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Evaluation of the Swollen Leg
Suman W Rathbun MD, MS
Director, Vascular Medicine
University of Oklahoma Health Sciences Center
Disclosure
• Diagnostica Stago: Grant support
Outline
• Acute versus Chronic
• Unilateral versus Bilateral
• Systemic Causes
• Testing
• Approach to evaluation
Approach
Is the edema acute or chronic?
Is it unilateral or bilateral?
Are there systemic causes?
Is imaging or labwork required to evaluate?
APPROACH TO THE PATIENT WITH LEG PAIN AND SWELLING
New or worsening symptoms
Yes
Objective testing for DVT
Abnormal:
Treat DVT
Normal:
Withhold DVT Treatment
Possible Diagnoses
Abscess
Muscle strain from
Baker’s cyst,
unaccustomed exercise
cyst rupture
muscle tear
Cellulitis
superficial phlebitis
Compartment
Swelling in paralyzed leg
syndrome,
Twisting leg injury
revascularization
Venous valvular
Lymphedema, lymphangitis
insufficiency
Major orthopedic surgery,
leg trama
No
Chronic swelling
Tumors
Drug Induced
Vascular
Lymphatic
Systemic, medical
Orthopedic
Miscellaneous
Dependency
Factitial limb swelling
Lipedema
Obesity
Reflex sympathetic dystrophy
Retroperitoneal fibrosis
Common Causes of Leg Edema
Unilateral
Acute (<72 hours)
Deep vein thrombosis
Chronic
Venous insufficiency
Ely et al. JABFM 2006;19:148
Deep-vein thrombosis
DVT with venous stasis and purpura
Venous insufficiency
Less Common Causes of Leg Edema
Unilateral
Acute (<72 hours)
Ruptured Baker’s cyst
Chronic
Secondary lymphedema
(tumor, radiation, surgery,
bacterial infection)
Ruptured medial head of gastrocnemius Pelvic tumor or lymphoma
causing external pressure on veins
Compartment syndrome
Reflex sympathetic dystrophy
Rare Causes of Leg Edema
Unilateral
Acute (<72 hours)
Chronic
Primary lymphedema (congenital
lymphedema, lymphedema praecox,
lymphedema tarda)
Congenital venous malformations
May-Thurner syndrome (iliacvein compression syndrome)51
Lymphedema praecox
Lymphedema
Lymphedema
Positive Stemmer Sign
Neurofibromatosis with unilateral lymphedema
Cellulitis
Klippel-Trenaunay syndrome
May-Thurner
Common Causes of Leg Edema
Bilateral
Chronic
Acute (<72 hours)
Venous insufficiency
Pulmonary hypertension
Heart failure
Idiopathic edema
Lymphedema
Drugs
Premenstrual edema
Pregnancy
Obesity
Drugs That May Cause Leg Edema
Antihypertensive drugs
Calcium channel blockers
Beta blockers
Clonidine
Hydralazine
Minoxidil
Methyldopa
Hormones
Corticosteroids
Estrogen
Progesterone
Testosterone
Other
Nonsteroidal anti-inflammatory drugs
Pioglitazone, Rosiglitazone
Monoamine oxidase inhibitors
Less Common Causes of Leg Edema
Bilateral
Chronic
Acute (<72 hours)
Bilateral deep vein thrombosis
Renal disease (nephrotic syndrome,
glomerulonephritis)
Acute worsening of systemic cause
(heart failure, renal disease)
Liver disease
Secondary lymphedema (secondary to tumor,
radiation, bacterial infection, filariasis)
Pelvic tumor or lymphoma causing external
pressure
Dependent edema
Preeclampsia
Lipidema
Anemia
Lipedema
Lipedema
Rare Causes of Leg Edema
Bilateral
Acute (<72 hours)
Chronic
Primary lymphedema (congenital lymphedema,
lymphedema praecox, lymphedema tarda)
Protein losing enteropathy, malnutrition,
malabsorption
Restrictive pericarditis
Restrictive cardiomyopathy
Beri Beri
Myxedema
Diagnostic Imaging of Edema
• Duplex: Exclude DVT, evaluate reflux
• Venogram: Exclude chronic venous obstruction
• Venous physiological testing
• Lymphoscintogram
• CT abdomen/pelvis: exclude tumor/extrinsic compression
Deep Vein Thrombosis
Venous reflux
Color doppler showing venous reflux
Venogram showing deep venous obstruction
Air plethysmography
• 35 cm long polyurethrane tubular air chamber surrounding entire leg
• Air chamber is inflated with air at 6 mm Hg and connected to the air
circuit for calibration
• Changes in the volume of the leg as a result of filling or emptying of
veins produce corresponding changes in the air chamber pressure.
