Eedema refers to the accumulation of excessive body fluid in the tissue space outside blood vessels, which is one of the common clinical symptoms. Different from obesity, edema is manifested as an obvious depression when fingers press parts with little subcutaneous tissue (such as the front of the calf). Traditional Chinese medicine calls it "water vapor", also known as "edema". Edema is a common pathological process in which the accumulation of body fluid comes from plasma, which has roughly the same ratio of sodium to water as plasma. Traditionally, the accumulation of excess body fluid in the body cavity is called hydrops or effusion, such as pleural hydrops, peritoneal hydrops, hydropericardium, etc.
Classification and common diseases
The classification methods of edema are: ① According to the scope of edema, it is divided into general edema (anasarca) and local edema (local edema); ② According to the occurrence of edema Name the parts, such as cerebral edema, laryngeal edema, pulmonary edema, lower limb edema, etc.; ③ According to the cause of edema, it is divided into cardiac edema, renal edema, hepatic edema, inflammatory edema, dystrophic edema, lymphedema, special Epidemic edema (unknown cause), etc.
1. Generalized edema
Can be divided into the following categories according to its cause:
(1) Cardiogenic edema: common in congestive heart failure, acute or chronic pericarditis, etc.
(2) Nephrogenic edema: common in glomerulonephritis, pyelonephritis and nephrotic syndrome.
(3) Hepatogenic edema: common in viral hepatitis, cirrhosis, etc.
(4) Dystrophic edema: common in hypoalbuminemia, vitamin B1 deficiency, etc.
(5) Edema caused by connective tissue diseases: common in lupus erythematosus, scleroderma, dermatomyositis, etc.
(6) Allergic edema: such as serum sickness, etc.
(7) Endocrine edema: common in Sheehan's disease, hypothyroidism and Cushing's syndrome.
(8) Idiopathic edema: such as functional edema, etc.
(9) Others: anemic edema, toxic edema of pregnancy.
Overview
Eedema refers to the retention of water in the body, which overflows the skin and causes swelling of the head, face, eyelids, limbs, abdomen and back, and even the whole body. Edema is a manifestation of systemic qi dysfunction and is closely related to the lungs, spleen, kidneys, and triple burner organs. According to different symptoms, it is divided into two categories: yang water and yin water. It is common in diseases such as nephritis, pulmonary heart disease, liver cirrhosis, nutritional disorders, and endocrine disorders.
Medical History and Pathogenesis
(1) Rheumatism attacks externally and is internally trapped in the lungs. If the lungs fail to circulate and descend, the water channels will be blocked and water will overflow on the skin, causing edema.
(2) Excessive eating and drinking can damage the spleen and stomach, cause loss of transportation and transformation, stop accumulation of water and dampness, and overflow the skin, causing edema.
(3) Excessive sexual exertion, internal damage to the kidneys, inability to transform qi and move water, and water-dampness stops internally, overflowing into the skin and resulting in edema.
Syndrome differentiation treatment
(1) Yang Shui
Main syndrome: acute onset, slight swelling of the face at first, then spread throughout the body, severe swelling above the waist , the skin is shiny, the scrotum is swollen and bright, the chest is upset, and the breath is short. Or the symptoms are cold and no sweating, the coating is white and slippery, and the pulse is floating and tight; or the throat is swollen and painful, the coating is thin and yellow, and the pulse is floating and rapid.
Treatment method: Mainly focus on the lung and spleen meridian points. The acupuncture method is used to nourish the lungs, relieve external factors and diuresis. After the external evils subside, it is advisable to use Yin water therapy.
Prescription: Lieqihegubiaoliyinlingquanweiyang
Prescription: Yang water is a disease caused by the loss of lung qi, internal stasis of water and dampness, and swelling above the waist. It is suitable for sweating, so choose Lieqi and Hegu to relieve muscles and relieve muscle qi, and relieve lung qi; for swelling below the waist, it is suitable to facilitate urination, so choose Pianli and Yinlingquan to facilitate urination and eliminate edema; Weiyang is the combined point under the triple burner, and the function can be adjusted The function of triple burner gasification is to eliminate edema.
(2) Yin water
Main symptoms: slow onset, edema of the soles of the feet, gradually spreading to the whole body, body swelling is especially severe below the waist, depression when pressed, recovery is slow , dull skin, lack of urination. Or it may be accompanied by abdominal distention, loss of appetite, loose stools, tired limbs, white and greasy tongue coating, and wet and slow pulse; or it may be accompanied by low back pain, soreness in the legs, chills and cold limbs, mental fatigue, pale tongue with white coating, and a heavy and thready pulse.
