1. EVALUATION OF LOWER EXTREMITY SWELLING
David Southwick DO
Medical 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. OBJECTIVES
1) Identify the most common causes of lower extremity swelling
2)Establish a differential diagnosis for less common causes of lower extremity swelling
3)Explain the pathophysiology of lower extremity swelling
4)Explain the work up of the most common causes of lower extremity swelling
5) 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 permeability
Decrease in the intravascular osmotic pressure
Excess bodily fluids
Lymphatic obstruction
Local injury
Infection
Medication effect

8. Pathophysiology of edema
1) Alteration in capillary hemodynamics favoring the movement of fluid from the intravascular to the interstitial space
2) Retention of dietary or intravenously administered sodium and water by the kidneys
Rose, 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 compensation
Initial movement of fluid from the vascular space into the interstitium results in reduction of plasma volume and hence tissue perfusion
Decreased tissue perfusion results in renal retention of sodium and water
Some of this fluid stays within the vascular space returning the plasma volume toward normal while most of the fluid enters the interstitium
Net effect is a marked expansion of total extracelluar volume- EDEMA
Rose 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

12. Workup of Lower Extremity edema

13. Basically there are two reasons for lower extremity edema
1) Venous origin
2) Lymphatic origin

14. Differential diagnosis of lower extremity edema
Venous obstruction
Venous insufficiency
Deep venous thrombosis
Right sides heart failure
Pericardial effusion
Cor pulmonale
Tricuspid stenosis
Pulmonary stenosis
Tricuspid regurgitation
Pericarditis
Congenitial heart disease

15. Differential diagnosis continued
Premenstrual fluid accumulation
Preeclapsia-eclampsia
Pregnancy
Idiopathic edema
Myxedema
Liver diease- cirrhosis
Low albumin states

16. Differential diagnosis continued
Fluid overload
Lipedema
Cellulitis
Compartment syndrome
Baker’s cyst
Malignancy
Lymphatic obstruction intralumenal and extralumenal
Medication effect
Limb dependency in wheelchair bound or patients with contractures
Oedema of the lower extremity- Right Diagnosis.com
Dolmatch B, Lower Extremity Venous Thrombosis and Leg Swelling: The Role of CT Venography; Stanford Radiology 10th Annual Multidetector CT Symposium: May 15, 2008
Arumilli,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 Edema
Common, yet unrecognized, cause of lower extremity edema is Pulmonary Hypertension often associated with Sleep Apnea
Ely, J et al Approach to Leg Edema of Un clear Etiology J. of the American Board of Family Practice MAR- Apr 2006 vol 19 no
Blankfield R et al Bilateral Leg Edema, Obesity, Pulmonary Hypertension and Obstrctive Sleep Apnea: Arch Intern Med/ vol. 160 Aug 14/

18. Caveats continued
For 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 therapy
Overnight improvement
Other symptoms
Pain: onset, degree and nature
Drug History
History of pelvic or abdominal neoplasia
History cardiac or renal disease
History Sleep Apnea
History Radiation therapy
Travel history/ Country of origin

20. Medications associated with edema
Antihypertensive drugs
Calcium channel blockers
Beta blockers
Clonidine
Hydralazine
Minoxidil
methyldopa
Hormones
Corticosteroids
Estrogen
Progesterone
Testosterone
Other
NSAID’s
Monoamine oxidase inhibitors
Rosiglitazone, Piogliatazone
docetaxel

21. Painful swollen legs
Pain to palpation: DVT, RSD lipedema, ruptured Baker’s cyst or gastrocnemius tear
Acute onset: less then 72 hours duration: DVT
Consider when : history cancer, recent surgery, bed ridden, limb immobilization, hypercoagulable state
Work up DVT: Unilateral painful swollen leg with history: D-dimer: if greater than 500 ng/ml then Doppler: if positive treat
Work 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 etiology
Elephantiasis:
Lymphatic filariasis: wucheria bancrofti, bruga malayi, bruga timori or protozoal: leischmania
Nonfilarial elephantiasis: volcanic ash residue chemical absorption via bare feet causing irritation and blockage of lymph vessels
Repeated streptococcal infection
Surgical removal lymph nodes
Hereditary birth defect

