Peripheral Edema
Chronic venous insufficiency affects up to 25% of the general population and is the most common cause of edema or swelling of the lower extremities. Normal venous blood return to the heart requires competent venous valves, intermittent muscle contraction of the legs, and the force of respiration; venous hypertension, leading to insufficiency and edema, results when one of these components fail. Edema can be described as pitting (an indentation left after pressing in with a finger, which indicates fluid movement with pressure) or nonpitting (edema caused by swelling of tissue rather than fluid in the tissue, as occurs with lymphedema or myxedema).
Differential Diagnosis
- Venous insufficiency
–Caused by incompetent venous valves
–Skin characteristically has superficial varicose veins associated with a reddish-brown pretibial discoloration (“venous stasis skin changes”)
–Swelling is typically worse after legs are held in a dependent position and is least noticeable after a night's sleep
-
Congestive heart failure
–Associated with pitting peripheral edema
–Other signs of heart failure include a third
heart sound, cardiomegaly, and hepatomegaly
-
Cellulitis
–Usually unilateral
–Edematous legs are typically red, warm,
and inflamed
–The patient may exhibit signs of systemic toxicity with fever and leukocytosis
- Deep venous thrombosis
–Typically unilateral swelling
–May exhibit a palpable cord representing a thrombosed vein
–Homan's sign (pain in the calf with passive dorsiflexion of the foot)
–Virchow's triad (hypercoagulable states, venous stasis, and vessel injury) are risk factors
- Cirrhosis
–Advanced liver disease results in hypoalbuminemia and poor venous return through cirrhotic liver tissue
–Other stigmata of chronic liver disease include caput medusae, ascites, and spider angiomata
-
Nephrotic syndrome
–Glomerular damage results in protein loss and decreased oncotic pressure
-
Less common etiologies (“zebras”) include filariasis (lymphatic infection by Wuchereria bancrofti worm), myxedema (seen in patients with severe hypothyroidism), Milroy's disease (congenital lymphedema), chronic lymphedema (e.g., lymphatic damage due to surgery, such as vein harvesting for CABG), and gout
Workup and Diagnosis
-
History and physical examination should focus on time course, associated symptoms (e.g., dyspnea, urinary changes, fever), unilateral versus bilateral involvement, pitting versus nonpitting edema, and risk factors for DVT
-
Initial labs may include CBC, electrolytes, BUN/creatinine, urinalysis, coagulation studies, LFTs, serum albumin, and thyroid function tests
-
Chest X-ray may reveal signs of pulmonary edema or cardiomegaly
-
Duplex ultrasound of the legs is useful in diagnosing deep venous thrombosis
-
Echocardiography may reveal a depressed ejection fraction in cases of congestive heart failure
-
Blood cultures are often indicated in immunocompromised or systemically ill patients
-
Renal or liver biopsy may be necessary to diagnose cirrhosis or renal pathology leading to nephrotic syndrome
Treatment
-
Venous insufficiency: Mild cases should respond to leg elevation, avoidance of standing for prolonged periods, and compression stockings; surgical stripping of varicosities may relieve pain in severe cases
-
Congestive heart failure: Dietary salt restriction, diuretics, digoxin, ACE-inhibitors, β-blockers to improve cardiac
function and control fluid overload
-
Cellulitis: Elevation of extremity, antibiotics to cover skin flora (streptococci, staphylococci)
-
Deep venous thrombosis: Anticoagulation with unfractionated heparin, low molecular weight heparin or warfarin for 3–6 months
-
Cirrhosis: Liver disease is typically progressive; symptoms may respond to diuretics and low salt diet; hepatic bypass procedures (e.g., TIPS) or transplantation may be necessary
-
Nephrotic syndrome: 80% of cases in children are caused by minimal change disease and treated with steroids; adults tend to have progressive illness; dialysis or renal transplant may be necessary
Book Source Details
- Book Title: In a Page: Signs and Symptoms
- Author(s): Scott Kahan, Ellen G. Smith
- Year of Publication: 2004
- Copyright Details: In a Page: Signs and Symptoms, Copyright © 2004 Lippincott Williams & Wilkins.
Other Book Chapters Related to Foot swelling
Read excerpts from these other book chapters related to Foot swelling:
Medical Books Excerpts
- Edema
- "In A Page: Pediatric Signs and Symptoms" (2007)
- [ read ]
- Edema
- "A Pocket Manual of Differential Diagnosis" (1999)
- [ read ]
- Edema
- "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
- [ read ]
- Edema
- "Field Guide to Bedside Diagnosis" (2007)
- [ read ]
- Edema, facial
- "Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series" (2007)
- [ read ]
- Edema, generalized
- "Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series" (2007)
- [ read ]
- Edema
- "The Diagnostic Approach to Symptoms and Signs in Pediatrics" (2006)
- [ read ]
Copyright Details: In a Page: Signs and Symptoms, Copyright © 2008 Williams & Wilkins.
More About Causes of Foot swelling
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More About This Book:
Title: In a Page: Signs and Symptoms
Authors: Scott Kahan, Ellen G. Smith
Publisher: Lippincott Williams & Wilkins
Copyright: 2004
ISBN: 1-4051-0368-X
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» Next page: Edema (In A Page: Pediatric Signs and Symptoms)
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