Edema of the feet is diagnosed
As shown in the figurealgorithm, when evaluating a patient with peripheral edema, the best way is to try to classify edema into general or local edema. Within these two broad categories, first of all, it is necessary to define "curability" and "reversibility of edema.
Scheme of diagnostic approach in a patient with peripheral edema
When the basis of edema is the systemicthey have a generalized character and capture if not all, at least two limbs. Often ascites is observed, and the fluid retention is so marked that pain marks a significant increase in body weight.
With cardiac edema, there is usually an anamnesisan indication of heart disease or cardiac symptoms: dyspnea, orthopnea, palpitation, and chest pain. Important physical symptoms are changes in heart size, rhythm disturbances (especially the alternating pulse) or heart tones (especially the third tone), as well as enlargement of the jugular veins. When analyzing the pulse curve on the jugular veins, important symptoms characterizing the type of cardiac pathology can be obtained: pronounced negative x and y waves with chronic compressive pericarditis, a large cv wave when the tricuspid valve is inadequate, and a slow wave with stenosis of the tricuspid valve. With cardiomyopathy, there may be accompanying symptoms, ranging from the newly emerging influenza state to such non-specific symptoms as fatigue, lack of appetite and weight loss.
In patients with edema due to diseasekidneys, usually in history, there are indications of a recent pharyngitis, infectious urinary tract disease, or changes in urine analysis. With a long-term kidney disease, hemorrhages or exudates on the fundus can occur. The patient with thrombosis of the renal veins often has pain in the sloping parts of the abdomen, recently suffered or concomitant thrombosis of peripheral veins, as well as severe proteinuria. With tomography, ultrasound examination and computer tomography scanning, a change in the size of the kidneys is detected, however, excretory urography should be performed to prove violations of the state of the cup-lobe system or ureters.
If swelling is of hepatic origin,it is usually not difficult to diagnose. As a rule, detect previous alcoholism, hepatitis or jaundice, as well as some or all of the symptoms of chronic liver failure: arterial arachnid hemangiomas, hepatic palms (erythema), gynecomastia and developed venous collaterals in the anterior abdominal wall. Characteristic signs are ascites and splenomegaly.
Edema associated with malnutrition, althoughare rare, also worthy of attention. Usually there are other symptoms of nutritional deficiency: cheilosis, red tongue, weight loss. The relative frequency of neurotic loss of appetite has recently brought this disease to the number of the most frequent causes of edema of nutritional origin in modern clinical practice. With swelling due to bowel disease, there is often a history of intestinal pain or profuse diarrhea in the anamnesis. In these cases, it is necessary to analyze the stool for fat content and the radiography of the organs of the gastrointestinal tract.
Probably the most diagnostic problemscause idiopathic edema. In typical cases, women are treated by a doctor, whose edema appears periodically with prolonged stays on their feet during the day; accumulation of fluid during the day leads to the fact that by the evening there is an increase in body weight. In addition to swelling of the lower extremities, patients can note an increase in the abdomen and mammary glands. Patients often complain of swelling of the face and hands in the morning, which decreases with movement. The fluid retention occurring during the day (in the vertical position) tends to decrease at night (in horizontal position) as a result of urination. This orthostatic nature of idiopathic edema can be demonstrated by a sample of water excretion, which also allows to determine whether edema is caused by orthostatic sodium retention or orthostatic water retention.
If edema affects only one limb, theyusually due to local causes. However, local edema can cover both lower limbs, which makes differential diagnosis difficult with general edema.
Venous edema can be either acute orchronic. For acute deep vein thrombosis, in addition to edema, characterized by the appearance of a pit under pressure, pain and soreness are typical for palpation of the affected vein. When the thrombus of larger veins (popliteal, superficial and general femoral) is clogged, an increase in the surface venous pattern is also usually observed. When chronic venous hypertension is caused by varicose veins or insolvency (postphlebitic) deep veins, symptoms of chronic venous stasis (stagnant pigmentation, trophic ulcers) are added to orthostatic swelling. In patients with deep vein obstruction due to their compression (volumetric formations or scarring), swelling in its consistency and slow reverse development when raising a limb may resemble lymphatic edema, however, the symptoms of chronic venous obstruction (venous stars), collateral venous routes and cyanotic skin color. Using a portable device for Doppler ultrasound can provide immediate confirmation of obstruction or failure of venous blood flow in these cases.
