Ankle oedema

Amlodipine and nifedipine are dihydropyridine calcium-channel blockers. Amlodipine differs from nifedipine in that it has a longer duration of action and can therefore be given once daily, unlike nifedipine. Both are indicated in hypertension and angina and tend to cause ankle oedema that does not respond to diuretic therapy. Neither amlodipine nor nifedipine are available as spray formulations. 

Headache, flush, dizziness, hypotension, ankle oedema (mostly dihydropyridines), bradycardia, and impaired atrioventricular conduction (verapamil and, to a lesser extent, diltiazem), constipation (verapamil), heart failure (verapamil, rare), oesophageal reflux. 

Calcium channel blockers are well known to cause peripheral oedema, in particular ankle oedema. This occurs as the vasodilatation induced by the drug tends to make the blood vessel walls leaky, and so fluid escapes to, and accumulates in the surrounding tissues. Unfortunately, this condition is unresponsive to diuretic therapy, and so the only way to reverse it is to discontinue the drug. 

Adverse effects of class II calcium channel blockers are reflex tachycardia, headache, flushing, palpitations and ankle oedema. 

On examination, you And that this sore has all the characteristics of an ulcer. Mr Buckley s feet are cold to the touch and he confirms that he often finds it difficult to keep his feet warm. He admits to having hypertension, for which he is being treated, but also says he has not seen his GP for 18 months other than to arrange this visit to the podiatrist. His current drug therapy has not changed for the past five years. There also appears to be significant ankle oedema, which has worsened since Mr Buckley retired 10 weeks ago. 

Amantadine has few side effects, mainly gastrointestinal disturbances and ankle oedema, but becomes less effective over time as the dopaminergic neurones are progressively lost. 

SI. a 37-year-old male, presented to his GP complaining of nocturia, frequency of micturition and polydipsia. On examination, he had mild truncal obesity, plethora, and ankle oedema. He had purpura of his arms but no striae. Mis blood pressure was 185/115 mm Hg. Biochemistry results in a serum specimen showed ... 

A hypertensive woman taking felodipine 10 rag daily developed taehy-cardia, flushing and massive ankle oedema within 2 to 3 days of starting to take erythromycin 250 mg twice daily. Her blood pressure had fallen from 120/90 to 110/70 mmHg. She fully recovered within a few days of stopping the erythromycin. ... 

A 39-year-old man taking ciclosporin, whose second kidney transplant functioned subnormally, and who required treatment for hypertension with atenolol and minoxidil, developed ankle oedema, which was resistant to furosemide, despite doses of up to 750 mg daily. When metolazone 2.5 mg daily was added for 2 weeks his serum creatinine levels more than doubled, from 193 to 449 micromol/L. When metolazone was stopped the creatinine levels fell again. Ciclosporin serum levels were unchanged and neither graft rejection nor hypovolaemia occurred. ... 

Erythrodermic psoriasis results in a widespread erythema that affects most of the body. It is often associated with pustular psoriasis. Oedema, particularly around the ankles, is common, as is excessive exfoliation of the skin and severe itching and/or pain. 

Mrs MW presented with a swollen abdomen, swollen ankles, pitting oedema and breathlessness. There are two key factors involved in the pathogenesis of ascites formation, namely, sodium and water retention and portal hypertension. 

Q2 Yes. Luckily, Harry does not seem to have suffered a heart attack, but he has developed mild heart failure, shown by cardiac enlargement and swollen ankles. A normal heart can pump out the blood returning to it via the veins. As the heart begins to fail it is unable to maintain this output and the ventricles enlarge, because of additional blood. Venous pressure rises and disturbs tissue fluid formation as a result of increased hydrostatic pressure in the capillaries. More fluid moves out of the capillaries than can be reabsorbed and this leads to tissue oedema, which is most easily observed in the areas of body particularly affected by gravity the ankles and feet. 

The main function of albumin in the plasma is to provide colloid osmotic pressure. It is of major importance in maintaining blood volume and in the exchange of fluid between blood and the tissues. Heavy proteinuria may involve the loss of >3.5 g of albumin per day and this, in turn, causes a reduction in plasma oncotic pressure. When plasma oncotic pressure is reduced, fluid is not completely reabsorbed from the tissues at the venous end of capillaries. The fluid is retained within the tissues, causing oedema. The effects of gravity on fluid accumulation in the body causes oedema to be more marked in the lower body than in the upper parts, so oedema is often noticed first around the ankles. 

