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Peripheral Oedema

 
 
 
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Overview

Swelling of one or multiple limbs - usually the legs - is a common presentation that may be due to cardiac, venous, lymphatic, musculoskeletal or metabolic pathology.

Aetiology

  • Pathophysiology

  • Peripheral oedema occurs when the capillary filtration rate exceeds the lymphatic drainage rate.
  • Capillary filtration is influenced by capillary hydrostatic pressure, plasma oncotic pressure and capillary permeability.
  • Lymphatic drainage can be limited by obstruction.
  • Causes of Peripheral Oedema

  • Unilateral

  • Impaired venous drainage - DVT, venous insufficiency, pelvic tumour
  • Impaired lymphatic drainage - lymphoedema
  • Cellulitis
  • Musculoskeletal - soft tissue injury, fracture, compartment syndrome
  • Bilateral

  • Volume overload - heart failure, liver failure, renal failure, pregnancy
  • Right ventricular failure / pulmonary hypertension
  • Impaired lymphatic drainage - lymphoedema
  • Hypoalbuminaemia - malnutrition, malabsorption, nephrotic syndrome, liver (synthetic) failure
  • Endocrine - pretibial myxoedema (profound hypothyroidism)
  • Medications - NSAIDs, calcium channel blockers, aciclovir, cyclophosphamide, cyclosporine, corticosteroids, oestrogen, progesterone

History of Presenting Complaint

  • Distribution

    Whether the swelling is unilateral or bilateral.
  • Unilateral swellingSuggestive of localised cause e.g. venous or lymphatic obstruction
  • Bilateral swellingSuggestive of systemic cause
  • Timing

    When the swelling started, whether it came on suddenly or gradually, and whether it comes and goes.
  • Sudden onset oedemaMore likely to represent a severe cause such as DVT
  • Onset post traumaSuggestive of musculoskeletal cause
  • Onset post surgeryRisk factor for DVT or iatrogenic lymphoedema
  • Onset post commencement of new medicationSuggestive of drug-induced oedema
  • Cyclical with menstrual cycleSuggestive of premenstrual oedema
  • Associated Symptoms

    Whether the oedema is associated with any other symptoms.
  • Redness, warmth and tendernessSuggestive of cellulitis or DVT
  • Chest painMay suggest heart failure with cardiac pain, or DVT with PE
  • DyspnoeaSuggestive of heart failure or DVT with PE
  • Significant weight lossRed flag for ?pelvic tumour causing venous obstruction
  • Severity

    Ask about how the swelling is affecting the patient's day to day life. Some clues about severity can be:
  • Visible enlargement of the limb
  • Difficulty in moving the affected limb(s)
  • Clothes and jewelery no longer fit
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