a common cause of swelling in the ED, but the normal treatments are not working so at this stage we need to stop and think again. Allergy conditions are triggered by exposure to environmental allergens and involve interaction with Immunoglobulins, either free in the plasma or attached to cells, resulting in the release of histamine from mast cells. Probably not as this syndrome is almost certainly mediated via the transmitter, Bradykinin. Angioedema is a deep dermal, submucosal or subcutaneous swelling associated with vascular leakage. A recent publication describes an algorithm supporting the diagnosis and treatment of acute attacks of angioedema presenting to the ED. A typical and common example of bradykinin activity is the congestion of the upper airway present during an URTI.
Based on this work, a treatment regimen was developed, using Fresh Frozen Plasma to replace the C1inhib that has now been refined to deliver the isolated plasma derived inhibitor (Cinyrise) or a synthetic inhibitor (Berinert). It is most commonly seen in women but not is not exclusively so, it seems to be oestrogen driven and is seen to run in families.
Given the incidence of ACE inhibitors in the community, this group will make up a significant number of cases that will present to the ED. Review of the patho-physiology above suggests that steroids and antihistamines are unlikely to be effective.
The suggestion is that Tranexamic acid works on the secondary prostaglandin activation or somewhere in the Thrombin pathway.
It has become apparent that where oestrogens increase the amount and activity of factor XII, androgens reduce both the oestrogen level and consequently the stimulation to the factor XII, and also may have a direct suppression effect on Factor XII. Currently there is a BK2 receptor blocker (Icatibant) in the formulary, which has a license for use in Hereditary Angioedema. It’s fantastic to share the story and photographs to help others learn about the condition and to support other patients with the condition. Obviously the soft tissue swelling can be a bit scary in the ED when you’re seeing someone with a swollen mucosa and contemplating the A of ABC. Haven’t looked through references above but a descriptive case series detailing course and outcomes would be a useful addition to the literature.
Airway compromise due to angiotensin-converting enzyme inhibitor-induced angioedema: clinical experience at a large community teaching hospital. I did a BestBet on the specific topic (unpublished) of ACE inhibitor induced angiooedmea and came to the conclusion that there was no strong evidence either way for the use or non-use of steroids and anti-histamines in the treatment (this was simply through the lack of any good quality studies specifically addressing the question). Hopefully someone somewhere will run and publish a DBRCT to answer the question definitively.
We see the acute attack but haven’t been told of the new treatments, and when they should be used. According to Human Rights Watch, over 50,000 people have been killedover 50,000 people have been killed to date, with over one million people having been displaced. Sie sind vorwiegend im Bereich von Lippen und Augenliedern, sowie an Schleimhauten des Rachenraums und der Zunge wiederzufinden. Eiwei?haltige-Nahrungsmittel, Konservierungsmittel oder irgendwelche Zusatzstoffe in Lebensmitteln ausgelost werden.
Im Bereich der Augenlieder, am Kinn, an Wangen, Lippen und Zunge beginnt eine blasse Schwellung mit Rotungen aufzugehen, ebenso konnen Korperteile wie Hande, Fu?e etc.
Je nach dem, wie hoch der Schweregrad liegt, verschreibt der Arzt die entsprechenden Mittel ( wie z.B.

It is recommended that the patient begins in the first stage to walk on foot for short distances, and then extend the walks time.
A lovely part of the world with sea, hills, forests, beaches…pretty much everything really.
The clinical differentiation of Histamine based allergy and Bradykinin mediated Angioedema is based on the lack of an identifiable allergic trigger, the burning nature of the pain, the slow progression, with a period of acceleration, the lateralization of the swelling when it first develops and the lack of response to adrenaline and antihistamine and has been described in a recent paper in the European Journal of Emergency Medicine There is a nice algorithm in that paper that we cannot reproduce here for copyright reasons. Depending upon the region affected, the swelling may be described as burning or having a deep itch and often described being painful.
Patients with a known diagnosis tend to understand their peripheral swellings and so will only present to the Emergency Department when they are suffering an attack that is different, more painful or is life threatening. Many such patients end up having surgery where there is little found to explain the clinical findings.
Bradykinin is generated on the surface membrane of most endothelial cells by the interaction of Kallikrein and high molecular weight Kininogen that circulate bound together in the plasma.
These traditional HAE types only make up about 1-2% of all cases of Angioedema that present clinically.
Clinically it’s presentation is indistinguishable from traditional HAE other than having a normal C1 inhib level and activity.
The activity of Angiotensin Converting Enzyme is known to vary between individuals by as much as 60%. Adrenaline might be expected to be helpful, however experience suggests that the effect is quite small in practice.
