EVALUATION OF LOWER EXTREMITY SWELLING

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 6 2000

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 • Corpulmonale • 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. 6 2008

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 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

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: wucheriabancrofti, brugamalayi, brugatimori 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 vsNonpitting 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. Phlegmasiaceruleadolens 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, 148-160 • Arumilli B, et al; Painful swollen leg – think beyond deep vein thrombosis or Baker’s cyst- World J SurgOncol 2008 6:6

37. Pleomorphic sarcoma post compartment Arumilli: Painful swollen leg- World J SurgOncol 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 horizontalVenous pressure superficial venous system is 20-30 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 Chronic venous insufficiency Secondary lympedema Pelvic tumor or lymphoma causing external pressure on veins Reflex sympathetic dystrophy May-Thurner syndrome Deep venous thrombosis Ruptured Baker’s cyst Ruptured medial head gastrocnemius muscle Compartment syndrome

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

49. 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

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