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

4/14/2016 Disclosures � None The Workup of a Patient with Chronic, Unilateral Leg Swelling 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 Work-up of Unilateral Leg Swelling: Overview How I do it? � 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 1

4/14/2016 Etiology of Edema Anatomy and Pathophysiology � 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 2

4/14/2016 Classification Common causes of Leg Edema � Two types of leg edema Unilateral Unilateral Bilateral Bilateral � Venous edema: low-viscosity, protein-poor interstitial fluid � Results from increased capillary filtration that cannot be � Acute (<72 hours) � Acute (<72 hours) accommodated by lymphatic system � Deep venous thrombosis � Lymphedema: protein-rich interstitial fluid � Chronic (>72 hours) � Accumulates in skin, subcutaneous tissue � Venous insufficiency � Results from lymphatic dysfunction � Chronic (>72 hours) � Pulmonary hypertension � Lipidema � Venous insufficiency � Heart failure � Idiopathic edema � Not true edema � Lymphedema � Results from fat maldistribution � Drugs � Premenstrual edema Less Common Caused of Leg Edema Rare Causes of Leg Edema Unilateral Unilateral Bilateral Bilateral Unilateral Unilateral Bilateral Bilateral � Acute (<72 hours) � Acute (<72 hours) � Acute (<72 hours) � Acute (<72 hours) Bilateral DVT � � Ruptured Baker’s cyst � Deterioration of systemic disease � Ruptured medal head of the (CHF, renal failure) gastrocnemius � Chronic (>72 hours) � Chronic (>72 hours) � Compartment syndrome � Chronic (>72 hours) Renal disease (nephrotic syndrome, � Primary lymphedema � � Primary lymphedema glomerulonephritis) (congenital, praecox, tarda) � Chronic (>72 hours) Secondary lymphedema (tumor, � (congenital, praecox, radiation, filariasis, bacterial infection) � Secondary lymphedema � Protein-losing enteropathy, tarda) � Pelvic tumor or lymphoma (compress (tumor, radiation, surgery, malnutrition, malabsorption pelvic veins) bacterial infection) � Congenital venous Dependent edema � � Restrictive pericarditis � Pelvic tumor or lymphoma � Diuretic-induced edema malformations (compress pelvic veins) Pre-eclampsia � � Restrictive cardiomyopathy Anemia � Reflex sympathetic dystrophy � � May-Thurner syndrome 3

4/14/2016 History Painful Swelling � What is the duration of the edema? Reflex Sympathetic Dystrophy Reflex Sympathetic Dystrophy Acute Deep Venous Thrombosis Acute Deep Venous Thrombosis � 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 History Physical exam � Distribution of edema � What medications are being used? � Unilateral more likely due to local cause � Calcium channels blockers, steroids, anti-inflammatory meds � DVT, venous insufficiency, can all cause leg edema lymphedema � History of systemic diseases? � Bilateral or generalized edema more likely with � Heart, liver or kidney disorders can cause edema systemic disease � History of pelvic/abdominal neoplasm or radiation? � Heart, kidney or liver failure, meds � History of lower extremity or back trauma? � Dorsum of the foot and toes usually involved in � Travel history? lymphedema � Does the edema improve at night? With elevation? � “boxcar” toes � Kaposi-Stemmer sign � More likely venous edema than lymphatic edema (pinch skin fold 2 nd toe) 4

4/14/2016 Physical Examination Physical examination: Venous insufficiency � Tenderness Varicose veins Varicose veins Venous stasis dermatitis Venous stasis dermatitis � 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 Physical Examination: Lymphedema Physical Examination: RSD Hyperkeratosis (warty) Hyperkeratosis (warty) Papillomatosis Papillomatosis Early Stage Early Stage Chronic Stage Chronic Stage � Warm, tender, increased � Thin, shiny atrophic sweating � flexion contractures 5

4/14/2016 Laboratory Tests Systemic Evaluation for Leg Edema � 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 Work-up of Acute Unilateral Leg Edema Work-up of Chronic Unilateral Leg Edema 6

4/14/2016 Diagnostic Tests Diagnostic Tests: Lymphscintigraphy � Duplex exam of lower extremity � Distinguish venous edema from lymphedema � Venous reflux exam � Determine cause and location of lymph obstruction � Lower extremity venous phlethesmography � Inject radioactive tracer in first web space, monitor with gamma camera � Ambulatory venous testing � Lymphoscintigraphy � MR venogram � CT venogram � Catheter venogram (with IVUS) Summary Summary � In acute unilateral leg edema, DVT should always be � Lymphedema should be suspected with toe and foot ruled out with D-dimer and venous duplex involvement, verrucous skin and chronic non-pitting edema. Diagnosis can be made on clinical grounds and with lymphoscintigraphy � Chronic unilateral leg edema is mostly likely due to chronic venous insufficiency, which should be suspected on clinical grounds and diagnosed with � Reflex sympathetic dystrophy is diagnosed on venous reflux testing clinical grounds with a history of trauma or neurological injury and with characteristic acute and chronic skin changes and atrophy 7

4/14/2016 Summary Thank you � With bilateral chronic edema, consider systemic causes (cardiac, renal, hepatic), which can be determined based on clinical suspicion, laboratory exams and directed further testing 8