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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

  • 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

Table 2–4.Risk stratification of adults referred for ultrasound to rule out DVT.

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, ...

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