The side effects of danozol and stanozolol limit their acceptability as prophylaxis in most patients. However, do remember that both Berinet and cinryse come in at ?1500 per treatment, Berinet needs 3 vials for a 70kg person at ?500 per vial plus is IV so Icatibant is arguably comparable. Cicardi M, Bork K, Caballero T, Craig T, Li HH, Longhurst H, Reshef A, Zuraw B on behalf of HAWK (Hereditary Angioedema International Working Group). However that does not appear to be the case with the non-ACE associated ones if the family mortality described by Andy is to be believed. I have had some hairy experiences in Resus with a few cases and have learned a thing or two watching my wife’s disorder being mistreated by a number of colleagues.
Die meisten Quincke-Odeme enstehen meist erst im Erwachsenenalter, bei Kindern und Jugendlichen sind sie eher selten zu beobachten.
A unilateral swelling of a leg, caused by phlebitis, is reduced by anticoagulant treatment. Interstitial space is the extravascular compartment of the extracellular fluid and surrounds the cells of a given tissue. If there is generalized release then the patient can suffer hypotension due to vessel dilatation and leakage, as well as bronchospasm and local swelling that can affect the airway.
This interaction is initiated by an activated factor XII (which is common to both the clotting and complement cascades). Activated Factor XII activates Factor XI in coagulation cascade, resulting in Thrombin formation.
The vast majority of cases have normal levels and activities of plasma inhibitor when measured during attacks, and so other precipitating causes need to be sought. So far about 20% of these cases have been found to have an abnormal structural form of factor XII but how this abnormality alters its function is as yet unclear. This might suggest that a patient with a low activity ACE might be more susceptible to ACE Inhibitor associated angioedema when challenged by stimulation to their complement system. And indeed I have found it very effective in patients with non hereditary angioedema though it is an off licence use of the drug. These symptoms can and usually are reversed by the use of adrenaline and antihistamines. Similarly, steroids will suppress the Immunoglobulin production and reduce the chances of recurrent allergic response. Many of these patients may attend gynaecology clinics with repetitive cyclical pain and may also present with unilateral labial swelling. Activated Factor XII converts pre-kallikrein into Kallikrein, which produces bradykinin from Kininogen.
Activated Factor XII is also cleaved by Kallikrein to produce another active form that activates the first step of the Classical Complement cascade (C1 esterase). Allergy related swelling of the upper airway, mediated by histamine, is indeed seen and must not be ignored, and in the early phases of resuscitation should be treated until a more accurate diagnosis can be made. What does appear to be true is that factor XII acts as a more efficient amplifier of bradykinin production and possibly this version of XII is less susceptible to inhibitory factors. Other known causes are autoimmune diseases and haematological malignancies such as lymphoma. Case reports exist showing rapid resolution of attacks of ACEI induced Angioedema using FFP suggesting that replacing both the inhibitor and unblocked plasma ACE removes the bradykinin.
A bilateral lower limb edema, attributable to heart failure, is treated by administering anti-diuretic drugs, and vasodilators.
Further reading about basics of fluid compartment and fluid therapy: Basics of fluid therapy. It is not surprising that many of these patients become labeled, as “irritable bowel” or “dysmenorrhea” and many are not diagnosed as having angioedema for an average of 10 years after their first presentation to a doctor. Kallikrein also activates Complement factors 3 and 5 directly, further driving the classical complement system.
In general, it has a short time scale, an identifiable probable trigger and is responsive to antihistamine and adrenaline treatment.
It has been recently shown that factor XII is directly activated by contact with unfolded proteins such as Bence Jones and Amyloid suggesting a reason why these diseases may predispose to expression of excess bradykinin production.
The two concentrated C1 esterase inhibitors (nanofiltered, human derived, Cinryse or synthetic, Berinert) are now available and have been shown to be very fast and effective in reversing symptoms. Factor XII activation is part of the “Contact Activation” response of the Complement Cascade. Recent studies suggest that these pathways can be triggered selectively although how this occurs is currently unknown. Interestingly, we have seen cases of patients on oestrogen therapy for conditions such as prostate cancer present with angioedema and this may be a mechanism for such attacks. The activated Kininogen cleaves Kallikrein to produce the 9-peptide transmitter Bradykinin.
It also triggers the prostaglandin cascades associated with inflammation and attracting leucocytes to the area. These activities are moderated by a number of suppressing factors: The Kininogen and Carboxypeptidase activity and factor XII activation is suppressed by C1 esterase inhibitor (C1inhib) that circulates in the plasma, and as previously described, bradykinin is broken down to non active moieties by ACE which is in close proximity to the BK2 receptor. In myxedema, there is infiltrative edema with deposition of mucinous materials under the skin.
Learning is not memorizing but conceptualizing.Epomedicine also provides quick access to case discussion on interesting medical cases, videos for developing correct clinical skills and a blog to go beyond notes and research articles to explore the inner-self of medical students and healthcare professionals.

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