Treatment method: Mainly focus on the Taiyin and Shaoyin meridian points. Acupuncture uses tonic methods, and moxibustion is used to warm the spleen and kidneys, diuresis and reduce swelling.
Prescription: Pishu Shenshu Water Fuliu Guanyuan Sanyinjiao
Fang Yi; The cause of Yinshui is spleen and kidney yang deficiency, acupuncture of Pishu, Shenshu and Fuliu can warm the spleen and kidneys Yuanyang promotes the qi transformation of the triple burner; moxibustion dilutes water to eliminate edema; moxibustion Guanyuan nourishes vitality to warm the lower burner; tonic Sanyinjiao invigorates the spleen, removes dampness, and facilitates urination.
Other therapies
Auricular acupuncture
Acupoint selection: lung, spleen, kidney, triple burner, subcortical bladder
Method: 2-3 points each time Acupoint, moderate stimulation, once every other day. You can also use the method of burying beans in the ear points.
2. Localized edema
(1) Venous obstructive edema: common in thrombophlebitis, varicose veins of lower limbs, etc.
(2) Lymphatic obstructive edema: common in elephant skin legs caused by filariasis, chest edema caused by mumps, etc.
(3) Inflammatory edema: Commonly seen in local edema caused by erysipelas, boils, cellulitis, etc.
(4) Allergic edema: common in angioedema, contact dermatitis, etc.
Diet therapy
(1) Corn silk grass root drink: 50 grams each of corn silk grass and Imperata cognac root, make a decoction, add appropriate amount of sugar and take it in divided doses. Suitable for Yang Shui.
(2) Adzuki bean and carp soup: 60 grams of adzuki beans, 1 carp (intestines removed), 10 grams of ginger, stew soup without salt, eat fish and drink the soup. Suitable for yin water.
(3) Astragalus lean meat soup: 60 grams of astragalus, appropriate amount of lean pork, *** decoction, no salt, eat the meat and drink the soup. Suitable for yin water.
The pathogenesis of edema
Under physiological conditions, the interstitial fluid of the human body is in constant exchange and renewal, but the amount of interstitial fluid is relatively constant. The maintenance of constant interstitial fluid volume depends on the balance of fluid exchange inside and outside blood vessels and the balance of fluid exchange inside and outside the body. If these two balances are disrupted, excess fluid accumulation in tissue spaces or body cavities may result.
1. The imbalance of fluid exchange inside and outside blood vessels leads to an increase in interstitial fluid
The factors that cause the imbalance of fluid exchange inside and outside blood vessels include:
1. Increased capillary hydrostatic pressure
The main reason for increased capillary hydrostatic pressure is increased venous pressure. The factors causing increased venous pressure are:
①Cardiac insufficiency: right heart function Insufficiency of the superior and inferior vena cava blocks the return of the superior and inferior vena cava and increases the systemic venous pressure, which is an important cause of cardiac edema; left ventricular insufficiency blocks the return of the pulmonary veins and increases pressure, which is an important cause of pulmonary edema.
② Thrombosis or embolism, and tumor compression can increase local venous pressure and form local edema.
③ Increased blood volume can also cause an increase in capillary hydrostatic pressure. The increase in capillary hydrostatic pressure will lead to an increase in effective hydrostatic pressure, an increase in the average actual filtration pressure, and an increase in the production of interstitial fluid.
2. Decreased plasma colloid osmotic pressure
Reduced plasma colloid osmotic pressure is due to a decrease in plasma protein. Among them, albumin is the most important factor that determines the osmotic pressure of plasma glue. Causes of reduced albumin:
① Reduced synthesis. It is seen in the lack of synthetic raw materials caused by malnutrition or the low ability to synthesize albumin caused by severe liver dysfunction.
② Excessive loss is seen in nephrotic syndrome. Due to severe damage to the glomerular basement membrane, a large amount of albumin is lost in the urine.
③ Increased decomposition: Malignant tumors, chronic infections, etc. increase albumin catabolism.
④Hemodilution is seen in the retention of sodium and water in the body or the infusion of too much non-colloid solution, which reduces the concentration of plasma albumin. The decrease in plasma glue osmotic pressure reduces the effective glue osmotic pressure, and increases the average actual filtration pressure, resulting in increased interstitial fluid production.
3. Increased permeability of microvascular walls
Common in inflammation, hypoxia, acidosis, etc. Since the plasma protein concentration is much higher than the interstitial fluid protein concentration, the increased permeability of the capillary wall causes plasma proteins to penetrate into the interstitial space, resulting in a decrease in the plasma glue osmotic pressure and an increase in the interstitial fluid glue osmotic pressure. The effective glue osmotic pressure decreases, on average. The actual filter pressure increases. This type of edema fluid has a high protein content, up to 30g/L - 60g/L, and is called exudate.
