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Differential Diagnosis of Edema
Jillian Caster PT DPT WCC CLT Chatham University Grand Rounds 11/10/16
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Objectives At the conclusion of this course you will be able to
Effectively evaluate and diagnose causes of edema Rule out/in red flag causes of edema and appropriately refer Effectively treat edema
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Edema What is edema? Definition: Edema is a palpable swelling produced by expansion of the interstitial fluid volume
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Pathophysiology Over filtration Increased capillary hydraulic pressure
Reduced capillary oncotic pressure Increased capillary permeability Reduced drainage Venous insufficiency Lymphatic insufficiency Increased interstitial oncotic pressure
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Causes Systemic Localized Allergic reaction Cardiac disease
Hepatic disease Malnutrition Sleep Apnea Pregnancy/premenstrual Renal disease Pulmonary hypertension Idiopathic edema Medication Localized Acute injury Cellulitis Chronic Venous Insufficiency Compartment Syndrome Complex Regional Pain Syndrome DVT & Post Thrombotic Syndrome Lipedema Lymphedema May Thurner
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Evaluation History Medication Onset Unilateral or bilateral
Positional changes in edema Coloring and skin texture Pitting or non-pitting History of wounds Stemmer sign Weight Pain Temperature Strength and mobility Jugular vein distention SOB Irregular heart rhythm Lung crackles Wells Rule Blood Work
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Red Flags Red Flags SOB and coughing Tachypnea, tachycardia
Irregular heat beat Ascites Periorbital edema Abnormal Labs Acute onset Redness Warmth Pain Fever + Wells
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Red Flags Numbness and tingling Pulslessness Acute injury
Proximal swelling distribution
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Wells Rule
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Stemmer’s Positive Negative
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Pitting Edema Scale Grade Definition 1+ 2mm or less
disappears immediately 2+ 2-4 mm few second rebound 3+ 4-6 mm 10-12 second rebound 4+ 6-8 mm > 20 second rebound
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Case 1 65 year old male with bilateral LE edema present for 10 years; former smoker; retired bus driver PMH: obesity, retinopathy, CHF, CAD, HTN, hyperlipidemia, aortic valve disease and replacement, CABG, sleep apnea, CKD, CVA, DM type 2, skin CA
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Case 1
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Case 1 History Bilateral Chronic 3+ Pitting edema Obesity
Cardiac disease Sleep apnea CKD CVA Medication
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Evaluation & Special Tests
Reduction with elevation Brawny, hemosiderin staining History of wounds Large amount of exudate -Stemmer’s Dull achiness Vitals WNL Ambulates community distances with minimal difficulty use of RW Well nourished 4/5 strength in L LE DF/PF, Quads, Hams, hip flexors otherwise LE MMT= WFL
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What can we rule out? Lymphedema Lipedema Dependent edema
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Diagnosis CVI CKD Cardiac Hemosiderin staining
Low viscosity/ protein poor Pitting edema Chronic Bilateral Achy/ heaviness Volume reduction overnight Possible varicosities Hemosiderin staining Inverted champagne bottle Ulcerations - Stemmer’s CKD Cardiac
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Treatment Wound care: absorbent dressings ABI Vascular Testing
Short stretch multilayer compression bandages Compression garments: 30-40mmHg LE elevation Therapeutic exercise
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ABI Highest systolic ankle / Highest systolic Brachial 1.0 < Normal
Abnormal Compromised < 0.5 Severe PAD- Do not compress!
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Case 2 66 y.o. Female with 30 year history of bilateral LE edema; works as CNA PMH: obesity, cataract repair, hyperlipidemia, HTN, CKD II, bilateral knee arthritis, DM type 2, hypothyroidism
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Case 2
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Case 2 History Bilateral Chronic 2+ Pitting edema Obesity
Cardiac disease CDK Stage II Bilateral knee arthritis Hypothyroidism
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Evaluation & Special Tests
Edema is stable with positional changes No wounds + Stemmer’s 10# weight gain No pain Normal Temp and skin coloring Areas of fibrosis and papillomas Bil LE strength WNL Ambulates unlimited distances no AD Vitals WNL
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What can we rule out? Venous insufficiency Lipedema Dependent edema
Medication Malnutrition
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Diagnosis Lymphedema CKD Hyperkeratotic skin Protein rich swelling
Chronic Painless Unilateral or Bilateral Stage I – Stage II Pitting Stage II – III non pitting Fibrosis Hyperkeratotic skin Squared of toes + Stemmers CKD
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Squared off toes Fibrosis & Hyperkeratosis
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Lymphedema Primary Secondary Milroy’s Meigs Lymphedema Tarda Tumor
Birth-2 years Meigs 2-35 years Lymphedema Tarda 35+ Secondary Tumor Surgery Radiation Infection Filariasis Venous Insufficiency Bilateral Phlebolymphostatic edema
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Treatment ABI CDT Therapeutic exercise
MLD Short stretch compression bandages Therapeutic exercise Flat knit custom compression garments
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Case 3 82 y.o. female; 3 month history of bilateral LE swelling; retired secretary; former smoker; limited ambulation PMH: HTN, CAD, CHF, A-fib, GERD, bowel obstruction, CKD, gout, bipolar disorder, hysterectomy, thyroidectomy
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Case 3
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Case 3 History Bilateral Chronic 4+ Pitting edema CHF, A-fib, HTN, CAD
CKD Medication Malnutrition Dependent edema Gout Hysterectomy
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Evaluation & Special Tests