23. Physical Examination BMI: Elevated think sleep apnea
Distribution of edema: unilateral, bilateral or generalized
Pain on palpation
Pitting vs Nonpitting edema
Varicosities, telangectasia
Kaposi- Stemmer sign
Skin changes; waxy texture, papillomatosis, hemosiderin deposition,
Systemic signs: JVD, lung crackles, ascites spider hemangiomas jaundice

24. Phlegmasia alba dolens right leg

25. Phegmasia alba dolens

26. Phlegmasia cerulea dolens right leg

27. Unilateral right leg swelling: DVT

28. May Thurner syndrome
Compression Left greater saphenous vein by crossing Right common iliac artery

29. Pitting Edema

30. Ruptured Baker’s cyst Right leg

31. Ruptured right gastrocnemius muscle

32. Varicose veins

33. Elephantiasis Left leg

34. Laboratory testing few helpful
CBC UA
Electrolytes
BUN/ Creatinine
Blood sugar
Thyroid stimulating hormone
Serum albumin

35. If known cardiac history or if suspect cardiac disease
EKG
Echocardiogram: patient greater than 45 y.o. with edema uncertain etiology, suspect other cardiac disease
Chest Xray
Brain natriuretic peptide in dyspneic patient

36. Other testing: base on diagnosis
D-dimer: R/O DVT
Serum lipids: nephrotic syndrome
Lymphosintography: lymphedema
Directed Plain films , MRI : if suspect tumor
Venous doppler: if suspect DVT or Chronic Venous Insufficiency- be specific when ordering test; if suspect CVI specify reflux and perforator evaluation
Arterial doppler with ABI: if suspect CVI – 30% have unsuspected PAD, also compressive therapy requires verification of adequate arterial flow
Ely 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

38. Chronic venous insufficiency
Requirements for venous return are:
Competent bicuspid venous valves
Effective calf muscle contraction: “ankle-calf pump”
Normal respiration

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 edema
Often has associated with hemosiderin deposition
Ulceration over the “gaiter area” of shins- especially over medial malleolus : shallow ulcers with irregular margins
Common findings of varicose veins, retinacular veins, ankle flaring
Atrope blanche
Stasis dermatitis
Lipodermatosclerosis

41. Venous hemosiderin deposition

42. Venous ulceration
Shallow 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 cycle
Pathologic fluid retention in upright position
Weight gain due to fluid retention can be greater than 1.4 kg over 24 hours
Diagnosis by exclusion in young females

44. Summary

45. Unilateral Acute Chronic
Deep venous thrombosis Ruptured Baker’s cyst Ruptured medial head gastrocnemius muscle Compartment syndrome
Chronic venous insufficiency
Secondary lympedema
Pelvic tumor or lymphoma causing external pressure on veins
Reflex sympathetic dystrophy
May-Thurner syndrome

46. Bilateral Acute Chronic Bilateral DVT
Acute exacerbation of systemic etiology ie; heart failure or renal disease
CVI
Pulmonary hypertension
Heart failure
Idiopathic edema
Lymphedema
Drug effect
Premenstrual edema
Pregnancy
Obesity
Renal disease

47. Bilateral Acute Chronic Liver disease
Secondary lymphedema (tumor, radiation, bacterial infection, filariasis)
Pelvic tumor or lymphoma causing external pressure
Dependent edema- prolonged sitting, wheel chair bound
Diuretic –induced edema
Preeclampsia
Lipedema

48. Bilateral Acute Chronic Primary lymphedema
Protein losing enteropathy, malnutrition, malabsorption
Restrictive pericarditis
Restrictive cardiomyopathy
Beri beri
Myxedema

49. Zebras
Portal hypertension with a patent paraumbilical vein connection to the leg: Sivo J:J Ultrasound Med 21: , 2002
Bilateral peroneal compartment syndrome after horseback riding: Naidu, et al: Am J Emerg Med Sep:27(7): 901.e3-5
Painful 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. Recommendations
Go 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 therapy
There 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 Lipedema
Use 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

53. Questions?