Leg and ankle swelling

Probability diagnosis

Physiological:

• dependency/gravitational

• prolonged sitting, standing, walking

• hot weather

• pregnancy

• mechanical (e.g. constricting clothing)

Chronic venous insufficiency (varicose veins)

Congestive cardiac failure

Drugs (e.g. calcium antagonists, NSAIDs)

Local trauma

Obesity

Serious disorders not to be missed

Vascular:

• deep venous thrombosis (DVT)

• inferior vena cava thrombosis

• thrombophlebitis

Infection:

• cellulitis

• tropical infections (e.g. filariasis, hookworm)

Cancer:

• obstruction from pelvic cancer

• localised malignancy

Other:

• kidney disease (e.g. nephrotic syndrome)

• liver disease (e.g. cirrhosis)

• skin allergy (e.g. angioneurotic oedema)

Pitfalls (often missed)

Idiopathic (periodic or cyclic) oedema

Protein-losing enteropathy (e.g. Crohn)

Lipoedema (fat and fluids) of legs

Lipidema (fat) of legs

Rarities:

• malnutrition

• lymphoedema: primary or secondary

Masquerades checklist

Diabetes

Drugs (multiple; see list)

Thyroid/endocrine (hypothyroidism, Cushing syndrome)

Key history

Past history (esp. liver, heart, kidney disease), travel, drugs, occupation, recent trauma. Circumstances of swelling (e.g. prolonged walking, long journey).

Key examination

• Cardiovascular, abdomen (signs of liver disease), legs including circulation, varicose veins and evidence DVT

Key investigations

Consider:

• urinalysis (?albumin)

• FBE

• ESR/CRP

• U&E

• KFTs

• serum albumin/LFTs

• TSH

• ultrasound (DVT screen)

• CXR

• pelvic ultrasound

• other radiographs (e.g. CT scan, venogram).

Diagnostic tips

• Not all swollen legs require investigation.

• If the onset of oedema is acute (often <72 hours) suspect DVT.

• Pitting oedema is a feature of venous thrombosis or insufficiency, not lymphatic obstruction.

• The significance of leg swelling varies according to the age group, whether it is bilateral or unilateral and whether the onset is sudden or gradual.

• Drugs that can cause leg and ankle swelling include calcium antagonists, NSAIDs, corticosteroids, glitazones, beta blockers.