Leg and ankle swelling Flashcards
Probability diagnosis
Physiological:
- dependency/gravitational
- prolonged sitting, standing, walking
- hot weather
- pregnancy
- mechanical (e.g. constricting clothing)
Chronic venous insufficiency (varicose veins)
Congestive cardiac failure
Drugs (e.g. calcium antagonists, NSAIDs)
Local trauma
Obesity
Serious disorders not to be missed
Vascular:
- deep venous thrombosis (DVT)
- inferior vena cava thrombosis
- thrombophlebitis
Infection:
- cellulitis
- tropical infections (e.g. filariasis, hookworm)
Cancer:
- obstruction from pelvic cancer
- localised malignancy
Other:
- kidney disease (e.g. nephrotic syndrome)
- liver disease (e.g. cirrhosis)
- skin allergy (e.g. angioneurotic oedema)
Pitfalls (often missed)
Idiopathic (periodic or cyclic) oedema
Protein-losing enteropathy (e.g. Crohn)
Lipoedema (fat and fluids) of legs
Lipidema (fat) of legs
Rarities:
- malnutrition
- lymphoedema: primary or secondary
Masquerades checklist
Diabetes
Drugs (multiple; see list)
Thyroid/endocrine (hypothyroidism, Cushing syndrome)
Key history
PMHx esp. liver, heart, kidney disease
travel
drugs
occupation
recent trauma.
Circumstances of swelling (e.g. prolonged walking, long journey).
Key examination
Cardiovascular
abdomen (signs of liver disease)
legs including circulation
varicose veins and evidence DVT
Key investigations
urinalysis (?albumin)
FBE
ESR/CRP
U&E
KFTs
serum albumin/LFTs
TSH
- ultrasound (DVT screen)
- CXR
- pelvic ultrasound
- other radiographs (e.g. CT scan, venogram).
Diagnostic tips
Not all swollen legs require investigation.
If the onset of oedema is acute (often <72 hours) suspect DVT.
Pitting oedema is a feature of venous thrombosis or insufficiency, not lymphatic obstruction.
The significance of leg swelling varies according to;
- the age group
- whether it is bilateral or unilateral
- whether the onset is sudden or gradual.
Drugs that can cause leg and ankle swelling include;
- calcium antagonists
- NSAIDs
- corticosteroids
- glitazones
- beta blockers.
