SWELLING

Present as:
Swelling of the lower extremities, often referred to as edema, has a variety of causes.  Most causes of lower extremity edema are actually not due to a direct vascular problem; rather, the swelling is a sign of another process within the body.  The most frequent causes of leg swelling are congestive heart failure, kidney disease or infections.
Leg swelling, simply defined, is an increase in the girth (circumference) of the leg as compared to the “normal” state—often the contralateral limb.  

Swelling can be a sign of a very serious condition.  Heart failure, as mentioned above, can cause leg swelling in both (bilateral) legs.  Kidney problems (renal failure) can produce leg edema – again, usually in both legs.  These problems need immediate medical attention because if left unchecked, they can put the patient in a life threatening situation.
Leg swelling may also be due to a problem with the veins in the leg(s).  Veins transport blood from the leg to the heart.  If there is a blockage (clot) in one of the veins, the outflow of blood from the leg can be impeded.  This causes an increase in pressure in the leg veins and results in leg swelling.  Additionally, a blood clot in the deeper leg veins is a serious, more complicated problem since these clots have the ability to travel to the lung (pulmonary embolus)  which  can be fatal if it occurs.

A less dangerous cause of leg swelling is Lymphedema.  This condition occurs when there is damage to small vessels in the leg called lymphatics.  The function of the lymphatic vessels is to transport excess fluid from the legs that “leaks out” of the arteries and veins back to the heart.  If the lymphatic vessels are damaged, this “clean-up process” is impaired and can result in Lymphedema.


Diagnosis:
Once a history has been taken and an appropriate physical examination conducted, the patient may have to undergo noninvasive tests to ensure that there are no blood clots present.  Since this presents the most immediate danger of all the causes of leg swelling, it is appropriate to “rule out” the presence of a blood clot in one of the deep veins of the leg as soon as possible.

The most appropriate test to assess the veins in the leg(s) is the Duplex Ultrasound examination performed by a qualified vascular technologist.  This test, done in an accredited noninvasive vascular laboratory, is highly accurate and easily performed. There are no injections or needles and the test is risk and pain-free to the patient.


Treatment Options:
The appropriate treatment for leg swelling is based on its cause.  Swelling due to heart failure or kidney disease requires that those underlying conditions be treated primarily.  This will, in most cases, reduce the swelling dramatically.  Swelling caused by blood clots in the deep veins of the leg necessitates aggressive (and immediate) treatment with blood thinners (anticoagulants heparin and warfarin).  Failure to appreciate the significance of this problem can have fatal consequences if the blood clot (thrombus) in the leg were to travel to the lungs.

The treatment of Lymphedema is different from that of vein disorders.  Once the absence of a blood clot has been confirmed, appropriate therapy must be started.  Simple treatments, such as leg elevation, restriction of dietary salt intake, and the use of appropriately fitted and supported compression stockings are valuable.  However, perhaps the best results for Lymphedema have been obtained with the use of a sequential compression device.  This machine acts to “milk” the excess fluid from the leg by alternately inflating and deflating a stocking (with several “fillable” air cells) that is placed on the leg. The prohibitive cost and the unwillingness of many third party payers to approve the use of these devices are the biggest obstacles in treating this disease.