Leg edema

Causes

  • Increased plasma volume due to renal sodium retention
    • Heart failure
      • Shortness of breath
    • Renal failure
      • Urinalysis (red cell casts), elevated BUN and creat
    • Nephrotic syndrome
      • Periorbital edema
      • Hypoalbuminemia, heavy proteinuria
  • Venous obstruction or insufficiency
    • Cirrhosis
      • Ascites, then edema
    • Venous thrombosis
    • Chronic venous insufficiency - post-thrombotic syndrome
  • Arteriolar vasodilation
    • Drug-induced
      • Vasodilators (CCB, hydralazine, minoxidil)
      • Thiazolidinediones (for diabetes) and NSAIDs can worsen edema from CHF or cirrhosis

Unilateral edema

  • Deep vein thrombosis
    • Tenderness
  • Venous insufficiency
    • Brown hemosiderin deposits
  • Lymphedema
    • History of surgery
    • Kaposi-Stemmer sign: inability to pinch a fold of skin at dorsum proximal second toe is a sign of lymphedema

Nonpitting edema

  • Lymphedema or pretibial myxedema

Investigations

  • CBC, electrolytes, creatinine, LFT, TSH, albumin
  • UA, consider urine microscopy
  • Consider D-dimer
  • Consider echocardiography

Treatment

  • If chronic venous insufficiency, mobilization, leg elevation and 30-40mmHg compression stockings
    • ABI prior to compression therapy if arterial insufficiency (normal 0.8-1.2)
      • Consider nonelastic compression bandage for ABI 0.6-0.8
    • Consider horse chestnut seed extract 200mg (50mg escin) BID
  • If volume overload, consider loop diuretic eg. furosemide 20-40mg PO daily
    • In cirrhosis, add spirinolactone 50-100mg PO daily (can go up to QID) to loop diuretic to prevent hypokalemia
    • If resistant, consider thiazide (metolazone)

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