Differential Diagnosis of Differential Diagnosis of EdemaEdemaJillian Caster PT DPT WCC CLTChatham University Grand Rounds11/10/16

ObjectivesObjectivesAt 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

EdemaEdemaWhat is edema?

◦Definition: Edema is a palpable swelling produced by expansion of the interstitial fluid volume

PathophysiologyPathophysiologyOver filtrationIncreased

capillary hydraulic pressure

Reduced capillary oncotic pressure

Increased capillary permeability

Reduced drainageVenous

insufficiencyLymphatic

insufficiencyIncreased

interstitial oncotic pressure

CausesCauses• Systemic– Allergic reaction– Cardiac disease– Hepatic disease– Malnutrition – Sleep Apnea– Pregnancy/

premenstrual– Renal disease– Pulmonary

hypertension– Idiopathic edema– Medication

• Localized– Acute injury– Cellulitis– Chronic Venous

Insufficiency– Compartment

Syndrome– Complex Regional

Pain Syndrome– DVT & Post

Thrombotic Syndrome

– Lipedema– Lymphedema– May Thurner

EvaluationEvaluation• History • Medication• Onset• Unilateral or

bilateral• Positional changes

in edema• Coloring and skin

texture• Pitting or non-pitting• History of wounds• Stemmer sign• Weight

PainTemperatureStrength and mobilityJugular vein

distentionSOBIrregular heart

rhythmLung cracklesWells RuleBlood Work

Red FlagsRed Flags• Red Flags– SOB and coughing– Tachypnea, tachycardia– Irregular heat beat– Ascites– Periorbital edema– Abnormal Labs– Acute onset– Redness– Warmth– Pain– Fever– + Wells

Red FlagsRed FlagsNumbness and tinglingPulslessnessAcute injuryProximal swelling distribution

Wells RuleWells Rule

StemmerStemmer’’ssPositive Negative

Pitting Edema ScalePitting Edema Scale

Grade Definition1+ 2mm or less

disappears immediately

2+ 2-4 mmfew second rebound

3+ 4-6 mm10-12 second rebound

4+ 6-8 mm> 20 second rebound

Case 1Case 165 year old male

with bilateral LE edema present for 10 years; former smoker; retired bus driver

PMH: obesity, retinopathy, CHF, CAD, HTN, hyperlipidemia, aortic valve disease and replacement, CABG, sleep apnea, CKD, CVA, DM type 2, skin CA

Case 1Case 1

Case 1 HistoryCase 1 History• Bilateral• Chronic• 3+ Pitting edema• Obesity • Cardiac disease• Sleep apnea • CKD• CVA• Medication

Evaluation & Special TestsEvaluation & Special TestsReduction with elevationBrawny, hemosiderin stainingHistory of wounds

◦ Large amount of exudate-Stemmer’sDull achinessVitals WNLAmbulates community distances with

minimal difficulty use of RWWell nourished4/5 strength in L LE DF/PF, Quads, Hams,

hip flexors otherwise LE MMT= WFL

What can we rule out?What can we rule out?LymphedemaLipedemaDependent edema

DiagnosisDiagnosisCVI

◦ Low viscosity/ protein poor

◦ Pitting edema◦ Chronic◦ Bilateral ◦ Achy/ heaviness◦ Volume reduction

overnight ◦ Possible

varicosities

◦ Hemosiderin staining

◦ Inverted champagne bottle

◦ Ulcerations◦ - Stemmer’s

CKDCardiac

TreatmentTreatmentWound care: absorbent dressingsABIVascular TestingShort stretch multilayer

compression bandagesCompression garments: 30-

40mmHgLE elevationTherapeutic exercise

ABIABIHighest systolic ankle / Highest

systolic Brachial1.0 < Normal0.8-0.99 Abnormal0.5-0.8 Compromised< 0.5 Severe PAD- Do not compress!

Case 2Case 266 y.o. Female

with 30 year history of bilateral LE edema; works as CNA

PMH: obesity, cataract repair, hyperlipidemia, HTN, CKD II, bilateral knee arthritis, DM type 2, hypothyroidism

Case 2Case 2

Case 2 HistoryCase 2 History• Bilateral • Chronic• 2+ Pitting edema• Obesity• Cardiac disease• CDK Stage II• Bilateral knee arthritis• Hypothyroidism

Evaluation & Special TestsEvaluation & Special TestsEdema is stable with positional

changesNo wounds+ Stemmer’s10# weight gainNo painNormal Temp and skin coloringAreas of fibrosis and papillomasBil LE strength WNLAmbulates unlimited distances no ADVitals WNL

