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A P P R O A C H TO TH E

LEG S W ELLIN G
Gatot Sugiharto, MD,
Internist
Internal Medicine
Department
Faculty of Medicine, Wijaya
Kusuma University Surabaya

Introduction
Edema:
Expansion of the interstitial fluid volume
Non-specific finding common to a host of
diseases
Reflects either:
Increased venous pressure
Decreased lymphatic drainage
Increased plasma volume
Or a combination
Severe Underlying Illness:
DVT
Heart failure
Severe volume overload

C auses of Leg Sw elling

Chronic Venous Insufficiency


CHF
DVT
Drugs
Hypoproteinemia / Nephrotic Sy. /
Cirrhosis
Myxedema
Constrictive / Restrictive
Cardiomyopathies
Lymphedema (elephantiasis)
Lipedema
Idiopathic
Misc. (Bakers cyst, cellulitis, pregnancy)

Pathophysilolgy
Starlings law:
Extravascular and intravascular hydrostatic
pressure
Differences in oncotic pressures within the
interstitial space and plasma;
The permeability of the blood vessel wall.

Vascular system
Interstitial space
Hydrostatic pressure

Hydrostatic pressure
Colloid oncotic pressure
(tissue
tension)
Colloid oncotic pressure

R ED U C ED P LA S M A
O S M O TIC P R ESS U R E
Albumin is the serum protein MOST

responsible for the maintenance of


colloid osmotic pressure

A decrease in osmotic pressure can

result from increased protein loss or


decreased protein synthesis

C A P ILLA R Y D A M A G E

Damage to the capillary endothelium


Increase its permeability and permits the
transfer of protein into interstitial
compartment
Injury agents
Drugs
Viral/bacterial agents
Thermal / mechanical trauma Immune
Responsible for inflammatory edema
Nonpitting localized redness and
tenderness

H ISTO RY

Worse in afternoon / hot days


Risk factors for venous insufficiency / DVT
Weight gain, DOE, Orthopnea, PND
Risk factors for heart disease (HTN, DM)
Medication , diet, fluid intake
Alcohol, hepatitis, trauma, pregnancy
Symptoms of hypothyroidism?
Ask questions such as the following:
Do the rings on your fingers get tight?
Have you had to let your belt out?
Have your clothes or shoes gotten too tight?

P H YSIC A L EX A M

Blood Pressure, HR
Venous pressure, rhales, murmur / gallop
Ascites
asymmetry
varicose veins, scars
dermal changes, ulcers
degree of pitting (1-4+) [subjective]

ED EM A

Pitting
Pittingedema
edema

Non-pitting
Non-pittingedema
edema

TESTIN G
RFT, LFT, CBC, TFT, Albumin, U/A, thiroid
ECG + ECHO (LV/RV fctn, valve disease, PA

pressure)
BNP?
CXR
Venous Duplex U/S (DVT, venous insufficiency,
popliteal aneurysm or cyst)
CT abdomen/pelvis (suspected pelvic obstruction)
V/Q scan or CT-A
Cardiac cath (CHF, Pulmonary HTN, Contrictive /
Restrictive Cardiomyopathy)
Arterial doppler studies (if ulcer or before
compression Rx.)

LO C A LIZ ED ED EM A
Inflammation
Venous/lymphatic obstruction
Chronic lymphangitis
Resection of regional lymph nodes
Filariasis

A P P R O A C H TO TH E
PATIEN T

Heart
Liver
Kidney

Generaliz
Generaliz
ed
ed

or
Venous obstruction
Lymphatic obstruction

Localized
Localized

ClinicalCauses ofEdem a
Systemic
edema
Congestive heart failure
Cirrhosis
Nephrotic

syndrome/other
hypoalbuminemia
Drug-induced
Idiopathic

Localized
edema
Venous/lymphatic

obstruction

C hronic Venous Insuf c


i
fiency (1)
Most common cause of leg swelling

(2% of population)
Venous incompetence venous
hypertension
women, multiparity, estrogen use

