Differential Diagnosis of Edema

Jillian Caster PT DPT WCC CLT

Chatham University Grand Rounds
11/10/16
Objectives
At the conclusion of this course you will
be able to
Effectively evaluate and diagnose causes of
edema
Rule out/in red flag causes of edema and
appropriately refer
Effectively treat edema
Edema
What is edema?
Definition: Edema is a palpable swelling
produced by expansion of the interstitial fluid
volume
Pathophysiology
Over filtration Reduced drainage
Increased capillary Venous insufficiency
hydraulic pressure Lymphatic
Reduced capillary insufficiency
oncotic pressure Increased interstitial
Increased capillary oncotic pressure
permeability
Causes
Systemic Localized
Allergic reaction Acute injury
Cardiac disease Cellulitis
Hepatic disease Chronic Venous
Malnutrition Insufficiency
Sleep Apnea Compartment
Syndrome
Pregnancy/premenstrual
Complex Regional Pain
Renal disease Syndrome
Pulmonary hypertension DVT & Post Thrombotic
Idiopathic edema Syndrome
Medication Lipedema
Lymphedema
May Thurner
Evaluation
History Pain
Medication Temperature
Onset
Unilateral or bilateral Strength and mobility
Positional changes in Jugular vein distention
edema SOB
Coloring and skin Irregular heart rhythm
texture
Pitting or non-pitting Lung crackles
History of wounds Wells Rule
Stemmer sign Blood Work
Weight
Red Flags
Red Flags
SOB and coughing
Tachypnea, tachycardia
Irregular heat beat
Ascites
Periorbital edema
Abnormal Labs
Acute onset
Redness
Warmth
Pain
Fever
+ Wells
Red Flags
Numbness and tingling
Pulslessness
Acute injury
Proximal swelling distribution
Wells Rule
Stemmers
Positive Negative
Pitting Edema Scale

