Pitting and non pitting edema
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Merck Manual edema pitting nonpitting examination
Pitting edema
Swelling in which firm finger pressure leaves a visible indentation for a few seconds after the pressure is released.
- It usually reflects excess, relatively mobile interstitial fluid.
- Common causes:
- Heart failure
- Chronic venous insufficiency
- Kidney disease or nephrotic syndrome
- Liver cirrhosis with low albumin
- Pregnancy, prolonged standing, some drugs such as calcium-channel blockers
- Deep-vein thrombosis can cause unilateral pitting swelling
- Often affects dependent areas: ankles and legs when standing, sacrum when bedbound.
- Can be graded clinically from 1+ to 4+, though grading definitions vary.
Frameworks for Internal Medicine, pp. 5626-5651.
Non-pitting edema
Swelling in which pressing the skin does not leave a persistent indentation.
- Usually results from protein-rich fluid, tissue inflammation, glycosaminoglycan accumulation, or fibrosis, rather than simple fluid overload.
- Common causes:
- Lymphedema, especially chronic disease, after lymph-node surgery/radiotherapy, malignancy, or filarial infection
- Myxedema in hypothyroidism due to glycosaminoglycan deposition
- Pretibial myxedema in Graves disease
- Lipedema, which classically spares the feet
- Chronic lymphedema may be firm or “brawny,” with thickened skin. Early lymphedema can still pit, then becomes non-pitting as fibrosis develops. Merck Manual overview
| Feature | Pitting edema | Non-pitting edema |
|---|---|---|
| Finger-pressure test | Indentation remains temporarily | No persistent indentation |
| Usual fluid/tissue change | Freely mobile interstitial fluid | Protein-rich fluid, mucopolysaccharides, fibrosis |
| Typical examples | Heart, renal, liver, and venous causes | Lymphedema, hypothyroid myxedema |
| Texture | Soft | Firm, thickened, sometimes brawny |
| Effect of elevation | Often improves | Less likely to improve in chronic cases |
Clinical warning: sudden one-sided leg swelling, pain, redness, or breathlessness needs urgent assessment to exclude DVT or pulmonary embolism.
How do I clinically grade pitting edema?
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pitting edema grading 1+ 2+ 3+ 4+ clinical examination source
Method
- Examine both legs and note site, symmetry, skin changes, tenderness, and how far the edema extends.
- Press your thumb firmly for about 2 seconds over a bony area:
- Dorsum of foot
- Just behind/above the medial malleolus
- Pretibial area
- Sacrum in a bedbound patient
- Release and assess the depth of the pit and time to refill. Document the grade, location, and laterality.
Common clinical grading scale
| Grade | Approximate pit depth | Refill time | Description |
|---|---|---|---|
| 1+ | ~2 mm | Immediate to a few seconds | Slight pit, no obvious limb distortion |
| 2+ | ~4 mm | Up to 10-15 seconds | Deeper pit, limb may look swollen |
| 3+ | ~6 mm | About 30-60 seconds | Noticeably deep pit; limb visibly full |
| 4+ | ~8 mm or more | More than 1-2 minutes | Very deep, persistent pit with gross swelling/distortion |
An example chart entry: “Bilateral, symmetrical 2+ pitting edema to mid-shin; no erythema or tenderness.”
The 1+ to 4+ system is subjective and exact depth/time cutoffs differ among institutions. For monitoring, use the same site, examiner technique, time of day, and add objective measurements such as serial ankle/calf circumference and daily weight where relevant. Textbooks recommend measuring indentation depth over a bony prominence for greater precision. Frameworks for Internal Medicine, pp. 5626-5651.
Urgently assess new unilateral swelling with pain, warmth, or redness, particularly if accompanied by chest pain or breathlessness.
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