- hereditary
occupational (prolonged standing)
post-phlebitic syndrome
iatrogenic (CABG, FPBPG, pelvic
surgery)
obesity, age

C hronic Venous
(2)
I
nsuf
c
i
f
i
ency
Unilateral or bilateral
Exacerbated by prolonged standing, or

hot days
Typically worse in PM, less upon arising
Often complain of generalized leg aching
Often hyperpigmentation due to
hemosiderin deposition
(lipodermatosclerosis thick, brawny
skin)

TR EATM EN T
Venous Insufficiency
life-style changes : weight loss,
limit dietary salt, exercise (calf
muscle pump) avoid prolonged
immobility, standing
leg elevation (night, 30min 3-4X
daily)
Graduated compression
stockings : mainstay of treatment
(30-40mmHg @ ankle)
Diuretics

D eep Venous Throm bosis


Typically asymmetric
swelling
Many are asymptomatic;
<1/3 have classic triad
Risk Factors:

Age > 50
Immobilization / surgery /

GA
Hx. DVT
Malignant disease /
hypercoaguable state
Pregnancy hormonal
contraception
Trauma

D rugs:
Antihypertensives
Ca-blockers* Vasodilators (minoxidil,

hydralazine), B-blockers, clonidine,


methyldopa

NSAIDs
Hormones
estrogens, testosterone, corticosteroids,

progesterone, androgens

Hypoglycemics

thioglitazones

Antidepressants

R EN A L D IS EA S ES
Mainly due to hypoabluminemia

and salt/water retention


Associated with hematuria,
proteinuria, hypertention and
impaired renal functional
Characteriastic of edema of
renal origin: puffiness of the face
prominent in the periorbital areas

N
H R primary
O TIC
EP
The
alteration:
S Ydecreased
N D R O M E/Hcolloid
Y P O A LBoncotic
U M IN EM IC
S TATES

pressure, protein loss in the


urine, severe nutritional
deficiency, protein loss
enteropathy
Promotes fluid move into the
interstitium hypovolemia ,
salt/water retention activation
RAA axis etc

C O N G ES TIV E H EA R T
FA
I
LU
R
E
Left-sided heart failure: shortness of
breath with exertion and when lying down
at night pulmonary edema
Right-sided heart failure: swelling in the
legs and feet, peripheral edema
The physician examining a patient who
has congestive heart failure with fluid
retention looks for certain signs: pitting
edema; rales in the lungs, a gallop
rhythm, distended neck veins,
hepatomegali, ascites

Systemic Edema
Congestive heart failure

the lower
periobital areas
of the body
Progression
progress quickly
D IFFER EN TIA L D IA G
slowly
Identity
soft and mobile
relatively solid, less
mobile
Other signs
proteinuria
heart failure:
hypertension
cardiac enlargement
impaired renal
venous distention
functional test
hepatomegaly

part
progress

N O S IS

signs of

LIV ER D IS EA S ES (C IR R H O S IS )

Clinical evidence of hepatic disease


jaundice spider angiomas

ascites

Ascites refractory to the treatment


Edema may also occur in other

parts of the body due to:


Hypoalbuminemia
increased intraabdominal pressure
impede venous return from the
lower extremities

Systemic Edema

ID IO PATH IC ED EM A
Exclusive in women
Periodic episodes
Accompanied by abdominal

distention

ID IO PATH IC ED EM A
Diurnal alterations in weight

occurring with orthostatic retention


of sodium and water
Increase in capillary permeability
Fluctuate in severity
aggravated by hot weather
Reduction in plasma volume in this
condition with secondary activation
of the RAA system

O TH ER C A U S ES O F ED EM A
Hypothyroidism (myxedema,

periorbital puffiness, nonpitting)


Exogenous
hyperadrenoncortism
Pregnancy
Estrogens
Angioneurotic edeme

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