What can we rule out?What can we rule out?Venous insufficiencyLipedemaDependent edemaMedicationMalnutrition

DiagnosisDiagnosisLymphedema

◦ Protein rich swelling◦ Chronic◦ Painless◦ Unilateral or

Bilateral◦ Stage I – Stage II

Pitting◦ Stage II – III non

pitting◦ Fibrosis

◦ Hyperkeratotic skin

◦ Squared of toes◦ + Stemmers

CKD

Squared off toes Fibrosis & Hyperkeratosis

LymphedemaLymphedemaPrimary

◦ Milroy’s Birth-2 years

◦ Meigs 2-35 years

◦ Lymphedema Tarda 35+

Secondary◦ Tumor◦ Surgery◦ Radiation◦ Infection◦ Filariasis◦ Venous

Insufficiency Bilateral Phlebolymphostatic

edema

TreatmentTreatmentABICDT

◦MLD◦Short stretch compression bandages

Therapeutic exerciseFlat knit custom compression

garments

Case 3Case 382 y.o. female; 3

month history of bilateral LE swelling; retired secretary; former smoker; limited ambulation

PMH: HTN, CAD, CHF, A-fib, GERD, bowel obstruction, CKD, gout, bipolar disorder, hysterectomy, thyroidectomy

Case 3Case 3

Case 3 HistoryCase 3 HistoryBilateralChronic4+ Pitting edema

◦CHF, A-fib, HTN, CAD◦CKD◦Medication◦Malnutrition◦Dependent edema◦Gout◦Hysterectomy

Evaluation & Special TestsEvaluation & Special Tests Increased edema in dependent positionNormal skin color and tempNo Hx of non healing wounds- Stemmers 10# weight loss in 1 monthNo pain associated with edemaMin A for sit <> stand; ambulates with RW

household distances and uses W/C long distances

Bilateral LE weakness Jugular vein distention Irregular hear rhythmSOB

What can we rule out?What can we rule out?CVILymphedemaLipedemia

DiagnosisDiagnosisCHF

◦Chronic◦Bilateral ◦Pitting◦Jugular vein distention◦Gallop rhythm◦C/O dyspnea

CKDDependentMalnutrition

TreatmentTreatmentRefer to cardiologist/kidney

specialistNutrition consultLight compression garments

once medically managedEducation on elevating LEs

Case 4Case 443 y.o. female

with 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

PMH: HTN, LBP

Case 4Case 4

Case 4 HistoryCase 4 HistoryUnilateral edema Acute symptoms3+ Pitting

Evaluation & Special TestsEvaluation & Special TestsNo change in edema with elevationRedness with irregular borders, warmth7/10 pain in R LENo woundsOnchomychosis-Stemmer’s signTemp: 99.1, BP: 137/88, HR: 92, SpO2:

98%Strength and mobility WNL- Well’s

What can we rule out?What can we rule out?LymphedemaLipedemaCVICardiacKidneyLiverDVTBaker’s Cyst

CRPSCompartment

SyndromeMay ThurnerMalnutritionDependentIdiopathic

CellulitisCellulitisUnilateral Acute onsetPainfulRedWarmthSystemic

symptoms◦ Fever◦ malaise◦ achiness

PittingWoundsOnychomycosis

CellulitisCellulitisAntibioticsRefer Pt to ERMultilayer short stretch

compression

Everything else to keep in Everything else to keep in mindmindLipedema

◦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 Everything else to keep in mindmindCRPS

◦Chronic, unilateral, pitting◦Sweating, pallor, irregular hair growth◦Hx of traumatic injury◦Therapeutic exercise, refer for medical

managementRuptured Baker’s Cyst

◦Acute, unilateral, pitting◦Redness, warmth, trickling feeling◦Hx of knee complications◦Rest, elevation, compression

Everything else to keep in Everything else to keep in mindmindPulmonary 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 Everything else to keep in mindmindDependent edema

◦Chronic, unilateral or bilateral, pitting◦Paralysis, reduced strength, dependent

position◦Hx of CVA, MS etc◦Short stretch compression, compression

garmentsMedication

◦Chronic, bilateral, pitting◦Occurs with use of medication◦Refer for change in medication or compression

MedicationMedicationClass Specific MedicationAntidepressants MAOIs, trazodoneAntihypertensives Beta blockers, Ca++ blockers,

clonidine, hydralazine, methyldopa, minoxidil

Antivirals ZoviraxChemotherapeutics 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 Everything else to keep in mindmindCompartment 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 Everything else to keep in mindmindMalnutrition

◦ 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 Everything else to keep in mindmindLiver 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

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