Lymphatic edema is usually painful, prone toprogression and are accompanied by symptoms of chronic venous congestion. When palpation, the area of swelling is dense, the skin is thickened ("pig skin" or "orange peel"), when the limb is raised, the puffiness decreases more slowly than with venous edema. Inflammatory form of edema is observed in all age groups; The most common cause is dermatophytosis; The entrance gates for pathogenic bacteria, usually streptococci, are skin cracks in the finger spaces. Early lymphatic edema usually can be distinguished from obstructive lymphatic edema on the basis of clinical data, as in women they occur 9 times more often than men, appear before the age of 40, often in a period close to menarche. Obstruction of lymph vessels can occur as a result of surgical intervention, scarring due to radiation damage and with neoplastic lymph node involvement. Obstructive lymphatic edema arising as a result of the tumor process usually appears after 40 years (their frequency does not depend on sex) and, as a rule, is caused by tumors of the pelvic organs (genito-urinary tract, gastrointestinal tract) or lymphoma; lymph nodes in malignant tumors are usually found during physical examination or in computed tomographic pelvic scan. If there are doubts about the permeability of the deep veins of the limb affected by lymphatic edema, an informative method of noninvasive evaluation of venous blood flow in these cases is Doppler ultrasound.
Explain why a patient with fatty edemathere are so great diagnostic difficulties, it is not easy. Almost always arising in women, this type of edema manifests a noticeable, symmetrical obesity of the legs. The usual complaint that is presented to the doctor is "swelling of the legs," which actually takes place and increases in the orthostatic position. Like other types of orthostatic edema, they usually intensify before menstruation begins, when swimming in warm water, with prolonged sitting or uncontrolled use of salt. The area of edema is mild, with pressure, a depression appears quickly (excluding lymphatic edema), there are no symptoms of chronic venous stasis (excluding chronic venous insufficiency); the prolonged existence of these edemas makes it possible to exclude deep vein thrombosis. Diagnostic difficulties occur with concomitant varicose veins, but the symmetry of the lesion and the typical location of the fat deposits, as well as the normal shape of the feet and fingers, should help to establish the correct diagnosis.
Orthostatic edema of independent significanceDont Have. Indeed, the majority of peripheral edema is orthostatic, and only occasionally the primary cause of soft edema, with pressure on which a depression forms, is the lack of pumping muscle function. Most often this is observed in elderly patients, as well as persons who have a habit of sleeping in an armchair or hanging legs from a bed during sleep (for example, when trying to relieve ischemic pain).
When there are arteriovenous anastomoses, highThe arterial pressure is transmitted to the venous system distal to the place of their connection! As a result of venous hypertension, veins expand, varicose can develop, resulting in the limb becoming edematous, cyanotic and warm to the touch. If the limb is injured, ulcers appearing in this case have the appearance of venous trophic ulcers. Arteriovenous anastomoses can be easily diagnosed during auscultation, in which the long noise characteristic of congenital fistula, or systolic and diastolic murmur of complex tonal character, characteristic of acquired arteriovenous fistulas, is determined.
Very often after restoration of arterialblood flow in the ischemic limb as a result of vascular surgery or percutaneous balloon angioplasty for a short period of time, there may be swelling of the limb distal to the site of operation, as well as the feet. Despite the presence of an orthostatic effect, this form of postoperative edema appears to be most correctly explained by an increase in vascular permeability in the ischemic limb; they usually go away without treatment within one or several weeks. Venous Doppler ultrasound is a convenient bedside tool for differentiating this form of edema from postoperative venous thrombosis.
If edema complicates lesions of the osteomuscularsystem, most often the dominant complaint is pain and tenderness in palpation; the patient often notices edema only after their appearance. When a shank muscle rupture (for example, the tendon of the plantar muscle), the sudden appearance of pain, as well as the appearance of a meniscus-shaped bruise below the ankle, make it easy to distinguish these swelling from other types of local edema. When swelling complicates the inflammation of the tendon sheath or a fracture of the bones of the metatarsus, the most valuable diagnostic sign is local soreness. The popliteal cyst can lead to edema of the distal leg sections as a result of compression of the popliteal vein in the popliteal fossa or hernial protrusion into the head region of the gastrocnemius muscle; in both cases a clinical picture of venous obstruction is observed, accompanied by pain and pain in palpation in the popliteal region or in the upper part of the tibia. As indicated earlier, ultrasound is the preferred method for determining popliteal cysts.
Reflex sympathetic dystrophy representsis a primary neurological disorder, but this pathology deserves discussion in this article, as it accompanies certain types of trauma and usually a "wet" phase is observed during which the affected limb is swollen. Usually the limb is edematic and moist, but retains a normal color; despite the presence of edema, the patients, as a rule, are concerned only with diffuse disorders of sensitivity and pain. Over time, as well as blockade of sympathetic nerves or the use of ganglion blocking drugs (eg, prazosin), edema decreases, indicating that the basis of edema in reflex sympathetic dystrophy is an increase in vascular permeability.