Management of the patient with the swollen lower limb

Introduction

The swollen lower limb is a common presentation that all clinicians, be they vascular specialists or otherwise, will encounter in their routine clinical practice. Defined as a volumetric increase in the lower limb due to an increase in interstitial fluid volume, oedema stems from a variety of both systemic and localised causes. Systemic causes should be suspected especially if bilateral swelling is present, while localised, vascular causes of swelling usually affect a single limb.

In the assessment and management of patients presenting with a swollen lower limb, a thorough medical history and physical examination is required to determine the likely cause. This will allow for appropriate referrals to other specialities, undertaking further investigations, and targeted management of the underlying cause. This article seeks to highlight the management recommendations from the International Union of Phlebology (UIP), with an accompanying one-page guideline that includes an algorithm that can be followed to investigate and manage a swollen lower limb that can be used by all clinicians and allied health professionals.

Management recommendations

Clinicians are reminded to consider systemic causes of swollen lower limbs, a selection of which are detailed in Table 1, especially if the patient has bilateral oedema. These causes include dysfunction in other organ systems (e.g. cardiac, renal, and endocrine) or other disease processes that lead to increased intra-abdominal pressures (e.g. neoplasm and obesity), medications, or central venous or lymphatic obstruction.^1,2 In bilateral swelling of the lower limbs, medication control is appropriate. Additionally, stasis oedema due to a non-functioning calf muscle pump (NFCMP) (e.g. paresis, immobilisation) can be an important cause of oedema in elderly patients. It should however also be noted that unilateral aetiologies can affect both lower limbs, leading to bilateral symmetrical swelling. Additionally, there may be multiple underlying causes for lower limb swelling that present concurrently. Such presentations may be differentiated from isolated systemic causes based on clinical examination findings. Depending on the clinical findings on examination, patients with suspected systemic causes should be referred on to the appropriate speciality for further assessment and treatment.

Table 1.

A selection of systemic causes of swollen lower limbs.

Congestive heart failure	Pelvic/abdominal neoplasm
Pulmonary hypertension	Central obesity
Renal dysfunction	Lymphatic/central venous obstruction
Medications (e.g. amlodipine)

Patients should undergo a duplex ultrasound of the lower limbs to elucidate any venous causes for lower limb swelling. These include deep venous obstruction (DVO), deep venous insufficiency (DVI), superficial venous insufficiency (SVI), or deep venous thrombosis (DVT). If the duplex ultrasound is normal, clinicians should consider further imaging modalities such as computed tomography (CT), magnetic resonance arterial imaging, and trans-abdominal ultrasound (TAUS) of the abdomen and pelvis to rule out intra-abdominal/pelvic compression. If lymphoedema (LO) is suspected, clinicians may consider performing lymphoscintigraphy. ³

If vascular causes for the oedema are identified on duplex ultrasound, further investigations and management should be tailored according to the diagnosis and the availability of treatment modalities at each centre. This is summarised in Table 2.

Table 2.

Further investigation and management of venous causes of a swollen lower limb.

Diagnosis	Location of lesion	Further investigations and management
DVO	IVC	MR/CT venography → intravascular ultrasound +/− venous stenting, bypass, endophlebectomyCompression therapy
	Iliac+common femoral
	Femoral-popliteal	Compression therapy
DVI	Femoral	Descending venography → valvuloplasty, valve/vein transposition, neovalveCompression therapy
SVI	-	Ablation/sclerotherapySurgical intervention (CHIVA, phlebectomy, high-tie+ligation)Compression therapy
DVT	Iliofemoral	Anticoagulation +/− venous stenting, bypass, compression therapy
	Femoral-popliteal/tibial	Anticoagulation and compression therapy
LO	-	LymphoscintigraphyCompression therapy, manual lymphatic drainageLymphatic surgery

Discussion

This article provides a one-page clinical practice guideline summarising the clinical management of patients presenting with a swollen lower limb. It is part of a series of publications for the UIP One-Page Guidelines which are aimed at ensuring that patients with venous disease receive timely and appropriate care based on current best evidence and expert consensus (Figure 1).

Figure 1.

The one-page guideline.

Oedema, of one or both lower limbs, is a common problem and can represent up to half the referrals to any vascular practice. ² When facing such a presentation, vascular specialists should be reminded not to restrict their assessment to the vascular system but instead maintain a wide differential diagnosis until medical history and examination findings narrow this down. Often, the diagnosis for patients’ oedema can be identified from these findings, for example, a patient with heart failure will also report other symptoms such as breathlessness on exertion or on lying flat. However, if there is any persisting uncertainty, the differential can be further refined by targeted investigations to include or exclude diagnoses. If a venous or lymphatic cause is identified, further investigations should be performed and treatments initiated according to evidence-based practice guidelines, for example, the other publications in this series of UIP One-Page Guidelines.