Pedal edema

Peripheral edema
Massive peripheral edema (Image courtesy of Charlie Goldberg, M.D., UCSD School of Medicine and VA Medical Center, San Diego, CA)
ICD-10	R60.0
ICD-9	782.3

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: M.Umer Tariq [2]

Overview

Competent venous valves, intermittent leg muscle contraction and respiration is required to support normal venous blood return. When these fail, venous insufficiency and edema occur. Edema can occur in 2 forms: pitting and non-pitting. Pitting occurs when there is fluid movement when pressure is applied. Non-pitting is swelling of the tissue itself, not an excess of fluid surrounding the tissue. Edema is caused by an accumulation of an excessive amount of watery fluid in the serous cavities, tissues or cells causing painless, non-reddened swelling

Epidemiology and Demographics

25% of the general population suffers from chronic venous insufficiency.

Complete Differential Diagnosis of Pedal Edema

In alphabetical order:

• Abscess
• ACE inhibitor
• Aceon
• Acquired C1-esterase inhibitor deficiency
• Actos
• Acute glomerulonephritis
• Addison's Disease
• Aldomet
• Amlodipine
• Amniotic band
• Angioneurotic edema
• Angiotensin converting enzyme inhibitor
• Anemia
• Anorexia Nervosa
• AV fistula
• Avandia
• Bartter's Syndrome
• Beriberi
• Beta blockers
• Boils
• Bruise
• Bulimia Nervosa
• Burn
• Cachexia
• Carbuncle
• Cardura
• Cellulitis
• Chemotherapy
• Cisplatin
• Cold (physical stimuli)
• Constrictive pericarditis
• Contact dermatitis
• Contusion
• Cushing's Syndrome
• Diltiazem
• Drugs
• Docetax
• Erysipelas
• Exudative enteropathy
• Filariasis
• Fracture
• Frostbite
• Gas gangrene
• Glitazones
• Gout
• Hyperthyroidism
• Hypoalbuminemia
• Hypoplasia
• Hypothyroidism
• Ibuprophen
• Idiopathic edema
• Insect bite
• Irritant
• Left heart failure
• Ligamentous sprain
• Liver failure
• Lymph node mass
• Malabsorption
• Malnutrition
• Mediastinal cancer
• Milroy's Disease
• Minipress
• Motrin
• Musculoskeletal trauma
• Myocardial Infarction
• Neoplasm
• Nephrotic Syndrome
• Nifedipine
• Norvasc
• Osteomyelitis
• Peripheral nerve lesion
• Premenstrual edema
• Right heart failure
• Scleroderma
• Sepsis syndrome
• Snakebites
• Starvation edema
• Sunburn
• Surgical excision
• Tendonous strain
• Thoracic aneurysm
• Thrombophlebitis
• Thrombosis
• Tight clothing
• [[Trentinion
• Trichinosis
• Tumors
• Univasc
• Valproic acid
• Varicose veins
• Vesinoid
• vytorin

Complete Differential Diagnosis of the Causes of Pedal Edema

(By organ system)

