Presentation on theme: "EVALUATION OF LOWER EXTREMITY SWELLING"— Presentation transcript:
1 EVALUATION OF LOWER EXTREMITY SWELLING David Southwick DOMedical Director Wound Healing Center Union Hospital Terre Haute Indiana
2 Evaluation of lower extremity can be straight forward or fraught with difficulty
3 Evaluation is largely one of establishing a differential diagnosis
4 OBJECTIVES1) Identify the most common causes of lower extremity swelling2)Establish a differential diagnosis for less common causes of lower extremity swelling3)Explain the pathophysiology of lower extremity swelling4)Explain the work up of the most common causes of lower extremity swelling5) Explain the work up of less common causes of lower extremity swelling
5 From a practical sense most causes of lower extremity swelling is due to edema
6 edema is defined as a palpable swelling caused by an increase in interstitial fluid volume
7 Etiology of edema Increase in intravascular pressure Increase in vessel wall permeabilityDecrease in the intravascular osmotic pressureExcess bodily fluidsLymphatic obstructionLocal injuryInfectionMedication effect
8 Pathophysiology of edema 1) Alteration in capillary hemodynamics favoring the movement of fluid from the intravascular to the interstitial space2) Retention of dietary or intravenously administered sodium and water by the kidneysRose, Burton MD Pathophysiology and etiology of edema I and II Aug
9 Edema, other than localized edema, does not become clinically apparent until the interstitial volume has increased by 2.5 to 3 liters. The reason this is not due to intravascular causes but is due to renal function.
10 Renal compensationInitial movement of fluid from the vascular space into the interstitium results in reduction of plasma volume and hence tissue perfusionDecreased tissue perfusion results in renal retention of sodium and waterSome of this fluid stays within the vascular space returning the plasma volume toward normal while most of the fluid enters the interstitiumNet effect is a marked expansion of total extracelluar volume- EDEMARose Burton MD Pathophysiology and etiology of edema I and II Aug 6, 2000
11 Renal sodium and water retention in most edematous states is an APPROPIATE compensation in that it restores the intravascular space and hence perfusion
15 Differential diagnosis continued Premenstrual fluid accumulationPreeclapsia-eclampsiaPregnancyIdiopathic edemaMyxedemaLiver diease- cirrhosisLow albumin states
16 Differential diagnosis continued Fluid overloadLipedemaCellulitisCompartment syndromeBaker’s cystMalignancyLymphatic obstruction intralumenal and extralumenalMedication effectLimb dependency in wheelchair bound or patients with contracturesOedema of the lower extremity- Right Diagnosis.comDolmatch B, Lower Extremity Venous Thrombosis and Leg Swelling: The Role of CT Venography; Stanford Radiology 10th Annual Multidetector CT Symposium: May 15, 2008Arumilli,B et al, Painful Swollen leg- Think Beyond DVT and Baker’s Cyst: World Journal of Oncology. V
17 Approach to Patient with Edematous Lower Extremity Caveats The most common cause of lower extremity edema is Chronic Venous Insufficiency-The most common cause of leg edema in females between menarche and menopause is Idiopathic EdemaCommon, yet unrecognized, cause of lower extremity edema is Pulmonary Hypertension often associated with Sleep ApneaEly, J et al Approach to Leg Edema of Un clear Etiology J. of the American Board of Family Practice MAR- Apr 2006 vol 19 noBlankfield R et al Bilateral Leg Edema, Obesity, Pulmonary Hypertension and Obstrctive Sleep Apnea: Arch Intern Med/ vol. 160 Aug 14/
18 Caveats continuedFor patients greater than 50 years of age CVI is most common cause of leg edema- CVI affects 30% of the population whereas Heart Failure affects only 1%.Unless otherwise suspected by History and Physical assume one of the above to be true.Exception to the rule is EARLY heart failure or pulmonary hypertension can cause leg edema before clinically obvious.
19 HISTORY Duration of edema: acute vs chronic Previous history lower extremity edema: if positive- response to therapyOvernight improvementOther symptomsPain: onset, degree and natureDrug HistoryHistory of pelvic or abdominal neoplasiaHistory cardiac or renal diseaseHistory Sleep ApneaHistory Radiation therapyTravel history/ Country of origin
21 Painful swollen legsPain to palpation: DVT, RSD lipedema, ruptured Baker’s cyst or gastrocnemius tearAcute onset: less then 72 hours duration: DVTConsider when : history cancer, recent surgery, bed ridden, limb immobilization, hypercoagulable stateWork up DVT: Unilateral painful swollen leg with history: D-dimer: if greater than 500 ng/ml then Doppler: if positive treatWork up for DVT: Unilateral painful swollen leg without history: D-dimer: if less then 500ng/mg and PE consistent for musculoskeletal etiol then pain control and elevation; if PE etiol still questionable the Venogram. Also consider getting abd/pelvic CT to R/O malgnancy.