Increased edema in dependent position Normal skin color and temp No Hx of non healing wounds - Stemmers 10# weight loss in 1 month No pain associated with edema Min A for sit <> stand; ambulates with RW household distances and uses W/C long distances Bilateral LE weakness Jugular vein distention Irregular hear rhythm SOB
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What can we rule out? CVI Lymphedema Lipedemia
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Diagnosis CHF CKD Dependent Malnutrition Chronic Bilateral Pitting
Jugular vein distention Gallop rhythm C/O dyspnea CKD Dependent Malnutrition
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Treatment Refer to cardiologist/kidney specialist Nutrition consult
Light compression garments once medically managed Education on elevating LEs
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Case 4 43 y.o. female with negative history of LE edema; woke up on 2 days ago with a red, swollen LE; typical, active life style, works as an elementary school teacher PMH: HTN, LBP
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Case 4
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Case 4 History Unilateral edema Acute symptoms 3+ Pitting
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Evaluation & Special Tests
No change in edema with elevation Redness with irregular borders, warmth 7/10 pain in R LE No wounds Onchomychosis -Stemmer’s sign Temp: 99.1, BP: 137/88, HR: 92, SpO2: 98% Strength and mobility WNL - Well’s
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What can we rule out? Lymphedema Lipedema CVI Cardiac Kidney Liver DVT
Baker’s Cyst CRPS Compartment Syndrome May Thurner Malnutrition Dependent Idiopathic
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Cellulitis Unilateral Acute onset Painful Red Warmth Systemic symptoms
Fever malaise achiness Pitting Wounds Onychomycosis
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Cellulitis Antibiotics Refer Pt to ER
Multilayer short stretch compression
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Everything else to keep in mind
Lipedema Chronic, bilateral, pitting Abnormal fat distribution from ankles to hips Treat with CDT and flat knit garments DVT Acute, unilateral, pitting Painful with palpation, redness, warmth, Wells Refer to ER
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Everything else to keep in mind
CRPS Chronic, unilateral, pitting Sweating, pallor, irregular hair growth Hx of traumatic injury Therapeutic exercise, refer for medical management Ruptured Baker’s Cyst Acute, unilateral, pitting Redness, warmth, trickling feeling Hx of knee complications Rest, elevation, compression
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Everything else to keep in mind
Pulmonary Hypertension Chronic, bilateral, pitting History of sleep apnea Refer to cardiologist Idiopathic edema Females <50, menstruating, weight gain through day, c/o hand and face edema, obesity, depression Refer- Spironolactone Compression garments if tolerated
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Everything else to keep in mind
Dependent edema Chronic, unilateral or bilateral, pitting Paralysis, reduced strength, dependent position Hx of CVA, MS etc Short stretch compression, compression garments Medication Chronic, bilateral, pitting Occurs with use of medication Refer for change in medication or compression
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Medication Class Specific Medication Antidepressants MAOIs, trazodone
Antihypertensives Beta blockers, Ca++ blockers, clonidine, hydralazine, methyldopa, minoxidil Antivirals Zovirax Chemotherapeutics Cyclophosphamide, cyclosporine, cytosine arabinoside, mithramycin Cytokines G-CSF, GM-CSF, interferon alfa, interluken-2 and 4 Hormones Androgen, corticosteroids, estrogen, progesterone, testosterone NSAIDs Celebrex, ibuprofen
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Everything else to keep in mind
Compartment Syndrome Acute, unilateral, pitting Pain, redness, paresthesia, pulse ER referral May Thurner Chronic, unilateral, pitting Left iliac vein is compressed by the right iliac artery Refer to vascular surgeon Compression following surgery
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Everything else to keep in mind
Malnutrition Chronic, bilateral, pitting Interstitial oncotic pressure is higher than capillary oncotic pressure drawing fluid out Typically older individuals, refer for blood work, nutrition consult Compression Kidney disease Reduced protein levels in blood causing interstitial oncotic pressure is higher than capillary oncotic pressure drawing fluid out Refer to nephrologist, conservative compression, garments
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Everything else to keep in mind
Liver disease Chronic, bilateral, pitting Ascites, jaundice, spider hemangiomas Reduced protein circulating, portal vein hypertension, refer for blood work and liver specialist Post thrombotic syndrome Chronic, unilateral or bilateral, pitting History of DVT causing deep venous insufficiency Blood clotting disorder Wound care, compression, refer for vascular testing and vascular surgeon
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References Al-Niami, F. (2009) Cellulitis and Lymphedema: A Vicious Cycle. Journal of Lymphedema 4(2): Ely, JW. (2006) Approach to Leg Edema of Unclear Etiology. JABFM 19(2): Sterns, RH. (2016) Clinical manifestations and diagnosis of edema in adults. Available from UpToDate.com. Accessed on 10 October 2016. World Union of wound healing societies initiative (2012). Compression in venous leg ulcers: A consensus document. Principles of Best Practice. Trayes, KP. (2013) Edema: Diagnosis and Management. Am Fam Physician 88(2): Norton, S. Norton School of Lymphatic Therapy Course Manual. Diagnosis & Therapy. Norton School of Lymphatic Therapy 2013. Banu, A. (2007) Lymphoedema- Up to Now- Review. Mædica A Journal of Clinical Medicine 2(1) Hogan, M (2007) Medical-Surgical Nursing (2nd ed.). Salt Lake City: Prentice Hall Zuther, J., Norton, S. Lymphedema Management: The Comprehensive Guide for Practitioners. 3rd Ed Theime, Stuttgart, Germany. Goodman, Fuller, Boissonnault. Pathology: Implications for the Physical Therapist. 2nd Ed Elsevier, USA. Caster, M (2016) Differential diagnosis & treatment considerations for the lower extremity.
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