Bilateral leg swelling

Background

• Bilateral leg swelling (bilateral pedal edema) is a common ED complaint
• Unlike unilateral swelling, bilateral edema usually indicates a systemic process
• Most common cause is bilaeral pedal edema
  • Definition: excess fluid in the lower extremity resulting in swelling of the feet and extending upward
  • Further classified as pitting (compressible) and non-pitting
• Key systemic causes to identify: heart failure, cirrhosis, nephrotic syndrome, renal failure
• Medication-related edema is common and often overlooked (calcium channel blockers, NSAIDs, gabapentin/pregabalin)

Causes of pedal edema

Mechanisms of Pedal Edema

• Increased hydrostatic pressure
• Decreased oncotic pressure
• Increased capillary permeability
• Lymphatic obstruction

Clinical Features

History

• Onset and progression
• Orthopnea, PND, dyspnea on exertion (heart failure)
• Abdominal distension, jaundice, alcohol use (cirrhosis)
• Foamy urine, periorbital edema (nephrotic syndrome)
• Medication review: calcium channel blockers (especially amlodipine), NSAIDs, gabapentin/pregabalin, pioglitazone, corticosteroids
• History of heart failure, liver disease, kidney disease, thyroid disease
• Dietary history (salt intake)

Physical Exam

Pitting pedal edema

• Assess degree and distribution of edema
• Pitting vs. non-pitting
  • Pitting: heart failure, cirrhosis, nephrotic syndrome, medications, venous insufficiency
  • Non-pitting ("woody"): lymphedema, pretibial myxedema (hypothyroidism), chronic venous changes
• JVD (heart failure)
• Lung crackles (pulmonary edema)
• Hepatomegaly, ascites, spider angiomata, jaundice (cirrhosis)
• S3 gallop, displaced PMI (heart failure)
• Periorbital edema (nephrotic syndrome)
• Skin changes: stasis dermatitis, hemosiderin staining (chronic venous insufficiency)

Differential Diagnosis

Bilateral leg swelling

Differential Diagnosis of Pedal Edema

• Pedal edema
  • Gravitational
  • Venous insufficiency
  • Thrombophlebitis
  • Drugs
    • NSAIDS
    • Birth control
    • Steroids
  • CHF
  • Lymphedema
  • Renal failure
  • Liver failure
  • Pregnancy
  • Heat edema
  • Idiopathic
• Other
  • DVT
  • Pretibial myxedema

Evaluation

Laboratory

• CBC
• BMP (renal function, electrolytes)
• Albumin (low in cirrhosis, nephrotic syndrome, malnutrition)
• UA with urine protein (nephrotic syndrome screening)
• BNP or NT-proBNP (elevated in heart failure)
• Liver function tests if hepatic cause suspected
• TSH if hypothyroidism suspected
• Lipid panel, 24-hour urine protein if nephrotic syndrome suspected

Imaging

• CXR: cardiomegaly, pulmonary edema, pleural effusions
• ECG: evaluate for ischemia, arrhythmia, chamber enlargement
• Bedside POCUS: cardiac function (EF), IVC diameter (volume status), lung B-lines (pulmonary edema), pleural effusion
• Echocardiography if new heart failure suspected
• Consider DVT ultrasound if asymmetry or concern for bilateral DVT (rare but possible with IVC thrombus or bilateral iliac disease)
• Abdominal ultrasound if cirrhosis or hepatic cause suspected

Diagnosis

• Idiopathic edema is a diagnosis of exclusion, must first rule out CHF, cirrhosis, renal failure, nephrotic syndrome, chronic venous insufficiency, and medication-induced edema

Management

General

• Treat underlying cause
• Sodium restriction
• Leg elevation
• Compression stockings for chronic venous insufficiency

Heart Failure

• See CHF for detailed management
• IV furosemide for acute decompensation with pulmonary edema
• Nitroglycerin for preload reduction if hypertensive

Cirrhosis

• Sodium restriction, spironolactone +/- furosemide
• See Ascites management

Nephrotic Syndrome

• Loop diuretics, sodium restriction
• Nephrology consultation

Medication-Induced

• Identify and discontinue or reduce offending agent if possible
• Idiopathic pedal edema need not be treated with diuretics

Disposition

Admit

• New diagnosis of heart failure
• Acute decompensated heart failure
• Respiratory compromise from volume overload
• Acute renal failure
• New diagnosis of cirrhosis with complications
• Concerning laboratory findings (severe hypoalbuminemia, elevated creatinine, new anemia)

Discharge

• Chronic stable edema with known cause
• Medication-induced edema with plan for medication change
• Chronic venous insufficiency
• Patients should be followed up in outpatient clinic for further investigation and care
• Return precautions: worsening swelling, shortness of breath, chest pain, decreased urine output, weight gain >2-3 lbs/day

See Also

• Unilateral leg swelling
• Congestive heart failure
• Cirrhosis
• Nephrotic syndrome

External Links

• DDxOf: Differential Diagnosis of Lower Extremity Edema