The above three factors lead to an increase in interstitial fluid. At this time, the lymphatic return flow may increase compensatoryly. If the increase in interstitial fluid exceeds the compensatory capacity of lymphatic return, the amount of interstitial fluid in the tissue space may increase. Excessive fluid accumulation occurs, leading to edema.
4． Lymphatic drainage is blocked
Seen in filariasis, tumors, etc. During filariasis, a large number of adult worms block lymphatic vessels; some malignant tumors can invade and block lymphatic vessels, and tumors can also compress lymphatic vessels; during radical mastectomy, a large number of lymphatic vessels are removed, and these pathological conditions can lead to obstruction of lymphatic return. . Lymphatic drainage is an important factor in the fight against edema because the potential for lymphatic drainage is large. When the increase in interstitial fluid production reaches a critical value and obvious pitting edema occurs, lymphatic drainage can increase 10-50 times. In addition, lymphatic reflux is also the only way for interstitial proteins to return to the bloodstream, which can reduce interstitial fluid colloid osmotic pressure. When the interstitial fluid increases and the pressure increases, part of the fluid can flow back through the capillaries, while the protein still remains in the interstitial space. Therefore, the protein content in the edema fluid is relatively high (see Figure 6-2), which can reach 40g/L -50g. /L. Compared with inflammatory exudate, this type of edema fluid is sterile, has fewer cells, and mostly contains small-molecule proteins, without high-molecular-weight proteins such as fibrinogen.
2. Imbalance of fluid exchange inside and outside the body causes sodium and water retention
Under normal circumstances, the intake and excretion of sodium and water maintain a dynamic balance, so that the extracellular fluid Capacity remains constant. The kidney is the main organ that excretes sodium and water and is adjustable, so it plays an important role in maintaining extracellular fluid volume.
Various causes cause the kidneys to reduce sodium and water excretion, causing the total intake of sodium and water to be greater than the amount excreted, resulting in sodium and water retention in the body. There are three possible types of decreased sodium and water excretion by the kidney: ① GFR decreases without a corresponding decrease in tubular reabsorption; ② GFR remains unchanged but tubular reabsorption increases; ③ GFR decreases accompanied by increased tubular reabsorption.
1. Decreased GFR
(1) Diseases of the kidney itself: Certain kidney diseases reduce the ability of the kidneys to excrete sodium and water, such as acute glomerulonephritis, which causes swelling of capillary endothelial cells and thrombosis in the capillary lumen. , inflammatory exudates and proliferated cells (including mesangial cells and endothelial cells) compress capillaries, narrowing or even occluding them, reducing renal blood flow; accumulation of fibrin and cells in the glomerular cyst cavity, and a large number of crescents Body formation and obstruction of glomerular cyst cavity; both reduce GFR. In chronic glomerulonephritis and chronic renal failure, a large number of nephrons are destroyed, and the number of nephrons with filtration function is significantly reduced, which reduces the filtration area and also reduces GFR.
(2) Reduction in effective circulating blood volume: seen in congestive heart failure, nephrotic syndrome, cirrhosis, ascites, and malnutrition. The decrease in effective circulating blood volume reduces renal blood flow. At the same time, the corresponding decrease in arterial blood pressure passes through the baroreceptors of the carotid sinus and aortic arch, reflexively causing excitement of the sympathetic-adrenal medullary system, causing renal vasoconstriction, and further reducing renal blood flow; Reduced renal blood flow weakens the stimulation of afferent arteriolar baroreceptors, causing activation of the renin-angiotensin system, causing further contraction of renal blood vessels, resulting in a decrease in GFR.
2. Increased reabsorption of sodium and water by the renal tubules
Under physiological conditions, 99%-99.5% of the sodium and water filtered out by the glomerulus are reabsorbed by the renal tubules. Therefore, in most cases, increased renal tubular reabsorption plays a more important role in sodium and water retention. Factors causing increased sodium and water reabsorption:
(1) Increased filtration fraction:
Filtration fraction (FF) refers to the relationship between GFR and renal plasma flow Ratio, normally about 20% (120/600). When the effective circulating blood volume decreases, both renal plasma flow and GFR decrease. Generally, renal plasma flow decreases by about 50%, but the decrease in GFR is not as significant as the former. This is because the efferent arteriole contracts more than the afferent arteriole at this time. Assuming that the FF decreases from 120ml/min to 90ml/min, the FF increases from 20% to 30% (90/300). Increased FF means an increase in non-colloid fluid filtered out by the glomerulus.
