A patient has severe bilateral lower extremity edema. the most likely cause is

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Clinical research studyLymphedemaThe clinical characteristics of lower extremity lymphedema in 440 patients
Conclusions
Cited by (0)
Introduction[edit | edit source]
Assessment of Oedema[edit | edit source]
Methods to Quantitatively Assess Peripheral Oedema[edit | edit source]
Conclusion[edit | edit source]
References[edit | edit source]

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Clinical research studyLymphedemaThe clinical characteristics of lower extremity lymphedema in 440 patients

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Abstract

Background

Lower extremity lymphedema is frequently encountered in the vascular clinic. Established dogma purports that cancer is the most common cause of lower extremity lymphedema in Western countries, whereas chronic venous insufficiency (CVI) is often overlooked as a potential cause. Moreover, lymphedema is typically ascribed to a single cause, yet multiple causes can coexist.

Methods

A 3-year retrospective analysis was conducted of demographic and clinical characteristics of 440 eligible patients with lower extremity lymphedema who presented for lymphatic physiotherapy to a university medical center's cancer-based physical therapy department.

Results

The four most common causes of lower extremity lymphedema were CVI (phlebolymphedema; 41.8%), cancer-related lymphedema (33.9%), primary lymphedema (12.5%), and lipedema with secondary lymphedema (11.8%). The collective cohort was more likely to be female (71.1%; P < .0001), to be white (78.9%; P < .0001), to demonstrate bilateral distribution (74.5%; P < .0001), and to have involvement of the left leg (bilateral, 69.1% [P < .0001]; unilateral, 58.9% [P = .0588]). Morbid obesity was pervasive (mean weight and body mass index, 115.8 kg and 40.2 kg/m2, respectively) and significantly correlated with a higher International Society of Lymphology lymphedema stage (stage III mean weight and body mass index, 169.2 kg and 57.3 kg/m2, respectively, vs stage II, 107.8 kg and 37.5 kg/m2, respectively; P < .0001). Approximately one in three (35.7%) of the population sustained one or more episodes of cellulitis, but patients with stage III lymphedema had roughly twice the rate of soft tissue infection as patients with stage II, 61.7% vs 31.8%, respectively (P < .001). Multifactorial lymphedema was present in 25%. Approximately half of the patients with lipedema with secondary lymphedema (48.1%) or primary lymphedema (45.5%) had a superimposed cause of swelling that was usually CVI. Total knee arthroplasty was the most common cause of noncancer surgery-mediated worsening of pre-existing lymphedema.

Conclusions

In a large cohort of patients treated in a cancer-affiliated physical therapy department, CVI (phlebolymphedema), not cancer, was the predominant cause of lower extremity lymphedema. One in four patients had more than one cause of lymphedema. Notable clinical characteristics included a proclivity for female patients, bilateral distribution, left limb, cellulitis, and nearly universal morbid obesity.

Keywords

Lymphedema

Chronic venous insufficiency

Lipedema

Morbid obesity

Cited by (0)

Introduction[edit | edit source]

Right foot and ankle edema- 2 weeks post-surgery

Oedema is defined as a palpable swelling produced by an accumulation of fluid in the intercellular tissue that results from an abnormal expansion in interstitial fluid volume.

The fluid between the interstitial and intravascular spaces is regulated by the capillary hydrostatic pressure gradient and the oncotic pressure gradient across the capillary.
The accumulation of fluid occurs when local or systemic conditions disrupt this equilibrium, leading to increased capillary hydrostatic pressure, increased plasma volume, decreased plasma oncotic pressure (hypoalbuminemia), increased capillary permeability, or lymphatic obstruction.[1][2]

The rapid development of generalized pitting edema associated with the systemic disease requires prompt diagnosis and management. [1]

Assessment of Oedema[edit | edit source]

History - Should include:

