When Is Limb Edema Not Heart Failure an Approach to the Swollen Leg

When is Limb Edema Not Heart Failure An Approach to the Swollen Leg

Greg Harding M.D. Vascular Surgeon Faculty/Presenter Disclosure • Faculty: Greg Harding M.D.

• Relationships with commercial interests: – None Objectives

1. Identify the major causes of lower limb edema

2. Develop an approach to the diagnosis of lower limb edema

3. Review the treatment strategies for the common causes of limb edema Edema • Palpable swelling caused by an increase in interstitial fluid volume

• Challenge for primary care physicians to determine the cause and find an effective treatment

• Venous Insufficiency: Most common cause in patients over the age of 50 • 30% of the population

• Heart Failure: Only 1% of population SPOILER ALERT! over the age of 50 Edema Classification 1. Venous Edema • Low viscosity, protein poor interstitial fluid from increased capillary filtration that cannot be accommodated by the normal lymphatic system

2. Lymphedema • Excess protein-rich interstitial fluid from lymphatic dysfunction

3. Lipedema (not really true edema) Venous Edema • Fat maldistribution Swollen Legs

Venous Edema Lymphedema Lipedema (with skin Changes) Common and less Common causes of Leg Edema Leg Edema-Framework Unilateral Bilateral Acute Chronic Acute Chronic <72 Hours <72hrs Common Causes of Leg Edema Unilateral Bilateral Acute Chronic Acute Chronic <72 Hours <72hrs Deep Venous • Venous • Venous Thrombosis Insufficiency insufficiency • Pulmonary Hypertension • Heart Failure • Idiopathic • Lymphedema • Drugs • Premenstrual • Pregnancy • Obesity Uncommon Causes of Leg Edema

Unilateral Bilateral Acute Chronic Acute Chronic <72 Hours <72hrs • Ruptured • Secondary • Bilateral • Renal Disease Baker’s cyst lymphedema DVT • Ruptured • Pelvic • Worsening of • Secondary Medial head of tumour or Systemic Lymphedema Gastrocnemius lymphoma Cause • Compartment • Reflex • Pelvic tumour syndrome Sympathetic • Dependent dystrophy edema • Pre-eclampsia • Lipedema • Anemia Rare Causes of Leg Edema

Bilateral Acute Chronic Unilateral <72hrs Acute Chronic • Primary <72 Hours lymphedema • Primary lymphedema • Protein losing • Congenital enteropathy venous • Malnutrition Malformation • Restrictive • May-Thurner pericarditis Syndrome • Beri-Beri • Myxedema How am I going to make a Diagnosis! How am I going to make a Diagnosis! History The first thing I do is look!

Most Likely Venous Most likely venous *But could be other stuff History • Is the onset acute (<72hrs)? • DVT • Is the edema painful? • DVT/infection • What drugs are being taken? • Calcium Channel blockers, Prednisone, NSAID • Is there a history of systemic disease • Cardiac, Liver, Renal • Is there a history of pelvic/Abdominal neoplasm or radiation? • Does the Edema improve overnight? Chronic venous insufficiency more likely to improve overnight • Is there a history of Sleep apnea • Pulmonary hypertension Physical Exam

• Body mass index • Venous insufficiency and Sleep Apnea • Distribution of the edema • Unilateral due to local cause • DVT, Venous, lymphedema • Bilateral: local or systemic cause • Generalized: systemic cause • Local Tenderness • DVT • Pitting Edema • DVT, Venous, systemic

• Myxedema and late Lymphedema do not Acute DVT pit Physical Exam

• Kaposi Stemmer sign • Inability to pinch fold of skin on the dorsum of foot • lymphedema • Skin Changes • Varicose Veins, Reticular veins Reticular Veins • Brown hemosiderin discoloration (venous) • Warty texture and induration (lymphedema)

• Signs of systemic disease • CHF • Liver Disease

Ascites An Approach to Leg Edema Leg Edema without apparent cause

Evaluate History and Physical Exam Unilateral Edema

Bilateral Edema

Are there red flags? • Acute onset • Age>45 (consider Pulm Htn) Yes • Suspect systemic cause (Heart, Liver, Kidney) Evaluation for Systemic Disease • History or Clinical suspicion of malignancy • Symptoms of sleep Apnea • Medications

Consider most common causes Unilateral Edema Acute (<72 hrs) Chronic

Suspicious for Malignancy. Refer Examine inguinal lymph nodes, pelvic rectal exam. CT ABD.

D-dimer +/- Ultrasound for DVT Findings consistent with venous Treat insufficiency

Findings do not indicate etiology

Doppler exam (DVT/Venous insufficiency) Evaluate for systemic disease Etiology Unclear: • Laboratory studies: CBC, Electrolytes, Creatinine, Urinalysis,TSH and Albumin

• Acute Edema: d-dimer, Ultrasound for DVT if elevated or suspicion high

• Age>45 years: Echocardiogram to rule out Pulmonary hypertension or Heart failure

• Suspect Heart disease: ECG, Echo, CXR

• Suspect liver Disease: ALT, AST, Bilirubin, ALP, INR, Albumin

• Suspect Renal Disease: Urinalysis, Lipids, Creatinine

• Suspect malignancy: CT abdomen/Pelvis

• Suspect Sleep Apnea: Sleep Study, Echocardiogram

• Lymphedema: Lymphoscintogram/CT Abd

• Medication known to cause edema: Reduction in dose or alternative Medication Treatment

Venous Insufficiency • Leg elevation • Compression stockings (20-30mmHg, 30-40mmHg) Lymphedema • Leg elevation • Compression garments • Lymphatic massage • Pneumatic compression

Treatment of Systemic Causes Conclusions • The vast majority of leg swelling is Chronic venous insufficiency

• Heart failure is overall a rare cause

• Further investigation for acute onset

• Further investigation for Red Flags • Signs of systemic disease • Suspicion for malignancy • Sleep Apnea Title & Full Image

Thanks! Gregory E.J. Harding MD, FRCSC Vascular Surgeon [email protected]