In this way, the hydrostatic pressure of the capillaries around the proximal tubule decreases and the plasma colloid osmotic pressure increases, thus promoting the increase in sodium and water reabsorption by the proximal tubule.
(2) Reduction of atrial natriuretic peptide:
Atrial natriuretic polypeptide (ANP) is a peptide hormone composed of 21 to 35 amino acid residues. It can inhibit the reabsorption of sodium by the proximal convoluted tubule and inhibit the release of aldosterone and ADH, thus promoting the excretion of sodium and water. When the effective circulating blood volume decreases, the excitability of the stretch receptors in the atrium decreases, the secretion of ANP decreases, and the reabsorption of sodium and water by the proximal convoluted tubule increases. At the same time, the inhibition of the release of aldosterone and ADH weakens, aggravating sodium and water retention.
(3) Renal blood flow redistribution:
Under physiological conditions, 90% of renal blood flow enters the cortical nephron. Reduction in effective circulating blood volume causes excitation of the sympatho-adrenomedullary system and activation of the renin-angiotensin system, resulting in renal vasoconstriction. Because the afferent arterioles of the cortical nephron are more sensitive to catecholamines, the blood flow in the cortical nephron is significantly reduced, and the blood flow through the juxtamedullary nephron is increased. This change is called renal blood flow redistribution. Because the medullary loops of the juxtamedullary nephron are thin and long, penetrate into the hypertonic zone of the medulla, and are accompanied by small blood vessels, their renal tubules have a strong ability to reabsorb sodium and water. As a result of the increased blood flow in the juxtamedullary nephron, the medullary loop increases sodium and water reabsorption.
(4) Increased aldosterone and ADH:
When the effective circulating blood volume is reduced and the renin-angiotensin-aldosterone system (RAAS) is activated , which increases the secretion of aldosterone and ADH, and severe liver disease can also reduce the inactivation of both.
Characteristics of edema and its impact on the body
1. Characteristics of subcutaneous edema
1. Pitting edema (pitting edema)
When too much body fluid accumulates in the subcutaneous tissue space, the skin becomes pale, swollen, and wrinkles become shallower. The local temperature is lower and the elasticity is poor. Press the local area (such as the medial malleolus) with your fingers. , pretibial area or forehead, zygomatic area) skin, if there is a depression, it is called pitting edema (pitting edema) or frank edema (frank edema). After releasing your fingers, it will take a few seconds to a minute for the dent to heal. This is because during pitting edema, there is more free water (free water) in the subcutaneous tissue space. Due to the increase in local pressure when pressing, the free water moves to the lower pressure point, so a depression appears. After the finger is released, the free water The time it takes for it to return to its original position is the time it takes for the dent to heal.
2. Recessive edema (recessive edema)
In fact, before obvious pitting edema appears, the fluid in the tissue space has increased, but there is no depression in the local area when pressed. This state is called "recessive edema" (recessive edema) edema). This is because the liquid is adsorbed by the gel network in the interstitial space and becomes gel bound water. Only when the amount of liquid in the interstitial space increases, the intertissue fluid pressure increases from -0.87kPa (-6.5mmHg) to 0kPa. (0mmHg) or above, the free water in the tissue space will increase significantly.
2. Characteristics of systemic edema
1. Decreased urine output and increased weight
Common systemic edema includes cardiac edema, hepatic edema and renal edema. Sodium and water retention are important intermediate links in the pathogenesis of these edemas. Because the basic mechanism of sodium and water retention is the reduction of sodium and water excretion by the kidneys, patients often present with reduced urine output, low urinary sodium content (except in the oliguric stage of renal failure), and weight gain. Weight gain results from a significant increase in extracellular fluid volume. Because sodium and water retention can reach several liters and a body weight increases by 10%, there may still be no obvious pitting edema. Therefore, urine output and weight are relatively sensitive indicators of edema. Observing the dynamic changes in urine output and weight can reflect the cause of edema. Growth and decline.
2. Edema caused by different causes has different distribution locations.
Cardiocardial edema caused by right ventricular insufficiency first appears in the drooping parts of the body. When standing or sitting, edema appears first in the ankle area; when lying on the back, edema appears first in the sacrum. Edema caused by liver cirrhosis is mainly manifested as ascites. Renal edema manifests as edema of the eyelids when waking up in the morning, and may also affect the face. When the condition worsens, generalized edema may occur. Factors that affect the distribution characteristics of edema are:
① Gravity and body position: For example, in right heart failure, edema appears in the lowest part of the body. This is because when right heart failure occurs, the return of the superior and inferior vena cava is blocked. Increased venous pressure leads to increased capillary hydrostatic pressure. Capillary hydrostatic pressure is also affected by gravity. Capillary pressure is higher in the lowest sagging areas, so edema appears first in the lowest sagging areas.
