Approach to Leg Edema of Unclear Etiology
Evidence-Based Clinical Medicine
Approach to Leg Edema of Unclear Etiology John W. Ely, MD, MSPH, Jerome A. Osheroff, MD, M. Lee Chambliss, MD, MSPH and Mark H. Ebell, MD, MS
Department of Family Medicine, University of Iowa Carver College of Medicine, Iowa City, IA (JWE)Thomson MICROMEDEX, Greenwood Village, CO (JAO)Moses Cone Hospital Family Medicine Residency, Greensboro, NC (MLC)Department of Family Practice, Michigan State University, East Lansing, MI (MHE)
Correspondence: Corresponding author: John W. Ely, MD, MSPH, University of Iowa College of Medicine, Department of Family Medicine, 200 Hawkins Drive, 01291-D PFP, Iowa City, IA 52242
A common challenge for primary care physicians is to determine the cause and find an effective treatment for leg edema of unclear etiology. We were unable to find existing practice guidelines that address this problem in a comprehensive manner. This article provides clinically oriented recommendations for the management of leg edema in adults. We searched on-line resources, textbooks, and MEDLINE (using the MeSH term, "edema") to find clinically relevant articles on leg edema. We then expanded the search by reviewing articles cited in the initial sources. Our goal was to write a brief, focused review that would answer questions about the management of leg edema. We organized the information to make it rapidly accessible to busy clinicians. The most common cause of leg edema in older adults is venous insufficiency. The most common cause in women between menarche and menopause is idiopathic edema, formerly known as "cyclic" edema. A common but under-recognized cause of edema is pulmonary hypertension, which is often associated with sleep apnea. Venous insufficiency is treated with leg elevation, compressive stockings, and sometimes diuretics. The initial treatment of idiopathic edema is spironolactone. Patients who have findings consistent with sleep apnea, such as daytime somnolence, load snoring, or neck circumference >17 inches, should be evaluated for pulmonary hypertension with an echocardiogram. If time is limited, the physician must decide whether the evaluation can be delayed until a later appointment (eg, an asymptomatic patient with chronic bilateral edema) or must be completed at the current visit (eg, a patient with dyspnea or a patient with acute edema [<72>Figure 1 could be used as a guide. If the full evaluation could wait for a subsequent visit, the patient should be examined briefly to rule out an obvious systemic cause and basic laboratory tests should be ordered for later review (complete blood count, urinalysis, electrolytes, creatinine, blood sugar, thyroid stimulating hormone, and albumin).
Edema is defined as a palpable swelling caused by an increase in interstitial fluid volume. The most likely cause of leg edema in patients over age 50 is venous insufficiency. Venous insufficiency affects up to 30% of the population,1,2 whereas heart failure affects only approximately 1%.34 The most likely cause of leg edema in women under age 50 is idiopathic edema, formerly known as cyclic edema.5 Most patients can be assumed to have one of these diseases unless another cause is suspected after a history and physical examination. However, there are at least 2 exceptions to this rule: pulmonary hypertension and early heart failure can both cause leg edema before they become clinically obvious in other ways.