The swollen leg

21st November 2010 by Daryll Baker0
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Introduction.

Swelling of the ankles and legs is common and patients usually seek advice because they want to know the cause.

 

Aetiology

The causes of a swollen leg include:

Central causes

  • Congestive cardiac failure
  • Renal diseases
  • Hepatic disease
  • Protein deficiency eg gastrointestinal disease involving malabsorption or malnutrition.
  • General allergic reactions eg to drugs.

Peripheral causes

  • Inflammation:
    • Local trauma (including a ruptured Bakers cyst)
    • Insect bites
    • Sun burn
  • Venous disease
    • Superficial incompetence (varicose veins)
    • Deep venous incompetence (absence of deep vein valves, previous DVT)
    • Venous outflow obstruction
    • Vein occlusion: eg pelvic  vein or IVCthrombosis, an aorto-caval fistula,
    • Mass (eg uterine cancer) pressing on the pelvic veins.
  •  Lymphoedema
    • Lymphoedema is the excessive accumulation of interstitial fluid as a result of defective lymphatic drainage.
    • Primary lymphoedemahas no known cause. It occurs in 1 in 33,000 people. In a third of cases there is a family history. Usually, the limb starts to swell insidiously between 10 and 25 years of age. It is 3 times more common in women than men.
    •  Secondary lymphoedema results from a pathological process disrupting the lymphatic drainage including
      • malignancies which spread to or include the lymph nodes
      • surgical block dissection of affected lymph nodes and radiotherapy
      • filariasis worm infections are a common cause world wide, but rare in the UK
      • self induced oedema from repeatedly applying a tight tourniquet to the limb or by never using it are recognised presentations of Munchausen’s syndrome.

Clinical features

Central causes

  • other suggestive symptoms have often previously been investigated
  • Both legs are  involved
  • There may be oedema elsewhere

Peripheral causes

  • Local inflammation
    • Examine for portal of entry or a haematoma
    • There may be a recent rash.
  • Venous swelling
    • Previous DVT or varicose veins are common
    • The swelling involves the ankles and legs maximally and spares the feet.
    • There may be associated haemosiderin and atrophic or ulcerated skin changes around the ankle.
  • Lymphoedema
    • It is important to determine whether this is primary or secondary
      • Note details of previous surgery and radiotherapy and recent travel abroad.
      • A family history of lymphoedema suggests a primary aetiology.
      • Examin the groins for pathological lymph nodes and a rectal and vaginal examination are indicated if a secondary cause is suspected.
    • The leg
      • Swelling is most prominent distally. Oedema is on the dorsum of the foot and the contour of the ankle is lost first. Rarely does it spread above the knee.
      • In long-standing cases the skin is hypertrophied and lichenified with cracks in the interdigital clefts.
      • Recurrent attacks of cellulitis are common, the infection entering via skin cracks.
      • Occasionally patients develop vesicles in the skin which leak clear lymph.

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Investigations

Investigations are undertaken to identify the cause of the leg swelling.

Central causes suspected

  • Serum urea and electrolyte levels
  • Liver function tests (including albumen and total protein)
  • Full blood count
  • ESR, CRP

Venous causes suspected

  • Duplex ultrasound scans of leg veins will demonstrate:
    • superficial venous incompetence and identify the sites of communication between deep and superficial venous systems.
    • patency of the deep venous system to exclude a deep vein thrombosis and determine if there is reflux
  • Pelvic and abdominal ultrasound to identify masses which may be compressing the pelvic veins or occluding the pelvic lymphatics. CT or MRIscan may be required to confirm
  • Photoplethysmography will confirm the findings of the duplex scan and provide information about the patency of the pelvic veins. If this suggests there is a venous outflow problem then a venogram should be performed.

Lymphoedema suspected

  • Pelvic and abdominal ultrasound to exclude a secondary cause
  • Radionuclear lymphscintogram is a simple test in which a small volume of a high-energy-emitting colloid-bound radionucleotide is injected into a webspace in both feet. Scintogram scans are then taken at regular intervals over the next few hours. This not only makes the diagnosis but also identifies the site of obstruction to lymphatic flow in the leg or the abdomen/thorax. This test is safe, uses a low dose of radiation, is easy to perform and is not painful
  • Lymphography is no longer used.

 

Management

  • Treatment depends on the aetiology and severity
  • Although cosmetically embarrassing, swollen legs are often only of nuisance value
  • In many cases aggressive treatment is not needed and only advice and reassurance need be given

 

Venous leg oedema management

  • If oedema is minor, a conservative approach is best as outlined below under “limiting oedema progression”.
  • If oedema is a major problem or there are concomitant venous leg problems then surgical intervention may be required. If appropriate this involves removing the superficial veins.

Primary Lymphoedema Management

  • Conservative (the vast majority)
    • Counselling explains that the disorder does not involve any major pathology and although it may progress it very rarely requires surgery. It is a life-long condition
    • Limiting oedema progression can be achieved by:web-soa-stockings
      • the continuous use of graduated compression stockings throughout the day (www.pebbleuk.com  to provide symptomatic relief from aching and to reduce the likelihood of progression. Compliance is a problem especially in hot weather and young female patients. Often the stocking is old or does not compress sufficiently to reduce the swelling as is the case here.
      • raising the foot of the bed at night and elevating the leg whenever possible
      • use of pneumatic compression pumps and leggings. The flowtron-boot sequential segmental machines such as the lymphopress are probably more effective than the single chamber boots, but are usually more expensive.
      • The patient and their partner can be taught leg and foot massage which provides both psychological and physical relief. Long term, regular massage prevents subcutaneous fibrous thickening.
      • Weight reduction is often beneficial
      • Drug treatment is of little proven value and diuretics and anticoagulation should be avoided.
    • web-soa-oilsSkin care:   As the lymphoedema progresses the skin of the foot, ankle and eventually the leg becomes hardened and irregular. To prevent this the patient needs to oil the skin at least once a day with a low allergenic oil; often olive oil is best. This is seen in this photo.
    • Treatment of infections
      • Lymphoedematous limbs do not respond normally to minor trauma or insect bites. Infection is more likely, causing increased swelling and cellulitis which can spread rapidly.
      • Antibiotics should be given promptly and hospital admission will be required if there is no rapid response.
      • Prevention requires careful foot hygieneweb-soa-infection, including the use of antifungal powder or cream to prevent athlete’s foot.

 

  • Surgical intervention
    • Should only be undertaken when the heaviness of the leg is severely hampering the patient’s quality of life.
    • It is possible to remove the mass of oedematous fatty tissue under the skin, superficial to the muscular fascia; only half the leg is treated at a time.
    • Post-operatively bed rest is required for several weeks. The leg is treated with a lymphopress; wound healing is often a severe problem.
    • The result is not always cosmetically pleasing.
    • This is only a temporary measure and the lymphoedema will redevelop.
    • However, if patients are selected carefully a very high patient satisfaction rate is achieved.

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Daryll Baker is a Consultant Vascular Surgeon at the Royal Free Hospital London and Clinical Lead for North Central Region Vascular Services.

He read Medicine at Oxford University and trained in Vascular Surgery in Nottingham, London and Edinburgh. He obtained his research PhD from the University of Wales.

Contact

Wellington Hospital
34 Circus Road
London
NW8 9SG

020 7722 7370

Copyright 2016 The Vascular Consultancy