Air plethysmography
The venoarterial reflex, or postural vasoconstriction reflex, is the decline in
limb blood flow in the dependent position due to an increase in pre-capillary
vascular resistance.1 Impairment of the venoarterial reflex may be a cause of
unexplained leg swelling.
ACCF Appropriate Use Criteria
JACC 2013;62:649-55
Lymphoscintogram showing dermal backflow
Lymphoscinogram showing delayed
progression of tracer on left
Pelvic gynecological tumor
Approach to Leg Edema
Leg edema without apparent cause
History and physical exam
Unilateral Edema
Bilateral edema
Are there any red flags?
Systemic Evaluation
Acute onset
Age > 45
Clinical suspicion of systemic cause
Suspicion of pelvic malignancy
Symptoms of sleep apnea
Medications
Adapted from Ely J et al. JABFM 2206;19:148
Consider common causes
Approach to Common Causes of Edema
Adolescent or adult female who is < 50
years old without signs of venous
insufficiency or systemic disease?
Yes
Treat for idiopathic edema
No
Yes
Does the patient have prominent signs of
venous insufficiency?
Treat for venous insufficiency
No
Evaluate for systemic cause
Adapted from Ely J et al. JABFM 2206;19:148
Evaluation of Systemic Causes of Edema
Acute edema: d-Dimer, follow with Doppler exam if d-Dimer elevated OR clinical suspicion of DVT high
Age > 45 years: echocardiogram to rule out pulmonary hypertension, heart failure
Suspicion of heart disease: ECG, echocardiogram, chest radiograph, brain failure
Suspicion of liver disease: ALT, AST, total bilirubin, alkaline phosphase, prothrombin time, serum albumin
Suspicion of kidney disease: urinalysis with exam of sediment, serum lipids
Suspicion of malignancy: abdominal/pelvic CT scan
Suspicion of sleep apnea: sleep study, echocardiogram
Lymphedema: abdominal/pelvic CT scan
Medication know to cause edema
Adapted from Ely J et al. JABFM 2206;19:148
Unilateral Edema: Acute
Acute (<72 hours)
D-Dimer
Negative
Positive
Low/mod pre-test probability
High pre-test probability: DUPLEX
Negative
Musculoskeletal
-Ruptured gastroc
-Baker’s cyst
Positive
+ DVT
Pain control; leg elevation
Adapted from Ely J et al. JABFM 2206;19:148
Unilateral Edema-Chronic
Reflex sympathetic dystrophy
Treat for reflex sympathetic dystrophy
No
Pelvic tumor
Abdominal/pelvic CT scan
No
Chronic Venous Insufficiency
Treat for venous insufficiency
No
Findings do not indicate an
etiology
Further testing
Adapted from Ely J et al. JABFM 2206;19:148
Summary
• Leg swelling is common
• Duration of swelling should be considered first, ie acute or chronic
• Unilateral versus bilateral swelling will direct differential diagnosis
• Imaging should be directed at both common and uncommon causes
• Swelling is sometimes multifactorial
• Systemic evaluation of edema requires a checklist approach