When is Limb Edema Not Heart FailureAn Approach to the

Swollen Leg

Greg Harding M.D.

Vascular Surgeon

Faculty/Presenter Disclosure• Faculty: Greg Harding M.D.

• Relationships with commercial interests:

– None

Objectives

1. Identify the major causes of lower

limb edema

2. Develop an approach to the

diagnosis of lower limb edema

3. Review the treatment strategies

for the common causes of limb

edema

Edema• Palpable swelling caused by an increase

in interstitial fluid volume

• Challenge for primary care physicians

to determine the cause and find an

effective treatment

• Venous Insufficiency: Most common

cause in patients over the age of 50

• 30% of the population

• Heart Failure: Only 1% of population

over the age of 50SPOILER ALERT!

Edema Classification1. Venous Edema

• Low viscosity, protein poor

interstitial fluid from increased

capillary filtration that cannot be

accommodated by the normal

lymphatic system

2. Lymphedema

• Excess protein-rich interstitial

fluid from lymphatic dysfunction

3. Lipedema (not really true edema)

• Fat maldistribution

Venous Edema

Venous Edema

(with skin Changes)Lymphedema Lipedema

Swollen Legs

Common and less Common

causes of Leg Edema

Leg Edema-FrameworkUnilateral

Acute

<72 Hours

Chronic

Bilateral

Acute

<72hrs

Chronic

Common Causes of Leg EdemaUnilateral

Acute

<72 Hours

Chronic

Deep Venous

Thrombosis

• Venous

Insufficiency

Bilateral

Acute

<72hrs

Chronic

• Venous

insufficiency

• Pulmonary

Hypertension

• Heart Failure

• Idiopathic

• Lymphedema

• Drugs

• Premenstrual

• Pregnancy

• Obesity

Uncommon Causes of Leg Edema

Unilateral

Acute

<72 Hours

Chronic

• Ruptured

Baker’s cyst

• Secondary

lymphedema

• Ruptured

Medial head of

Gastrocnemius

• Pelvic

tumour or

lymphoma

• Compartment

syndrome

• Reflex

Sympathetic

dystrophy

Bilateral

Acute

<72hrs

Chronic

• Bilateral

DVT

• Renal Disease

• Worsening of

Systemic

Cause

• Secondary

Lymphedema

• Pelvic tumour

• Dependent

edema

• Pre-eclampsia

• Lipedema

• Anemia

Rare Causes of Leg Edema

Unilateral

Acute

<72 Hours

Chronic

• Primary

lymphedema

• Congenital

venous

Malformation

• May-Thurner

Syndrome

Bilateral

Acute

<72hrs

Chronic

• Primary

lymphedema

• Protein losing

enteropathy

• Malnutrition

• Restrictive

pericarditis

• Beri-Beri

• Myxedema

How am I going to make a

Diagnosis!

How am I going to make a Diagnosis!

History

The first thing I do is look!

Most Likely Venous Most likely venous

*But could be other stuff

History• Is the onset acute (<72hrs)?

• DVT

• Is the edema painful?

• DVT/infection

• What drugs are being taken?

• Calcium Channel blockers, Prednisone,

NSAID

• Is there a history of systemic disease

• Cardiac, Liver, Renal

• Is there a history of pelvic/Abdominal

neoplasm or radiation?

• Does the Edema improve overnight?

Chronic venous insufficiency more likely to

improve overnight

• Is there a history of Sleep apnea

• Pulmonary hypertension

Physical Exam• Body mass index

• Venous insufficiency and Sleep Apnea

• Distribution of the edema

• Unilateral due to local cause

• DVT, Venous, lymphedema

• Bilateral: local or systemic cause

• Generalized: systemic cause

• Local Tenderness

• DVT

• Pitting Edema

• DVT, Venous, systemic

• Myxedema and late Lymphedema do not

pitAcute DVT

Physical Exam

• Kaposi Stemmer sign

• Inability to pinch fold of skin on the dorsum of foot

• lymphedema

• Skin Changes

• Varicose Veins, Reticular veins

• Brown hemosiderin discoloration (venous)

• Warty texture and induration (lymphedema)

• Signs of systemic disease

• CHF

• Liver Disease

Ascites

Reticular Veins

An Approach to Leg Edema

Leg Edema without apparent cause

History and Physical Exam

Bilateral Edema

Are there red flags?• Acute onset

• Age>45 (consider Pulm Htn)

• Suspect systemic cause (Heart, Liver, Kidney)

• History or Clinical suspicion of malignancy

• Symptoms of sleep Apnea

• Medications

Consider most common causes

Evaluation for Systemic Disease

Unilateral Edema

Yes

Evaluate

Unilateral EdemaAcute (<72 hrs)

D-dimer +/- Ultrasound for DVT

Chronic

Suspicious for Malignancy.

Examine inguinal lymph nodes,

pelvic rectal exam. CT ABD.

Findings consistent with venous

insufficiency

Findings do not indicate etiology

Doppler exam (DVT/Venous insufficiency)

Evaluate for systemic disease

Refer

Treat

No

Etiology Unclear:• Laboratory studies: CBC, Electrolytes, Creatinine, Urinalysis,TSH and Albumin

• Acute Edema: d-dimer, Ultrasound for DVT if elevated or suspicion high

• Age>45 years: Echocardiogram to rule out Pulmonary hypertension or Heart

failure

• Suspect Heart disease: ECG, Echo, CXR

• Suspect liver Disease: ALT, AST, Bilirubin, ALP, INR, Albumin

• Suspect Renal Disease: Urinalysis, Lipids, Creatinine

• Suspect malignancy: CT abdomen/Pelvis

• Suspect Sleep Apnea: Sleep Study, Echocardiogram

• Lymphedema: Lymphoscintogram/CT Abd

• Medication known to cause edema: Reduction in dose or alternative Medication

Treatment

Venous Insufficiency

• Leg elevation

• Compression stockings (20-30mmHg, 30-40mmHg)

Lymphedema

• Leg elevation

• Compression garments

• Lymphatic massage

• Pneumatic compression

Treatment of Systemic Causes

Conclusions• The vast majority of leg swelling is Chronic

venous insufficiency

• Heart failure is overall a rare cause

• Further investigation for acute onset

• Further investigation for Red Flags

• Signs of systemic disease

• Suspicion for malignancy

• Sleep Apnea

Title & Full Image

Gregory E.J. Harding MD, FRCSC

Vascular Surgeon

gharding2@hsc.mb.ca

Thanks!