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

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

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)

References:

UTD
Trayes KP, Studdiford JS, Pickle S, Tully AS. Edema: Diagnosis and Management. Am Fam Physician. 2013 Jul 15;88(2):102-10. http://www.aafp.org/afp/2013/0715/p102.html
Ely JW, Osheroff JA, Chambliss ML, Ebell MH. Approach to Leg Edema of Unclear Etiology. J Am Board Fam Med. 2006 Mar-Apr;19(2):148-60. http://www.jabfm.org/content/19/2/148.full

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