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Peripheral oedema and ankle swelling

Medicine > Cardiovascular

Differential Diagnosis Schema 🧠

Cardiovascular Causes

  • Heart failure: Bilateral pitting oedema, often worse in the evening; associated with dyspnoea, orthopnoea, and jugular venous distension.
  • Venous insufficiency: Chronic bilateral lower limb oedema, varicose veins, skin changes such as hyperpigmentation or ulceration; typically worsens with prolonged standing.
  • Deep vein thrombosis (DVT): Unilateral leg swelling, pain, erythema, and warmth; associated with immobility, recent surgery, or malignancy.
  • Pulmonary hypertension: May present with right heart failure and peripheral oedema; associated with dyspnoea on exertion.
  • Constrictive pericarditis: Presents with bilateral oedema, ascites, and pleural effusion; associated with raised jugular venous pressure.

Renal Causes

  • Nephrotic syndrome: Generalised oedema, including periorbital oedema; associated with proteinuria and hypoalbuminaemia.
  • Acute kidney injury (AKI): Sudden onset oedema, often associated with oliguria, raised creatinine, and electrolyte disturbances.
  • Chronic kidney disease (CKD): Bilateral lower limb oedema due to fluid retention; often with hypertension, proteinuria, and other signs of chronic renal failure.
  • Renal vein thrombosis: May present with unilateral leg swelling, flank pain, and haematuria.

Hepatic Causes

  • Liver cirrhosis: Bilateral oedema, often with ascites and jaundice; associated with signs of chronic liver disease and hypoalbuminemia.
  • Hepatic vein obstruction (Budd-Chiari syndrome): Presents with right upper quadrant pain, hepatomegaly, and bilateral lower limb oedema.
  • Portal hypertension: May lead to oedema, ascites, and variceal bleeding; often secondary to cirrhosis.
  • Acute hepatitis: Can cause mild bilateral oedema due to hypoalbuminemia.

Endocrine Causes

  • Hypothyroidism: Non-pitting oedema (myxoedema), particularly in the lower limbs and face; associated with fatigue, weight gain, and bradycardia.
  • Cushing’s syndrome: Bilateral oedema, especially in the lower limbs; associated with central obesity, moon face, and hypertension.
  • Diabetes mellitus: Can cause oedema due to nephrotic syndrome, heart failure, or diabetic foot complications.
  • Adrenal insufficiency: Mild oedema may occur, typically associated with hypotension, weight loss, and hyperpigmentation.

Lymphatic Causes

  • Lymphoedema: Chronic, non-pitting oedema often affecting one or both legs; may be primary or secondary to malignancy, surgery, or infection.
  • Lymphatic filariasis: Parasitic infection leading to chronic lymphatic obstruction and elephantiasis, causing severe lower limb swelling.
  • Lymphadenopathy: Can cause localised oedema due to obstruction of lymphatic drainage, particularly in malignancy.
  • Milroy disease: A congenital condition causing primary lymphoedema, typically presenting in infancy or early childhood.

Iatrogenic Causes

  • Medications: Common culprits include calcium channel blockers, NSAIDs, corticosteroids, and certain antidepressants.
  • IV fluids: Over-administration of intravenous fluids can lead to peripheral oedema, particularly in patients with heart or renal failure.
  • Surgery: Post-surgical oedema can occur due to lymphatic disruption, immobility, or venous thrombosis.
  • Radiotherapy: May cause lymphatic damage and subsequent lymphoedema, particularly in cancers such as breast or pelvic malignancies.
  • Prolonged immobility: Can lead to dependent oedema due to poor venous return and lymphatic drainage.

Key Points in History 🥼

Onset and Duration

  • Acute onset: Suggests DVT, cellulitis, or acute heart or renal failure.
  • Chronic or progressive: Consistent with chronic heart failure, chronic kidney disease, or venous insufficiency.
  • Intermittent symptoms: May indicate mild heart failure or lymphoedema, particularly if related to activity or position.
  • Sudden worsening: Could suggest a complication such as DVT, worsening heart failure, or renal decompensation.

Associated Symptoms

  • Dyspnoea and orthopnoea: Suggest heart failure or pulmonary hypertension.
  • Abdominal pain or distension: Indicates liver cirrhosis, ascites, or congestive heart failure.
  • Oliguria or anuria: Associated with acute or chronic kidney disease.
  • Skin changes: Erythema, warmth, and tenderness suggest cellulitis; hyperpigmentation and ulceration suggest chronic venous insufficiency.
  • Weight gain: Common in fluid retention states such as heart failure, nephrotic syndrome, or liver cirrhosis.
  • Fever: Suggests an infectious cause such as cellulitis or septic thrombophlebitis.
  • Fatigue and malaise: May indicate chronic disease, heart failure, or systemic conditions like hypothyroidism.
  • History of trauma or surgery: Raises suspicion for post-surgical oedema, lymphoedema, or DVT.

Background

  • Past medical history: Includes heart failure, renal disease, liver disease, or previous DVT or pulmonary embolism.
  • Medication history: Review for drugs that cause fluid retention, such as calcium channel blockers, NSAIDs, or corticosteroids.
  • Family history: Consider genetic predispositions to conditions like nephrotic syndrome, hereditary angioedema, or venous insufficiency.
  • Social history: Includes smoking, alcohol use, and occupational factors that may contribute to cardiovascular disease or venous stasis.
  • Travel history: Important in assessing risk for DVT, especially after long-haul flights or prolonged immobility.
  • Diet and lifestyle: High salt intake, sedentary lifestyle, or obesity may exacerbate conditions like heart failure or venous insufficiency.
  • Pregnancy: Raises suspicion for gestational hypertension, preeclampsia, or DVT.

Possible Investigations 🌡️

Imaging

  • Doppler ultrasound: First-line investigation for suspected DVT or venous insufficiency; assesses venous flow and compressibility.
  • Echocardiography: Useful in assessing cardiac function in suspected heart failure or pulmonary hypertension.
  • Chest X-ray: To assess for pulmonary congestion, cardiomegaly, or other signs of heart failure.
  • CT or MRI: Considered for complex cases or when there is suspicion of underlying malignancy or vascular abnormalities.
  • Venography: May be indicated in cases of suspected venous thrombosis not clearly diagnosed by ultrasound.
  • Renal ultrasound: Used to evaluate renal structure and function in cases of suspected renal causes of oedema.
  • Liver ultrasound: Assesses liver size, texture, and the presence of ascites in suspected liver disease.
  • Lymphoscintigraphy: Useful for diagnosing lymphedema by visualising lymphatic flow.

Laboratory Tests

  • Full blood count (FBC): May reveal anaemia or infection, particularly in cases of systemic disease or sepsis.
  • Renal function tests (U&E): Assess kidney function, important in cases of suspected renal causes of oedema.
  • Liver function tests: To assess for liver disease, particularly in patients with signs of cirrhosis or portal hypertension.
  • Thyroid function tests: Useful in suspected hypothyroidism.
  • Serum albumin: Low levels suggest nephrotic syndrome, liver disease, or malnutrition.
  • D-dimer: Elevated in cases of suspected DVT or pulmonary embolism, though not specific.
  • BNP or NT-proBNP: Useful in diagnosing and assessing the severity of heart failure.
  • Urinalysis: To check for proteinuria, haematuria, or signs of infection.
  • Coagulation profile: Important in assessing patients with suspected clotting disorders or those on anticoagulant therapy.
  • Blood glucose: Important in diabetic patients, where poor glycaemic control can exacerbate complications leading to oedema.
  • Cortisol levels: To rule out Cushing’s syndrome if clinical suspicion is high.

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Cardiovascular