22 Travel History or country of origin Recent travel to tropics or tropical country of origin think parasitic etiologyElephantiasis:Lymphatic filariasis: wucheria bancrofti, bruga malayi, bruga timori or protozoal: leischmaniaNonfilarial elephantiasis: volcanic ash residue chemical absorption via bare feet causing irritation and blockage of lymph vesselsRepeated streptococcal infectionSurgical removal lymph nodesHereditary birth defect
23 Physical Examination BMI: Elevated think sleep apnea Distribution of edema: unilateral, bilateral or generalizedPain on palpationPitting vs Nonpitting edemaVaricosities, telangectasiaKaposi- Stemmer signSkin changes; waxy texture, papillomatosis, hemosiderin deposition,Systemic signs: JVD, lung crackles, ascites spider hemangiomas jaundice
34 Laboratory testing few helpful CBCUAElectrolytesBUN/ CreatinineBlood sugarThyroid stimulating hormoneSerum albumin
35 If known cardiac history or if suspect cardiac disease EKGEchocardiogram: patient greater than 45 y.o. with edema uncertain etiology, suspect other cardiac diseaseChest XrayBrain natriuretic peptide in dyspneic patient
36 Other testing: base on diagnosis D-dimer: R/O DVTSerum lipids: nephrotic syndromeLymphosintography: lymphedemaDirected Plain films , MRI : if suspect tumorVenous doppler: if suspect DVT or Chronic Venous Insufficiency- be specific when ordering test; if suspect CVI specify reflux and perforator evaluationArterial doppler with ABI: if suspect CVI – 30% have unsuspected PAD, also compressive therapy requires verification of adequate arterial flowEly J, et al: Approach to Leg Edema of Unclear Etiology JABFM MAR-Apr 2006 vol19 no 2,Arumilli B, et al; Painful swollen leg – think beyond deep vein thrombosis or Baker’s cyst- World J Surg Oncol :6
37 Pleomorphic sarcoma post compartment Arumilli: Painful swollen leg- World J Surg Oncol 2008: 6:6
39 Venous pressure deep venous system 80 mm Hg when horizontal Venous pressure superficial venous system is mm Hg when horizontal
40 Chronic venous Insufficiency Characterized by:Chronic pitting edemaOften has associated with hemosiderin depositionUlceration over the “gaiter area” of shins- especially over medial malleolus : shallow ulcers with irregular marginsCommon findings of varicose veins, retinacular veins, ankle flaringAtrope blancheStasis dermatitisLipodermatosclerosis
42 Venous ulcerationShallow with irregular margins, reddish base with granulation tissue
43 Idiopathic edema Most common in women in 20-30 year old range Cyclical edema but may persist throughout menstrual cyclePathologic fluid retention in upright positionWeight gain due to fluid retention can be greater than 1.4 kg over 24 hoursDiagnosis by exclusion in young females
49 ZebrasPortal hypertension with a patent paraumbilical vein connection to the leg: Sivo J:J Ultrasound Med 21: , 2002Bilateral peroneal compartment syndrome after horseback riding: Naidu, et al: Am J Emerg Med Sep:27(7): 901.e3-5Painful leg: a very unusual presentation of renal cell carcinoma. Case report and review of the literature: Gozen et al; Urol Int. 2009;82:472-6
50 RecommendationsGo with the odds but keep an open mind: remember CVI comprises 30% of population while heart failure comprises only 1%If condition is chronic you usually have time to work up and assess response to your therapyThere are only a few causes of acute unilateral or bilateral lower extremity edema: all of them are generally bad- time is of the essence for treatment especially if due to DVT or compartment syndrone
51 Recommendations continued If premenopausal woman without systemic disease think Idiopathic edema.If edema is chronic and of unclear etiology think LipedemaUse your history and physical to guide you, supplement with lab and imaging studies; remember the differential is long so can’t use a shotgun approach
52 Recommendations continued For cases of chronic bilateral lower extremity edema use your H&P to ascertain if Cardiac, Renal ,Liver or Gut ; supplement with labs, imaging as directed.Think outside the box for more obscure etiologies: sleep apnea, anatomic anomalies
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