Download EVALUATION OF LOWER EXTREMITY SWELLING

EVALUATION OF LOWER
EXTREMITY SWELLING
David Southwick DO
Medical Director Wound Healing Center
Union Hospital Terre Haute Indiana
Evaluation of lower extremity can be
straight forward or fraught with
difficulty
Evaluation is largely one of establishing
a differential diagnosis
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
From a practical sense most causes of
lower extremity swelling is due to
edema
edema is defined as a palpable
swelling caused by an increase in
interstitial fluid volume
Etiology of edema
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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
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 6
2000
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.
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
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Rose Burton MD Pathophysiology and etiology of edema I and II Aug 6, 2000
Renal sodium and water retention in
most edematous states is an
APPROPIATE compensation in that it
restores the intravascular space and
hence perfusion
Workup of Lower Extremity edema
Basically there are two reasons for
lower extremity edema
• 1) Venous origin
• 2) Lymphatic origin
Differential diagnosis of lower
extremity edema
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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
Differential diagnosis continued
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Premenstrual fluid accumulation
Preeclapsia-eclampsia
Pregnancy
Idiopathic edema
Myxedema
Liver diease- cirrhosis
Low albumin states
Differential diagnosis continued
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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
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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. 6 2008
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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 2 148-160
• Blankfield R et al Bilateral Leg Edema, Obesity, Pulmonary Hypertension
and Obstrctive Sleep Apnea: Arch Intern Med/ vol. 160 Aug 14/28 2000
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.
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
Medications associated with edema
• Antihypertensive drugs
• Hormones
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Calcium channel blockers
Beta blockers
Clonidine
Hydralazine
Minoxidil
methyldopa
Corticosteroids
Estrogen
Progesterone
Testosterone
• Other
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NSAID’s
Monoamine oxidase inhibitors
Rosiglitazone, Piogliatazone
docetaxel
Painful swollen legs
• Pain to palpation: DVT, RSD lipedema, ruptured
Baker’s cyst or gastrocnemius tear
• Acute onset: less then 72 hours duration: DVT
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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: Ddimer: 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.
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
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
Phlegmasia alba dolens right leg
Phegmasia alba dolens
Phlegmasia cerulea dolens right leg
Unilateral right leg swelling: DVT
May Thurner syndrome
Compression Left greater saphenous vein by crossing Right common iliac
artery
Pitting Edema
Ruptured Baker’s cyst Right leg
Ruptured right gastrocnemius muscle
Varicose veins
Elephantiasis Left leg
Laboratory testing few helpful
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CBC
UA
Electrolytes
BUN/ Creatinine
Blood sugar
Thyroid stimulating hormone
Serum albumin
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
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
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Ely J, et al: Approach to Leg Edema of Unclear Etiology JABFM MAR-Apr 2006 vol19 no 2, 148-160
Arumilli B, et al; Painful swollen leg – think beyond deep vein thrombosis or Baker’s cyst- World J Surg
Oncol 2008 6:6
Pleomorphic sarcoma post compartment
Arumilli: Painful swollen leg- World J Surg Oncol 2008: 6:6
Chronic venous insufficiency
• Requirements for venous return are:
• Competent bicuspid venous valves
• Effective calf muscle contraction: “ankle-calf pump”
• Normal respiration
Venous pressure deep venous system
80 mm Hg when horizontal
Venous pressure superficial venous
system is 20-30 mm Hg when
horizontal
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
Venous hemosiderin deposition
Venous ulceration
Shallow with irregular margins, reddish base with granulation tissue
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
Summary
Unilateral
Acute
Deep venous thrombosis
Ruptured Baker’s cyst
Ruptured medial head
gastrocnemius muscle
Compartment syndrome
Chronic
• Chronic venous insufficiency
• Secondary lympedema
• Pelvic tumor or lymphoma
causing external pressure
on veins
• Reflex sympathetic
dystrophy
• May-Thurner syndrome
Bilateral
Acute
• Bilateral DVT
• Acute exacerbation of
systemic etiology ie; heart
failure or renal disease
Chronic
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CVI
Pulmonary hypertension
Heart failure
Idiopathic edema
Lymphedema
Drug effect
Premenstrual edema
Pregnancy
Obesity
Renal disease
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
Bilateral
Acute
Chronic
• Primary lymphedema
• Protein losing enteropathy,
malnutrition, malabsorption
• Restrictive pericarditis
• Restrictive cardiomyopathy
• Beri beri
• Myxedema
Zebras
• Portal hypertension with a patent paraumbilical
vein connection to the leg: Sivo J:J Ultrasound
Med 21: 807-809, 2002
• Bilateral peroneal compartment syndrome after
horseback riding: Naidu, et al: Am J Emerg Med.
2009 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
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
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
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
Questions?