Edema, Lower Extremity

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)

  • Venous insufficiency is common complication

• 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)

  • 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

    • Popliteal fossa

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

Clinical Findings

Symptoms and Signs

• Unilateral lower extremity edema

  • DVT most common life-threatening cause

  • Risk factors for DVT (Table 2–4)

    • History of cancer

    • Recent limb immobilization

    • Confinement to bed for at least 3 days after surgery within the last month

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

• 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, ...