Pedal edema

Peripheral edema
Massive peripheral edema (Image courtesy of Charlie Goldberg, M.D., UCSD School of Medicine and VA Medical Center, San Diego, CA)

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: M.Umer Tariq [2]

Synonyms and keywords: Lower extremity edema; leg edema

Overview

Competent venous valves, intermittent leg muscle contraction and respiration is required to support normal venous blood return. When these fail, venous insufficiency and edema occur. Edema is caused by an accumulation of an excessive amount of watery fluid in the serous cavities, tissues or cells causing painless, non-reddened swelling.

Classification

Edema can occur in 2 forms: pitting and non-pitting.

Pitting Edema

Pitting occurs when there is fluid movement when pressure is applied.

Non-Pitting Edema

Non-pitting is swelling of the tissue itself, not an excess of fluid surrounding the tissue.

Causes

Causes by Organ System

Cardiovascular	AV fistula, Constrictive pericarditis, Left heart failure, Myocardial Infarction, Right heart failure, Thoracic aneurysm, Thrombophlebitis, Thrombosis, Varicose veins,
Chemical / poisoning	Insect bite, Snakebites,
Dermatologic	Carbuncle, Cellulitis, Contact dermatitis, Contusion, Erysipelas, Gas gangrene,
Drug Side Effect	ACE inhibitors, aceon, actos, aldomet, amiodarone, amlodipine, arixtra, atorvastatin, avandia, beta blockers, cardura, casodex, cilostazol, cisplatin, clopidogrel, coreg, crestor, diltiazem, docetaxel, estrogen, evista, flecainide, fondaparinux, glitazones, hydralazine, ibuprofen, labetalol, lipitor, minipress, minoxidil, motrin, nifedipine, norpace, norvasc, pindol, plendil, tenormin, trentinion, univasc valproic acid, verapamil, vesinoid, vytorin, xeloda, Taxol, Tamoxifen, Herceptin
Ear Nose Throat	No underlying causes
Endocrine	Addison's Disease, Cushing's Syndrome, Hyperthyroidism, Hypothyroidism,
Environmental	Cold (physical stimuli), Frostbite, Sunburn,
Gastroenterologic	Exudative enteropathy, Liver failure, Malabsorption,
Genetic	No underlying causes
Hematologic	Anemia, Hypoalbuminemia,
Iatrogenic	No underlying causes
Infectious Disease	Filariasis, Trichinosis,
Musculoskeletal / Ortho	Fracture, Gout, Ligamentous sprain, Osteomyelitis,
Neurologic	Peripheral nerve lesion,
Nutritional / Metabolic	Acquired C1-esterase inhibitor deficiency, Beriberi, Malnutrition, Starvation edema,
Obstetric/Gynecologic	Amniotic band syndrome, Peripartum cardiomyopathy, Premenstrual edema,
Oncologic	Mediastinal cancer,
Opthalmologic	No underlying causes
Overdose / Toxicity	No underlying causes
Psychiatric	Anorexia Nervosa, Bulimia Nervosa,
Pulmonary	Pulmonary hypertension,
Renal / Electrolyte	Acute glomerulonephritis, Bartter's Syndrome, Nephrotic Syndrome,
Rheum / Immune / Allergy	Angioneurotic edema, Cachexia, Lymph node mass, Scleroderma, Sepsis syndrome,
Sexual	No underlying causes
Trauma	Bruise, Burn, Musculoskeletal trauma,
Urologic	No underlying causes
Miscellaneous	Idiopathic edema, Milroy's Disease, Sepsis syndrome, Tight clothing,

Causes in Alphabetical Order

ACE inhibitor Aceon Acquired C1-esterase inhibitor deficiency Actos Acute glomerulonephritis Addison's Disease Aldomet Amlodipine Amniotic band Angioneurotic edema Angiotensin converting enzyme inhibitor Anemia Anorexia Nervosa AV fistula Avandia Bartter's Syndrome Beriberi Beta blockers Boils Bruise Bulimia Nervosa Burn Cachexia Carbuncle Cardura Cellulitis Chemotherapy Cisplatin Cold (physical stimuli) Constrictive pericarditis Contact dermatitis Contusion Cushing's Syndrome Diltiazem Drugs Docetax Erysipelas Exudative enteropathy Filariasis Fracture Frostbite Gas gangrene Glitazones Gout Hyperthyroidism Hypoalbuminemia Hypoplasia Hypothyroidism Ibuprophen

Idiopathic edema Insect bite Irritant Left heart failure Ligamentous sprain Liver failure Lymph node mass Malabsorption Malnutrition Mediastinal cancer Milroy's Disease Minipress Motrin Musculoskeletal trauma Myocardial Infarction Neoplasm Nephrotic Syndrome Nifedipine Norvasc Osteomyelitis Peripheral nerve lesion Premenstrual edema Right heart failure Scleroderma Sepsis syndrome Snakebites Starvation edema Sunburn Surgical excision Tendonous strain Thoracic aneurysm Thrombophlebitis Thrombosis Tight clothing [[Trentinion Trichinosis Tumors Univasc Valproic acid Varicose veins Vesinoid vytorin

Epidemiology and Demographics

25% of the general population suffers from chronic venous insufficiency.

Natural History, Complications and Prognosis

Prognosis

Successful treatment depends on control of the underlying cause. Severe swelling can cause permanent damage to nerves, resulting in peripheral neuropathy. Many cases from temporary or minor causes resolve on their own, with no lasting damage.

Diagnosis

History and Symptoms

• History should include:

• DVT risk factors
• Time lapse
• Other associated symptoms
• Unilateral vs. bilateral
• Pitting and/or non-pitting

Physical Examination

(Images courtesy of Charlie Goldberg, M.D., UCSD School of Medicine and VA Medical Center, San Diego, CA)

Moderate edema

Massive edema

Laboratory Findings

• Labs include:

• Blood cultures
• BUN / creatinine
• CBC
• Coagulation
• Electrolytes
• LFTs
• Serum albumin
• Thyroid function tests
• Urinalysis

Chest X Ray

• Chest X-Ray may indicate pulmonary edema and/or cardiomegaly

Echocardiography or Ultrasound

• Duplex ultrasound for DVT
• Echocardiography for EF in patients with CHF

Other Diagnostic Studies

• liver biopsy for cirrhosis

Treatment

Acute Pharmacotherapies

• Congestive heart failure: Diuretics, ACE inhibitors, beta blockers, digoxin

Chronic Pharmacotherapies

• DVT: Anticoagulation with unfractionated heparin, low molecular weight heparin / warfarin for 3-6 months

Indications for Surgery

• Nephrotic syndrome: transplant in adult patients may be necessary
• Cirrhosis: liver transplant may be necessary

Additional therapies

• Venous insufficiency: Leg elevation, compression stockings, minimize time standing
• Cellulitis: extremity elevation and antibiotics
• CHF: Salt restriction and diuretics, preload reduction, afterload reduction
• Cirrhosis: Diuretics & low salt diet

References

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