Loss of albumin in the urine following glomerular dysfunction causes oedema, which is often first seen in the dependent parts of the body, for example ankles. 

Peripheral oedema is caused by fluid retention in the legs and ankles due to activation of the renin-angiotensin-aldosterone system. There are many causes of peripheral oedema other than liver dysfimction. 

ITRACONAZOLE KETOCONAZOLE t itraconazole levels, with risk of toxic effects Ketoconazole is a potent inhibitor of the metabolism of itraconazole by the CYP3A4 and a potent inhibitor of P-gp, which is considered to T bioavailability of itraconazole Warn patients about toxic effects such as swelling around the ankles (peripheral oedema), shortness of breath, loss of appetite (anorexia) and yellow discoloration of the urine and eyes (jaundice), i dose if due to interaction... 

Oedema states associated with sodium overload, e.g. cardiac, renal or hepatic disease, and also without sodium overload, e.g. acute pulmonary oedema following myocardial infarction. Note that oedema may also be localised, e.g. angioedema over the face and neck or aroimd the ankles following some calcium channel blockers, or due to low plasma albumin, or immobility in the elderly in none of these circumstances are diuretics indicated. 

Right ventricular failure can occur due to chronic lung disease, pulmonary valve disease and congenital defects. The symptoms are systemic oedema, particularly of the legs and ankles. 

A 20-year-old woman in her first pregnancy was referred to hospital by her GP when she was 31 weeks pregnant. At 12 weeks pregnant she appeared well, had no oedema and her blood pressure was 110/70 minHg. Now, she complained that she was unable to remove her wedding ring and that her vision was blurred. On examination ankle tx dcma was also observed and her blood pressure was found to be 180/ 110 mmHg. 

Eight months after an attack of acute glomerulonephritis, a. S-year-old housewife was hospitalized for investigation of progressive bilateral leg oedema. On examination, she was normotensive and exhibited pitting oedema of both ankles and dullness over her lung bases. Her face was pale and puffy and she admitted to frequent minor intercurrent infections. 

It is important to emphasize the difference between the previously mentioned acute oedema tests in the rat-foot, and chronic chemically-induced arthritis , an example of which is formalin arthritis . In this type of experiment, first described by Selye , two or more injections of formalin are made into the subplantar area of the foot. After the acute oedema has subsided, the surrounding skin remains hyperaemic and after a few days the peri-articular connective tissue begins to proliferate, especially in the region of the ankle joint. Other irritants, such as mustard and kaolin , have also been used to produce such chronic articular damage. 

Itraconazole can markedly raise the serum levels of felodipine, which Increases Its adverse effects, In particular ankle and leg oedema. A few case reports suggest that isradipine and nifedipine can interact similarly with itraconazole, and that fluconazole can also interact with nifedipine. Ketoconazole can markedly raise the plasma levels of lercanidipine and nisoldipine. Caution is warranted with all calcium-channel blockers when azole antifungals, particularly itraconazole and ketoconazole, are used. 

Fig. 5.9a,b. AP and lateral radiographs of the ankle show possible slight distortion of the medial malleolus with widening of the medial aspect of the distal tibia physis. Coronal STIR confirms the presence of a fracture involving the physis. There is extensive marrow oedema with a clearly visible low signal fracture line... 

Venous insufficiency is the most common cause of leg ulcers. Venous insufficiency is often caused by deep thrombosis or weakness of the valve system of the lower leg superficial veins, but the wound may also be caused due to, for example, arterial circulatory disorders, vasculitis or diabetes. The first sign of venous insufficiency is lower leg swelling but also eczema around the ankle, caused by venous stasis, can be an early marker (Mayrovitz and Larsen, 1997). The most important treatment is to counteract the oedema condition, which can be done by keeping the leg in a raised position or by applying a compression bandage to the leg (Reichenberg and Davis, 2005 Rajendran et al., 2007). 

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