②Local hemodynamic factors: For example, liver cirrhosis causes obstruction of hepatic venous return, which increases hepatic venous pressure and capillary hydrostatic pressure, becoming an important reason for the formation of ascites.
③Tissue structural characteristics: The eyelid tissue is relatively loose, the skin is thin and highly stretched, the interstitial pressure is low, and edema fluid is easy to accumulate here. In renal edema, there is no factor of increased capillary hydrostatic pressure. In the supine state at night, edema fluid accumulates in the eyelids with loose tissue. The edema is more obvious in the morning.
3. The impact of edema on the body
Edema has a variety of adverse effects on the body, and the size of the impact depends on the location, degree, occurrence speed and duration of the edema.
1. Cell dystrophy
Excessive fluid accumulation in tissue spaces increases the distance between tissue cells and capillaries, prolonging the transportation time of oxygen and nutrients; the accumulation of edema fluid can also compress local capillaries, causing blood loss The flow is reduced, causing cell trophic disorders. Tissue damage and ulcers are prone to occur in edema areas and are difficult to heal.
2. Organ dysfunction
Eedema can lead to corresponding organ dysfunction. For example, gastrointestinal mucosal edema can affect digestion and absorption, pulmonary edema can cause respiratory dysfunction, hydropericardium can affect the pumping function of the heart, and laryngeal edema can cause Airway obstruction or even suffocation, cerebral edema can lead to increased intracranial pressure, and even brain herniation, which is life-threatening. If edema occurs rapidly in important organs of life, it will be more harmful, while edema that occurs slowly in non-vital parts such as limbs may not have much impact on the body.
TCM interpretation:
Eedema, the name of the disease. A disease caused by retention of water and dampness in the body, resulting in swelling of the face, limbs, chest and abdomen, and even the whole body. "Suwen·Water-heat Acupoint Theory": "Therefore, the lungs are due to wheezing, the kidneys are edema, and the lungs are inverse and cannot lie down. They are divided into mutual losses, and both are affected by the retention of water and vapor." In ancient times, it was also called water and water vapor. , water disease. "The Synopsis of the Golden Chamber: Pulse Syndrome of Water Qi Disease" is divided into several types including Feng Shui, Pi Shui, Zheng Shui, Shi Shui, etc. It is also classified according to the five internal organs, including central water, lung water, liver water, spleen water, kidney water, etc. Later generations were divided into two categories: yang water and yin water. "Danxi Xinfa Edema": "If there is swelling all over the body, polydipsia, red and astringent urine, and constipation, this is Yang water. First drink it with Wupi powder or four grinds, and then grind it to produce Citrus aurantium. If it is severe, remove it. Drink. If there is swelling all over the body, no polydipsia, loose stools, and less astringent and red urine, this is Yin water, and it is appropriate to drink the spleen-enhancing drink or the woody-flavored drink. "Eedema is closely related to the spleen, lungs, and kidneys. "Jingyue Quanshu·Treatment of Edema": "If the lungs are deficient, the qi will not turn into essence but will turn into water; if the spleen is deficient, the earth will not control the water but will suppress it; if the kidneys are deficient, the water will have no owner and will move erratically; if the water does not return to the meridians, it will flow in the opposite direction." It spreads upward, so it passes into the spleen and causes edema of the skin and flesh, and passes into the lungs, causing shortness of breath. ""Jingui Synopsis" discusses the treatment principles of edema: "For those with water and swelling below the waist, it should be used to facilitate urination; above the waist. Swelling should be caused by sweating. "The syndrome is mostly caused by the invasion of external evils and abnormal qi transformation. The main treatment is to dispel the evils, and use methods such as dispelling wind, clearing the lungs, diuresis, and removing water. Use Ephedra and Forsythia Chixiaodou Decoction and Yuejiao. Add Shu Tang, Wuling Powder and other prescriptions. Deficiency syndrome is mostly caused by spleen and kidney yang deficiency, which cannot transport water and dampness. Treatment should focus on strengthening the body, using prescriptions such as warming the kidney, strengthening the spleen, replenishing qi, and unblocking yang, and Zhenwu Decoction and other prescriptions. It is also necessary to pay attention to the maintenance of diet and daily life, such as avoiding food, being careful about wind and cold, etc. See Feng Shui, Stone Water, Zheng Shui, Skin Water, Li Water, Qi Water, etc.