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For further information, see CMDT Part 2-07: Lower Extremity Edema

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

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

Clinical Findings

Symptoms and Signs

Unilateral edema

  • Deep venous thrombosis

    • Life-threatening

    • History of cancer, recent limb immobilization, or confinement to bed for at least 3 days following major surgery within the past month are suggestive clues

    • Adults with varicose veins have a significantly increased risk of DVT

    • Postphlebitic syndrome with valvular incompetence seen in patients with lower extremity swelling and inflammation in a limb recently affected by DVT

  • Other causes of a painful, swollen calf

    • Cellulitis

    • Musculoskeletal disorders (Baker cyst rupture ["pseudothrombophlebitis"])

    • Gastrocnemius tear or rupture

    • Calf strain or trauma

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

    • Other sites of nonthrombotic venous outflow obstruction, such as the inguinal ligament, iliac bifurcation, and popliteal fossa

  • Swelling of the ankle can be a manifestation of Charcot neuropathic osteoarthropathy

Bilateral edema

  • Bilateral involvement and significant improvement upon awakening

    • Favor systemic causes (eg, venous insufficiency)

    • Can be presenting symptoms of volume overload (HF, cirrhosis, kidney disease [eg, nephrotic syndrome])

  • Sensation of "heavy legs" is the most frequent symptom, followed by itching

  • Brawny, fibrotic skin changes; predisposition toward skin ulceration, particularly in the medial malleolar area

  • Lymphedema and lipedema

  • Pain is uncommon

  • Medications that may cause lower extremity swelling

    • Calcium channel blockers (particularly felodipine and amlodipine)

    • Pioglitazone

    • Gabapentin

    • Minoxidil

  • Pelvic congestion syndrome worsens symptoms of chronic venous symptoms of the lower extremities

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

    • Lymphedema (the Kaposi-Stemmer sign [the inability to pinch or pick up a fold of skin at the base of the second toe because of its thickness] can distinguish between lymphedema and chronic venous insufficiency)

    • Eclampsia

    • Hypothyroidism with myxedema

    • Filariasis


Laboratory Tests

  • Serum creatinine, blood urea nitrogen

  • D-dimers

  • Urinalysis

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

  • Thyroid-stimulating hormone

Imaging Studies


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