When is Limb Edema Not Heart Failure

Transcription

1 When is Limb Edema Not Heart Failure An Approach to the Swollen Leg Greg Harding M.D. Vascular Surgeon

2 Faculty/Presenter Disclosure Faculty: Greg Harding M.D. Relationships with commercial interests: None

3 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

4 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 over the age of 50 SPOILER ALERT!

5 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) Fat maldistribution Venous Edema

6 Swollen Legs Venous Edema (with skin Changes) Lymphedema Lipedema

7 Common and less Common causes of Leg Edema

8 Leg Edema-Framework Acute <72 Hours Unilateral Chronic Acute <72hrs Bilateral Chronic

9 Common Causes of Leg Edema Acute <72 Hours Deep Venous Thrombosis Unilateral Chronic Venous Insufficiency Acute <72hrs Bilateral Chronic Venous insufficiency Pulmonary Hypertension Heart Failure Idiopathic Lymphedema Drugs Premenstrual Pregnancy Obesity

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

11 Rare Causes of Leg Edema Bilateral Acute <72 Hours Unilateral Chronic Primary lymphedema Congenital venous Malformation May-Thurner Syndrome Acute <72hrs Chronic Primary lymphedema Protein losing enteropathy Malnutrition Restrictive pericarditis Beri-Beri Myxedema

12 How am I going to make a Diagnosis!

13 How am I going to make a Diagnosis!

14 History

15 The first thing I do is look! Most Likely Venous Most likely venous *But could be other stuff

16 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

17 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 pit Acute DVT

18 Physical Exam Kaposi Stemmer sign Inability to pinch fold of skin on the dorsum of foot lymphedema Skin Changes Varicose Veins, Reticular veins Brown hemosiderin discoloration (venous) Warty texture and induration (lymphedema) Reticular Veins Signs of systemic disease CHF Liver Disease Ascites

19 An Approach to Leg Edema

20 Leg Edema without apparent cause History and Physical Exam Unilateral Edema Evaluate Bilateral Edema Are there red flags? Acute onset Age>45 (consider Pulm Htn) Suspect systemic cause (Heart, Liver, Kidney) History or Clinical suspicion of malignancy Symptoms of sleep Apnea Medications Yes Evaluation for Systemic Disease Consider most common causes

21 Acute (<72 hrs) Unilateral Edema Chronic Suspicious for Malignancy. Examine inguinal lymph nodes, pelvic rectal exam. CT ABD. Refer D-dimer +/- Ultrasound for DVT Findings consistent with venous insufficiency No Findings do not indicate etiology Treat Doppler exam (DVT/Venous insufficiency) Evaluate for systemic disease

22 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

23 Treatment Venous Insufficiency Leg elevation Compression stockings (20-30mmHg, 30-40mmHg) Lymphedema Leg elevation Compression garments Lymphatic massage Pneumatic compression Treatment of Systemic Causes

24 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

25 Title & Full Image Thanks! Gregory E.J. Harding MD, FRCSC Vascular Surgeon