Timing of the edema- since when? Acute swelling of a limb over a period of less than 72 hours is more characteristic of deep venous thrombosis (DVT), cellulitis, ruptured popliteal cyst, acute compartment syndrome from trauma, or recent initiation of calcium channel blockers. The chronic accumulation of more generalized edema is due to the onset or exacerbation of chronic systemic conditions, such as congestive heart failure (CHF), renal disease, or hepatic disease.
Changes of edema with position
Unilateral or bilateral edema: Unilateral edema can result from DVT, venous insufficiency, venous obstruction by a tumor (e.g., tumor obstruction of the iliac vein), lymphatic obstruction (e.g., from a pelvic tumor or lymphoma), or lymphatic destruction (e.g., congenital vs. secondary from a tumor, radiation, or filariasis). Bilateral or generalized swelling suggests a systemic cause, such as CHF (especially right-sided), pulmonary hypertension, chronic renal or hepatic disease (causing hypoalbuminemia), protein-losing enteropathies, or severe malnutrition.
Medication history and
Assessment of systemic diseases.[1]

Physical Examination - In physical examination, pitting, tenderness, skin changes, and temperature are evaluated.[1]

Pitting: There are two types of edema, pitting and non- pitting edema. Pitting edema is described as an indentation that remains in the edematous area after pressure is applied. Its location, timing, and extent are determined for treatment response. It is mainly assessed on the medial malleolus, the bony portion of the tibia, and the dorsum of the foot. Non-pitting edema is seen in lymphoedema, myxedema, and lipedema.[1]
Tenderness: Pain to palpation over the edematous area is associated with DVT and complex regional pain syndrome type 1 (i.e., reflex sympathetic dystrophy).In contrast, lymphoedema generally does not elicit pain with palpation.
DVT in the right leg with swelling and redness
Change in skin temperature, color, and texture: Warmth in the edematous area is associated with acute DVT and cellulitis. Redness, shinny skin, and ulcer are to be noted. Yellow-brown hemosiderin deposition is seen in venous insufficiency.[1]

Methods to Quantitatively Assess Peripheral Oedema[edit | edit source]

There are various methods used in research to assess peripheral edema.[3]

The most commonly used tools to measure edema are:

Volume measurements (with a water volumeter)
Girth measurements (with a tape measure).
Pitting edema assessment (based on the depth and duration of the indentation).

Water displacement and ankle circumference had shown a high inter-examiner agreement (intraclass correlation coefficient 0.93, 0.96 right; 0.97, 0.97 left).

Water Displacement ( Volume measurements)

The volumeter:

Introduced into medicine by Glisson in 1622
Utilizes the same principle of water displacement first discovered by the ancient Greek mathematician, Archimedes, which states that the water volume displaced is equal to the volume of the object immersed in the water.
Clear acrylic rectangular box (13″x5″x9″) with a spout at the top of one of the short sides is filled with water until water rushes out of the spout. When the water level is stable, the patient places one foot in the volumeter, displaced water collected and measured in a graduated cylinder. The amount of water displaced in milliliters equals the volume of the foot/ankle or hand.
For the ankle, a volumetry test can be done in either sitting or standing with knees 90 degrees in sitting and foot flat in the base of the volumeter.[3]
For the hand, the participant’s hand is placed slowly into the volumeter with forearm pronated, fingers adducted, and thumb facing the spout until the web of the middle and ring finger rested on the stop dowel of the volumeter.[4]

Advantage - It is the gold standard tool for the measurement of edema.[5]

Disadvantages - There are various disadvantages to these methods in a clinical setting.

It is time taking as it has to be set up several minutes before the test as the water level needs to be stable.
It is difficult to move once filled with water.
It requires specialized equipments.
It is messy as they require the patients to immerse their hands in water, and it is therefore unsuitable for certain patient populations.[5]

[6]

2. Girth measurements (with a tape measure)

Circumferential Method

The circumferential method is one of the girth measurement techniques. For consistent measurements, each upper extremity or lower extremity is marked with a semi-permanent marker at a certain part with reference to the bony prominences,[3]

Figure-of-Eight method

It is also one of the girth measurement techniques. It is more reliable than the circumferential method as it covers a bigger area. A tension-controlled measuring tape is preferred to wrap around the ankle/foot or hand for the measurement of edema than standard tape.[5][3] A figure of 8 method is usually preferred in ankle and hand swelling. It has its own specific points across for consistency.