Cardiovascular	AV fistula, Constrictive pericarditis, Left heart failure, Myocardial Infarction, Right heart failure, Thoracic aneurysm, Thrombophlebitis, Thrombosis, Varicose veins,
Chemical / poisoning	Insect bite, Snakebites,
Dermatologic	Carbuncle, Cellulitis, Contact dermatitis, Contusion, Erysipelas, Gas gangrene,
Drug Side Effect	ACE inhibitors, aceon, actos, aldomet, amiodarone, amlodipine, arixtra, atorvastatin, avandia, beta blockers, cardura, casodex, cilostazol, cisplatin, clopidogrel, coreg, crestor, diltiazem, docetaxel, estrogen, evista, flecainide, fondaparinux, glitazones, hydralazine, ibuprofen, labetalol, lipitor, minipress, minoxidil, motrin, nifedipine, norpace, norvasc, pindol, plendil, tenormin, trentinion, univasc valproic acid, verapamil, vesinoid, vytorin, xeloda , axotereA,r omasinT,a xol, Tamoxifeann, dH ercept
Ear Nose Throat	No underlying causes
Endocrine	Addison's Disease, Cushing's Syndrome, Hyperthyroidism, Hypothyroidism,
Environmental	Cold (physical stimuli), Frostbite, Sunburn,
Gastroenterologic	Exudative enteropathy, Liver failure, Malabsorption,
Genetic	No underlying causes
Hematologic	Anemia, Hypoalbuminemia,
Iatrogenic	No underlying causes
Infectious Disease	Filariasis, Trichinosis,
Musculoskeletal / Ortho	Fracture, Gout, Ligamentous sprain, Osteomyelitis,
Neurologic	Peripheral nerve lesion,
Nutritional / Metabolic	Acquired C1-esterase inhibitor deficiency, Beriberi, Malnutrition, Starvation edema,
Obstetric/Gynecologic	Amniotic band syndrome, Peripartum cardiomyopathy, Premenstrual edema,
Oncologic	Mediastinal cancer,
Opthalmologic	No underlying causes
Overdose / Toxicity	No underlying causes
Psychiatric	Anorexia Nervosa, Bulimia Nervosa,
Pulmonary	Pulmonary hypertension,
Renal / Electrolyte	Acute glomerulonephritis, Bartter's Syndrome, Nephrotic Syndrome,
Rheum / Immune / Allergy	Angioneurotic edema, Cachexia, Lymph node mass, Scleroderma, Sepsis syndrome,
Sexual	No underlying causes
Trauma	Bruise, Burn, Musculoskeletal trauma,
Urologic	No underlying causes
Miscellaneous	Idiopathic edema, Milroy's Disease, Sepsis syndrome, Tight clothing,

Diagnosis

History and Symptoms

• History should include:

• DVT risk factors
• time lapse
• other associated symptoms
• unilateral vs. bilateral
• pitting and/or non-pitting

(Images courtesy of Charlie Goldberg, M.D., UCSD School of Medicine and VA Medical Center, San Diego, CA)

• 

  Moderate edema

• 

  Massive edema

Laboratory Findings

• Labs include:

• Blood cultures
• BUN / creatinine
• CBC
• Coagulation
• Electrolytes
• LFTs
• Serum albumin
• Thyroid function tests
• Urinalysis

Chest X Ray

• Chest X-Ray may indicate pulmonary edema and/or cardiomegaly

Echocardiography or Ultrasound

• Duplex ultrasound for DVT
• Echocardiography for EF in patients with CHF

Other Diagnostic Studies

• liver biopsy for cirrhosis

Treatment

Acute Pharmacotherapies

• Congestive heart failure: Diuretics, ACE inhibitors, beta blockers, digoxin

Chronic Pharmacotherapies

• DVT: Anticoagulation with unfractionated heparin, low molecular weight heparin / warfarin for 3-6 months

Indications for Surgery

• Nephrotic syndrome: transplant in adult patients may be necessary
• Cirrhosis: liver transplant may be necessary

Additional therapies

• Venous insufficiency: Leg elevation, compression stockings, minimize time standing
• Cellulitis: extremity elevation
• CHF: Salt restrictions
• Cirrhosis: Diuretics & low salt diet

Prognosis

Successful treatment depends on control of the underlying cause. Severe swelling can cause permanent damage to nerves, resulting in peripheral neuropathy. Many cases from temporary or minor causes resolve on their own, with no lasting damage.

Acknowledgements

The content on this page was first contributed by: C. Michael Gibson, M.S., M.D.

Additional Resources

• Cho S, Atwood J (2002). "Peripheral edema". Am J Med. 113 (7): 580–6. doi:10.1016/S0002-9343(02)01322-0. PMID 12459405.

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