Grade Definition
1+ 2mm or less
disappears immediately
2+ 2-4 mm
few second rebound
3+ 4-6 mm
10-12 second rebound
4+ 6-8 mm
> 20 second rebound
Case 1
65 year old male PMH: obesity,
with bilateral LE retinopathy, CHF,
edema present for 10 CAD, HTN,
years; former hyperlipidemia, aortic
smoker; retired bus valve disease and
driver replacement, CABG,
sleep apnea, CKD,
CVA, DM type 2,
skin CA
Case 1
Case 1 History
Bilateral
Chronic
3+ Pitting edema
Obesity
Cardiac disease
Sleep apnea
CKD
CVA
Medication
Evaluation & Special Tests
Reduction with elevation
Brawny, hemosiderin staining
History of wounds
Large amount of exudate
-Stemmers
Dull achiness
Vitals WNL
Ambulates community distances with minimal
difficulty use of RW
Well nourished
4/5 strength in L LE DF/PF, Quads, Hams, hip
flexors otherwise LE MMT= WFL
What can we rule out?
Lymphedema
Lipedema
Dependent edema
Diagnosis
CVI
Low viscosity/ protein Hemosiderin staining
poor Inverted champagne
Pitting edema bottle
Chronic Ulcerations
Bilateral - Stemmers
Achy/ heaviness CKD
Volume reduction Cardiac
overnight
Possible varicosities
Treatment
Wound care: absorbent dressings
ABI
Vascular Testing
Short stretch multilayer compression
bandages
Compression garments: 30-40mmHg
LE elevation
Therapeutic exercise
ABI
Highest systolic ankle / Highest systolic
Brachial
1.0 < Normal
0.8-0.99 Abnormal
0.5-0.8 Compromised
< 0.5 Severe PAD- Do not compress!
Case 2
66 y.o. Female with PMH: obesity,
30 year history of cataract repair,
bilateral LE edema; hyperlipidemia, HTN,
works as CNA CKD II, bilateral knee
arthritis, DM type 2,
hypothyroidism
Case 2
Case 2 History
Bilateral
Chronic
2+ Pitting edema
Obesity
Cardiac disease
CDK Stage II
Bilateral knee arthritis
Hypothyroidism
Evaluation & Special Tests
Edema is stable with positional changes
No wounds
+ Stemmers
10# weight gain
No pain
Normal Temp and skin coloring
Areas of fibrosis and papillomas
Bil LE strength WNL
Ambulates unlimited distances no AD
Vitals WNL
What can we rule out?
Venous insufficiency
Lipedema
Dependent edema
Medication
Malnutrition
Diagnosis
Lymphedema
Protein rich swelling Hyperkeratotic skin
Chronic Squared of toes
Painless + Stemmers
Unilateral or Bilateral CKD
Stage I Stage II
Pitting
Stage II III non
pitting
Fibrosis
 Squared off toes Fibrosis &
Hyperkeratosis
Lymphedema
Primary Secondary
Milroys Tumor
Birth-2 years Surgery
Meigs Radiation
2-35 years
Infection
Lymphedema Tarda Filariasis
35+
Venous Insufficiency
Bilateral
Phlebolymphostatic
edema
Treatment
ABI
CDT
MLD
Short stretch compression bandages
Therapeutic exercise
Flat knit custom compression garments
Case 3
82 y.o. female; 3 PMH: HTN, CAD,
month history of CHF, A-fib, GERD,
bilateral LE swelling; bowel obstruction,
retired secretary; CKD, gout, bipolar
former smoker; disorder,
limited ambulation hysterectomy,
thyroidectomy
Case 3
Case 3 History
Bilateral
Chronic
4+ Pitting edema
CHF, A-fib, HTN, CAD
CKD
Medication
Malnutrition
Dependent edema
Gout
Hysterectomy
Evaluation & Special Tests
Increased edema in dependent position
Normal skin color and temp
No Hx of non healing wounds
- Stemmers
10# weight loss in 1 month
No pain associated with edema
Min A for sit <> stand; ambulates with RW household
distances and uses W/C long distances
Bilateral LE weakness
Jugular vein distention
Irregular hear rhythm
SOB
What can we rule out?
CVI
Lymphedema
Lipedemia
Diagnosis
CHF
Chronic
Bilateral
Pitting
Jugular vein distention
Gallop rhythm
C/O dyspnea
CKD
Dependent
Malnutrition
Treatment
Refer to cardiologist/kidney specialist
Nutrition consult
Light compression garments once
medically managed
Education on elevating LEs
Case 4
43 y.o. female with PMH: HTN, LBP
negative history of
LE edema; woke up
on 2 days ago with a
red, swollen LE;
typical, active life
style, works as an
elementary school
teacher
Case 4
Case 4 History
Unilateral edema
Acute symptoms
3+ Pitting
Evaluation & Special Tests
No change in edema with elevation
Redness with irregular borders, warmth
7/10 pain in R LE
No wounds
Onchomychosis
-Stemmers sign
Temp: 99.1, BP: 137/88, HR: 92, SpO2: 98%
Strength and mobility WNL
- Wells
What can we rule out?
Lymphedema CRPS
Lipedema Compartment
CVI Syndrome
Cardiac May Thurner
Kidney Malnutrition
Liver Dependent
DVT Idiopathic
Bakers Cyst
Cellulitis
Unilateral Pitting
Acute onset Wounds
Painful Onychomycosis
Red
Warmth
Systemic symptoms
Fever
malaise
achiness
Cellulitis
Antibiotics
Refer Pt to ER
Multilayer short stretch compression
Everything else to keep in mind
Lipedema
Chronic, bilateral, pitting
Abnormal fat distribution from ankles to hips
Treat with CDT and flat knit garments
DVT
Acute, unilateral, pitting
Painful with palpation, redness, warmth,
+ Wells
Refer to ER
Everything else to keep in mind
CRPS
Chronic, unilateral, pitting
Sweating, pallor, irregular hair growth
Hx of traumatic injury
Therapeutic exercise, refer for medical
management
Ruptured Bakers Cyst
Acute, unilateral, pitting
Redness, warmth, trickling feeling
Hx of knee complications
Rest, elevation, compression
Everything else to keep in mind
Pulmonary Hypertension
Chronic, bilateral, pitting
History of sleep apnea
Refer to cardiologist
Idiopathic edema
Chronic, bilateral, pitting
Females <50, menstruating, weight gain through
day, c/o hand and face edema, obesity, depression
Refer- Spironolactone
Compression garments if tolerated
Everything else to keep in mind
Dependent edema
Chronic, unilateral or bilateral, pitting
Paralysis, reduced strength, dependent position
Hx of CVA, MS etc
Short stretch compression, compression
garments
Medication
Chronic, bilateral, pitting
Occurs with use of medication
Refer for change in medication or compression
Medication
Class Specific Medication
Antidepressants MAOIs, trazodone
Antihypertensives Beta blockers, Ca++ blockers,
clonidine, hydralazine, methyldopa,
minoxidil
Antivirals Zovirax
Chemotherapeutics Cyclophosphamide, cyclosporine,
cytosine arabinoside, mithramycin
Cytokines G-CSF, GM-CSF, interferon alfa,
interluken-2 and 4
Hormones Androgen, corticosteroids, estrogen,
progesterone, testosterone
NSAIDs Celebrex, ibuprofen
Everything else to keep in mind
Compartment Syndrome
Acute, unilateral, pitting
Pain, redness, paresthesia, pulse
ER referral
May Thurner
Chronic, unilateral, pitting
Left iliac vein is compressed by the right iliac
artery
Refer to vascular surgeon
Compression following surgery
Everything else to keep in mind
Malnutrition
Chronic, bilateral, pitting
Interstitial oncotic pressure is higher than capillary oncotic
pressure drawing fluid out
Typically older individuals, refer for blood work, nutrition
consult
Compression
Kidney disease
Chronic, bilateral, pitting
Reduced protein levels in blood causing interstitial oncotic
pressure is higher than capillary oncotic pressure drawing
fluid out
Refer to nephrologist, conservative compression, garments
Everything else to keep in mind
Liver disease
Chronic, bilateral, pitting
Ascites, jaundice, spider hemangiomas
Reduced protein circulating, portal vein
hypertension, refer for blood work and liver
specialist
Post thrombotic syndrome
Chronic, unilateral or bilateral, pitting
History of DVT causing deep venous insufficiency
Blood clotting disorder
Wound care, compression, refer for vascular
testing and vascular surgeon
References
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