A figure of 8 to measure hand swelling

[7]

A figure of 8 to measure ankle swelling

[8]

3. Pitting edema

Assessment - Press firmly with your thumb for at least 2 seconds on each extremity

Over the dorsum of the foot
Behind the medial malleolus
Lower calf above the medial malleolus

Pit depth and the time needed for the skin to return to its original appearance (recovery time) are recorded.

The grading of edema is determined by pit depth (measured visually) and recovery time from grade 0-4. The scale is used to rate the severity and the scores are as follows:

Grade 0: No clinical edema
Grade 1: Slight pitting (2 mm depth) with no visible distortion that rebounds immediately.
Grade 2: Somewhat deeper pit (4 mm) with no readily detectable distortion that rebounds in fewer than 15 seconds.
Grade 3: Noticeably deep pit (6 mm) with the dependent extremity full and swollen that takes up to 30 seconds to rebound.
Grade 4: Very deep pit (8 mm) with the dependent extremity grossly distorted that takes more than 30 seconds to rebound.[3]

Conclusion[edit | edit source]

Water displacement and ankle measurement more reliable methods
Clinical assessment highly variable due to its subjective nature

Pitting Oedema

The indention recovery time (how long it takes for the indention to refill) can be helpful in determining diagnosis
There is a direct relation between the serum albumin concentration and the indention recovery time (hypoalbuminemic edema recover time is < 40 seconds)

Focus assessment on: symmetry of swelling, pain, edema change with dependence, skin findings (hyperpigmentation, stasis dermatitis, lipodermatosclerosis, atrophie blanche, ulcerations), and history of venous thromboembolism[9]

References[edit | edit source]

↑ 1.0 1.1 1.2 1.3 1.4 1.5 Trayes KP, Studdiford JS, Pickle S, Tully AS. Edema: diagnosis and management. American family physician. 2013 Jul 15;88(2):102-10.
↑ Simon EB. Leg edema assessment and management. Medsurg Nursing. 2014 Jan 1;23(1):44-53.
↑ 3.0 3.1 3.2 3.3 3.4 Brodovicz KG, McNaughton K, Uemura N, Meininger G, Girman CJ, Yale SH. Reliability and feasibility of methods to quantitatively assess peripheral edema. Clinical medicine & research. 2009 Jun 1;7(1-2):21-31.
↑ Dewey WS, Hedman TL, Chapman TT, Wolf SE, Holcomb JB. The reliability and concurrent validity of the figure-of-eight method of measuring hand edema in patients with burns. Journal of burn care & research. 2007 Jan 1;28(1):157-62.
↑ 5.0 5.1 5.2 Nadar MS, Taaqi M. Reliability of Occupational Therapy Students Using the Figure-of-eight Technique of Measuring Hand Volume. Hong Kong Journal of Occupational Therapy. 2013 Jun 1;23(1):20-5.
↑ Wendy Huddleston. Lower extremity edema assessment (volumetry). Available from:https://www.youtube.com/watch?v=oR4bvb_DLjQ. [Lasted assessed: 10th Oct, 2020]
↑ University of Derby. Hand Therapy - Figure of 8 Measurement. Available from:https://www.youtube.com/watch?v=V49LQxtA95I. [lasted assessed: 10th Oct,2020]
↑ GC Ortho. Figure of Eight Ankle Measurement. Available from: https://www.youtube.com/watch?v=g_0hMZEq1iQ. [lasted assessed:10th oct,2020]
↑ EBPconsul Pitting edema Available from: https://www.ebmconsult.com/articles/pitting-edema-assessment(last accessed 19.10.2020)