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Sunday, August 17, 2025

Swollen ankles, feet and legs (oedema)


Introduction

Swelling of the ankles, feet, and legs is a common clinical problem referred to as peripheral edema. It occurs when fluid accumulates in the soft tissues of the lower limbs due to an imbalance between fluid filtration and reabsorption in the capillaries and lymphatic system.

Edema can be acute or chronic, unilateral or bilateral, and may result from a wide spectrum of causes ranging from benign conditions such as prolonged standing to serious systemic diseases such as heart failure, liver disease, kidney disease, or venous thrombosis.

Because of its broad differential diagnosis, evaluation of lower limb swelling requires careful consideration of duration, symmetry, associated symptoms, and risk factors.

Mechanisms of Edema

Edema results from one or more of the following mechanisms:

  1. Increased hydrostatic pressure (e.g., venous obstruction, right-sided heart failure).

  2. Reduced oncotic pressure (e.g., hypoalbuminemia due to liver disease or nephrotic syndrome).

  3. Increased capillary permeability (e.g., infection, inflammation, allergy).

  4. Lymphatic obstruction (e.g., lymphedema, tumor).

Causes of Swelling in Ankles, Feet, and Legs

1. Cardiovascular Causes

  • Heart failure (especially right-sided): bilateral pitting edema, often with dyspnea, orthopnea.

  • Chronic venous insufficiency: varicose veins, heaviness, skin discoloration, ulcers.

  • Deep vein thrombosis (DVT): sudden unilateral swelling, pain, redness, warmth.

  • Pulmonary hypertension: secondary to lung or cardiac disease, leading to right-sided heart failure.

2. Renal Causes

  • Nephrotic syndrome: bilateral edema, often with periorbital swelling.

  • Chronic kidney disease: impaired fluid excretion.

  • Acute glomerulonephritis: sudden edema, hypertension, hematuria.

3. Hepatic Causes

  • Cirrhosis with portal hypertension: hypoalbuminemia leading to fluid accumulation, often with ascites.

4. Endocrine and Metabolic Causes

  • Hypothyroidism (myxedema): generalized non-pitting edema.

  • Pregnancy: mild dependent edema common, but severe swelling may indicate pre-eclampsia.

5. Lymphatic Causes

  • Primary lymphedema: congenital abnormality of lymphatic system.

  • Secondary lymphedema: cancer, surgery (e.g., lymph node removal), radiotherapy, infection (filariasis).

6. Infections and Inflammation

  • Cellulitis: painful, red, warm swelling of affected leg.

  • Erysipelas: sharply demarcated superficial infection.

  • Septic arthritis or abscess.

7. Medications

  • Calcium channel blockers (amlodipine, nifedipine).

  • Corticosteroids.

  • NSAIDs.

  • Estrogens, androgens.

  • Thiazolidinediones (pioglitazone, rosiglitazone).

8. Other Causes

  • Prolonged standing or immobility.

  • Obesity.

  • Post-surgical edema.

Clinical Features

  • Pitting vs non-pitting edema:

    • Pitting: indentation remains when pressed (heart failure, renal disease, venous insufficiency).

    • Non-pitting: firm swelling (lymphedema, myxedema).

  • Unilateral swelling: DVT, cellulitis, trauma, localized obstruction.

  • Bilateral swelling: systemic causes (heart, liver, kidney disease, hypothyroidism).

  • Acute swelling: DVT, infection, trauma, acute heart failure.

  • Chronic swelling: venous insufficiency, lymphedema, liver/renal disease.

Diagnostic Evaluation

History

  • Onset and duration.

  • Symmetry (unilateral vs bilateral).

  • Associated symptoms: chest pain, dyspnea, fatigue, fever, pain.

  • Past history: cardiac, renal, hepatic disease.

  • Medication history.

Examination

  • Inspection: redness, skin changes, ulcers, varicosities.

