The spleen also may be enlarged and palpable, but this manifestation is uncommon and is almost always associated with hepatomegaly. On rare occasions, a protein-losing enteropathy can occur. This disorder is more common in patients with severe systemic venous congestion caused by tricuspid stenosis or constrictive pericarditis than in those with severe congestion caused by other lesions. Splanchnic congestion and bowel edema can lead to inadequate absorption of oral medications, particularly diuretics, and further exacerbate volume overload. Dependent edema is very common and is one of the early manifestations of right-sided congestive heart failure, as are distended neck veins.
Pitting edema appears in the dependent portions of the body.
Edema results from a combination of passive venous congestion and salt and water retention. The latter condition is related to increased aldosterone levels and decreased excretion of sodium by the kidneys. Ankle edema caused by right-sided heart congestion must be differentiated from ankle edema caused by local venous or lymphatic obstruction, cirrhosis, or hypoalbuminemia. Detection of jugular venous distention, which is not a feature of the last three causes of edema listed, permits easy determination of right-sided congestive heart failure.