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Key Features

Essentials of Diagnosis

  • Inquire about

    • History of venous thromboembolism

    • Symmetry of swelling

    • Pain

    • Change with dependence

    • Skin findings: hyperpigmentation, stasis dermatitis, lipodermatosclerosis, atrophie blanche, ulceration

General Considerations

  • Lower extremities can swell in response to

    • Increased venous or lymphatic pressures

    • Decreased intravascular oncotic pressure

    • Increased capillary leak

    • Local injury or infection

  • Acute lower extremity edema: deep venous thrombosis (DVT)

  • Chronic venous insufficiency is the most common cause of chronic lower extremity edema, affecting up to 2% of the population

  • Other causes of lower extremity edema

    • Cellulitis

    • Musculoskeletal disorders (Baker cyst rupture, gastrocnemius tear or rupture, diabetic myonecrosis)

    • Lymphedema, lipoedema

    • Heart failure (HF)

    • Cirrhosis

    • Nephrotic syndrome

    • Left common iliac vein compression (May-Thurner syndrome)

    • Medication side effects (eg, calcium channel blockers, gabapentin, minoxidil, or pioglitazone)

Clinical Findings

Symptoms and Signs

  • Most common symptom of chronic venous insufficiency is the sensation of "heavy legs," followed by itching

  • Assess heart, lungs, and abdomen for evidence of pulmonary hypertension (primary or secondary to chronic lung disease), HF, or cirrhosis

  • Size of both calves should be measured 10 cm below the tibial tuberosity

  • Swelling of the entire leg or swelling of one leg > 3 cm more than the other suggests deep venous obstruction

  • Elicit pitting and tenderness

  • Chronic venous insufficiency skin findings range from hyperpigmentation and stasis dermatitis to lipodermatosclerosis and atrophie blanche to skin ulceration

  • Stasis dermatitis: brawny, fibrotic skin changes

  • Skin ulceration can occur, particularly in the medial malleolar area, when due to chronic venous insufficiency

  • Other causes of medial malleolar skin ulceration

    • Arterial insufficiency

    • Vasculitis

    • Infections (including cutaneous diphtheria)

    • Cancer

Differential Diagnosis

  • Cardiovascular

    • HF (right-sided)

    • Pericardial effusion

    • Pericarditis

    • Tricuspid regurgitation

    • Tricuspid stenosis

    • Pulmonic stenosis

    • Cor pulmonale

    • Venous insufficiency (most common)

    • Venous obstruction

  • Noncardiovascular

    • Cirrhosis

    • Low albumin (nephrotic syndrome, malnutrition, protein-losing enteropathy)

    • Cellulitis

    • Premenstrual fluid retention

    • Drugs (vasodilators, eg, calcium channel blockers; salt-retaining medications, eg, nonsteroidal anti-inflammatory drugs, thiazolidinediones)

    • Musculoskeletal (Baker cyst, gastrocnemius tear, compartment syndrome)

    • Lymphatic obstruction

    • Eclampsia

    • Hypothyroidism with myxedema

    • Filariasis

  • Unilateral

    • DVT

    • Venous insufficiency

    • Baker cyst

    • Cellulitis

    • Trauma

    • Lymphatic obstruction, eg, obstruction by pelvic tumor

    • Reflex sympathetic dystrophy


Laboratory Tests

  • Serum creatinine, blood urea nitrogen

  • D-dimers

  • Urinalysis

  • Liver chemistries: alkaline phosphatase, aspartate aminotransferase, gamma glutamyl-transpeptidase, total bilirubin, albumin

  • Thyroid-stimulating hormone

Imaging Studies

  • Ultrasonography with gel pad can measure leg edema if physical exam is equivocal

  • Ankle-brachial pressure index (ABPI)

Diagnostic Procedures

  • Consider echocardiogram

  • The "Wells prediction rule" allows a clinician to exclude a lower extremity DVT in patients without an ultrasound if the patient has low pretest probability for DVT and has a negative sensitive D-dimer test


  • Treatment should ...

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