4/14/2016 Disclosures None The Workup of a Patient with Chronic, - - PowerPoint PPT Presentation

4/14/2016 1

John S. Lane III MD, FACS Professor of Vascular Surgery, UC San Diego Director, Endovascular Surgery, Sulpizio Cardiovascular Center Chief, Vascular Surgery, La Jolla VA Hospital

The Workup of a Patient with Chronic, Unilateral Leg Swelling

Disclosures

None

Work-up of Unilateral Leg Swelling: How I do it?

Overview

Anatomy and pathophysiology of edema Common causes of leg edema History and physical examination findings Laboratory and diagnostic testing Algorithms for diagnosis of lower extremity edema Treatment: covered in other lectures

4/14/2016 2 Etiology of Edema

Increase in intravascular pressure Increase in capillary wall permeability Decrease in intravascular osmotic pressure Excess bodily fluids Lymphatic obstruction Local injury Infection Medication effect

Anatomy and Pathophysiology Anatomy and Pathophysiology

Starling’s Law of Capillaries

Anatomy and Pathophysiology

4/14/2016 3 Classification

Two types of leg edema

Venous edema: low-viscosity, protein-poor interstitial fluid Results from increased capillary filtration that cannot be

accommodated by lymphatic system

Lymphedema: protein-rich interstitial fluid Accumulates in skin, subcutaneous tissue Results from lymphatic dysfunction

Lipidema

Not true edema Results from fat maldistribution

Unilateral Unilateral Bilateral Bilateral Acute (<72 hours)

Deep venous thrombosis

Chronic (>72 hours)

Venous insufficiency

Acute (<72 hours) Chronic (>72 hours)

Venous insufficiency Pulmonary hypertension Heart failure Idiopathic edema Lymphedema Drugs Premenstrual edema

Common causes of Leg Edema

Unilateral Unilateral Bilateral Bilateral

Acute (<72 hours)

Ruptured Baker’s cyst Ruptured medal head of the

gastrocnemius

Compartment syndrome

Chronic (>72 hours)

Secondary lymphedema

(tumor, radiation, surgery, bacterial infection)

Pelvic tumor or lymphoma

(compress pelvic veins)

Reflex sympathetic dystrophy

Acute (<72 hours)

• Bilateral DVT
• Deterioration of systemic disease

(CHF, renal failure) Chronic (>72 hours)

• Renal disease (nephrotic syndrome,

glomerulonephritis)

• Secondary lymphedema (tumor,

radiation, filariasis, bacterial infection)

• Pelvic tumor or lymphoma (compress

pelvic veins)

• Dependent edema
• Diuretic-induced edema
• Pre-eclampsia
• Anemia

Less Common Caused of Leg Edema

Unilateral Unilateral Bilateral Bilateral Acute (<72 hours) Chronic (>72 hours)

Primary lymphedema

(congenital, praecox, tarda)

Congenital venous

malformations

May-Thurner syndrome

Acute (<72 hours) Chronic (>72 hours)

Primary lymphedema

(congenital, praecox, tarda)

Protein-losing enteropathy,

malnutrition, malabsorption

Restrictive pericarditis Restrictive cardiomyopathy

Rare Causes of Leg Edema

4/14/2016 4 History

What is the duration of the edema?

Acute (<72 hours) vs. Chronic (>72 hours) DVT should be ruled out if unilateral edema is acute

Is the edema painful?

DVT and Reflex sympathetic dystrophy are usually painful Chronic venous insufficiency can have low-grade aching Lymphedema is usually painless

Reflex Sympathetic Dystrophy Reflex Sympathetic Dystrophy Acute Deep Venous Thrombosis Acute Deep Venous Thrombosis

Painful Swelling History

What medications are being used?

Calcium channels blockers, steroids, anti-inflammatory meds

can all cause leg edema History of systemic diseases?

Heart, liver or kidney disorders can cause edema

History of pelvic/abdominal neoplasm or radiation? History of lower extremity or back trauma? Travel history? Does the edema improve at night? With elevation?

More likely venous edema than lymphatic edema

Physical exam

Distribution of edema

Unilateral more likely due to

local cause

DVT, venous insufficiency,

lymphedema

Bilateral or generalized

edema more likely with systemic disease

Heart, kidney or liver

failure, meds

Dorsum of the foot and toes

usually involved in lymphedema

“boxcar” toes Kaposi-Stemmer sign

(pinch skin fold 2nd toe)

4/14/2016 5 Physical Examination

Tenderness

DVT and RDS are often

tender

Lymphedema is usually

non-tender (except with infection) Pitting

DVT, venous insufficiency

and early lymphedema usually pit

Myxedema and advanced,

fibrotic lymphedema typically do not pit Varicose veins Varicose veins Venous stasis dermatitis Venous stasis dermatitis

Physical examination: Venous insufficiency

Hyperkeratosis (warty) Hyperkeratosis (warty) Papillomatosis Papillomatosis

Physical Examination: Lymphedema

Early Stage Early Stage Chronic Stage Chronic Stage

Warm, tender, increased

sweating

Thin, shiny atrophic flexion contractures

Physical Examination: RSD

4/14/2016 6 Laboratory Tests

Rule out systemic diseases in patients over 50

CBC, serum electrolytes, creatinine Urinalysis Blood sugar Thyroid stimulating hormone Albumin (liver disease, nephrotic syndrome, enteropathy) BNP (with dypsnea)

D-dimer: rule out DVT

Systemic Evaluation for Leg Edema Work-up of Acute Unilateral Leg Edema Work-up of Chronic Unilateral Leg Edema

4/14/2016 7 Diagnostic Tests

Duplex exam of lower extremity Venous reflux exam Lower extremity venous phlethesmography Ambulatory venous testing Lymphoscintigraphy MR venogram CT venogram Catheter venogram (with IVUS)

Diagnostic Tests: Lymphscintigraphy

Distinguish venous edema from lymphedema Determine cause and location of lymph obstruction Inject radioactive tracer in first web space, monitor

with gamma camera

Summary

In acute unilateral leg edema, DVT should always be

ruled out with D-dimer and venous duplex

Chronic unilateral leg edema is mostly likely due to

chronic venous insufficiency, which should be suspected on clinical grounds and diagnosed with venous reflux testing

Summary

Lymphedema should be suspected with toe and foot

involvement, verrucous skin and chronic non-pitting

• edema. Diagnosis can be made on clinical grounds

and with lymphoscintigraphy

Reflex sympathetic dystrophy is diagnosed on

clinical grounds with a history of trauma or neurological injury and with characteristic acute and chronic skin changes and atrophy

4/14/2016 8 Summary

With bilateral chronic edema, consider systemic

causes (cardiac, renal, hepatic), which can be determined based on clinical suspicion, laboratory exams and directed further testing

Thank you