  • Palpation: pitting vs non-pitting.

  • Signs of systemic disease: jugular venous distension, ascites, periorbital edema.

Investigations

  • Blood tests: CBC, renal function, liver function, albumin, thyroid function.

  • Urinalysis: proteinuria (nephrotic syndrome).

  • Echocardiogram: heart failure.

  • Doppler ultrasound: venous thrombosis or insufficiency.

  • CT/MRI: suspected mass compressing venous/lymphatic flow.

Treatment

1. General Measures

  • Leg elevation above heart level.

  • Compression stockings for venous insufficiency or lymphedema.

  • Reduce salt intake.

  • Weight management and exercise.

2. Pharmacological Treatment

Symptomatic Relief

  • Diuretics:

    • Furosemide: 20–40 mg orally daily, titrated as needed.

    • Bumetanide: 0.5–1 mg daily.

    • Spironolactone: 25–100 mg daily (useful in cirrhosis and heart failure).

  • Analgesics:

    • Paracetamol: 500–1000 mg every 6 hours (max 4 g/day).

    • Ibuprofen: 200–400 mg every 6–8 hours if inflammatory component present.

Infections (Cellulitis)

  • Flucloxacillin: 500 mg orally every 6 hours × 7–10 days.

  • Clindamycin: 300 mg orally every 8 hours (if penicillin-allergic).

  • Severe: IV ceftriaxone or vancomycin.

DVT

  • Anticoagulation:

    • Enoxaparin: 1 mg/kg SC every 12 hours (initial).

    • Transition to Warfarin (dose adjusted to INR 2–3) or DOACs (e.g., apixaban 10 mg BID × 7 days, then 5 mg BID).

Heart Failure

  • Loop diuretics: furosemide, bumetanide.

  • ACE inhibitors/ARBs, beta-blockers for long-term management.

Liver Cirrhosis

  • Spironolactone: 100 mg/day (often combined with furosemide in 100:40 ratio).

  • Paracentesis if ascites severe.

Renal Causes

  • Control of underlying kidney disease.

  • Diuretics for volume overload.

  • Dialysis in advanced cases.

3. Non-Drug Interventions

  • Physiotherapy and exercise to improve venous/lymphatic return.

  • Manual lymph drainage and compression therapy for lymphedema.

  • Surgery: varicose vein ligation, vascular bypass, or lymphatic reconstruction in selected cases.

Red Flags (Urgent Referral)

  • Sudden painful unilateral swelling (possible DVT).

  • Red, hot, tender swelling with fever (cellulitis, abscess).

  • Swelling with dyspnea, orthopnea, or chest pain (heart failure, pulmonary embolism).

  • Rapid weight gain with generalized edema (renal or liver failure).

  • Persistent unexplained edema with constitutional symptoms (possible malignancy).

Prognosis

  • Mild, transient edema (e.g., after long flights or standing): resolves with rest and elevation.

  • Cardiac, hepatic, renal causes: chronic, requires long-term management.

  • DVT: good prognosis with prompt anticoagulation, but risk of recurrence.

  • Lymphedema: usually chronic but manageable with compression therapy.

  • Infections: good recovery if treated early.

Summary of Key Treatments with Doses

  • Furosemide: 20–40 mg PO daily (titrate as needed).

  • Bumetanide: 0.5–1 mg PO daily.

  • Spironolactone: 25–100 mg PO daily (100 mg/day for cirrhosis).

  • Paracetamol: 500–1000 mg PO q6h (max 4 g/day).

  • Ibuprofen: 200–400 mg PO q6–8h.

  • Flucloxacillin: 500 mg PO q6h × 7–10 days (cellulitis).

  • Clindamycin: 300 mg PO q8h (penicillin allergy).

  • Enoxaparin: 1 mg/kg SC q12h (DVT initial).

  • Apixaban: 10 mg PO BID × 7 days, then 5 mg PO BID (DVT treatment).




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