View source for Bilateral leg swelling

==Background==
*Bilateral leg swelling (bilateral pedal edema) is a common ED complaint
*Unlike unilateral swelling, bilateral edema usually indicates a systemic process
*Most common cause is bilaeral pedal edema
**Definition: excess fluid in the lower extremity resulting in swelling of the feet and extending upward
**Further classified as pitting (compressible) and non-pitting
*Key systemic causes to identify: [[congestive heart failure|heart failure]], [[cirrhosis]], [[nephrotic syndrome]], renal failure
*Medication-related edema is common and often overlooked (calcium channel blockers, NSAIDs, gabapentin/pregabalin)
{{Causes Pedal Edema}}

==Clinical Features==
===History===
*Onset and progression
*Orthopnea, PND, dyspnea on exertion (heart failure)
*Abdominal distension, jaundice, alcohol use (cirrhosis)
*Foamy urine, periorbital edema (nephrotic syndrome)
*Medication review: calcium channel blockers (especially amlodipine), NSAIDs, gabapentin/pregabalin, pioglitazone, corticosteroids
*History of heart failure, liver disease, kidney disease, thyroid disease
*Dietary history (salt intake)

===Physical Exam===
[[File:PedalEdema.jpg|thumb|Pitting pedal edema]]
*Assess degree and distribution of edema
*Pitting vs. non-pitting
**Pitting: heart failure, cirrhosis, nephrotic syndrome, medications, venous insufficiency
**Non-pitting ("woody"): [[lymphedema]], [[pretibial myxedema]] (hypothyroidism), chronic venous changes
*JVD (heart failure)
*Lung crackles (pulmonary edema)
*Hepatomegaly, ascites, spider angiomata, jaundice (cirrhosis)
*S3 gallop, displaced PMI (heart failure)
*Periorbital edema (nephrotic syndrome)
*Skin changes: stasis dermatitis, hemosiderin staining (chronic venous insufficiency)

==Differential Diagnosis==
{{Bilateral pedal edema DDX}}

==Evaluation==
===Laboratory===
*[[CBC]]
*[[BMP]] (renal function, electrolytes)
*[[Albumin]] (low in cirrhosis, nephrotic syndrome, malnutrition)
*[[UA]] with urine protein (nephrotic syndrome screening)
*[[BNP]] or NT-proBNP (elevated in heart failure)
*[[Liver function tests]] if hepatic cause suspected
*[[TSH]] if hypothyroidism suspected
*Lipid panel, 24-hour urine protein if nephrotic syndrome suspected

===Imaging===
*[[CXR]]: cardiomegaly, pulmonary edema, pleural effusions
*[[ECG]]: evaluate for ischemia, arrhythmia, chamber enlargement
*Bedside [[POCUS]]: cardiac function (EF), IVC diameter (volume status), lung B-lines (pulmonary edema), pleural effusion
*[[Echocardiography]] if new heart failure suspected
*Consider [[DVT ultrasound]] if asymmetry or concern for bilateral DVT (rare but possible with IVC thrombus or bilateral iliac disease)
*Abdominal ultrasound if cirrhosis or hepatic cause suspected

===Diagnosis===
*Idiopathic edema is a diagnosis of exclusion, must first rule out CHF, cirrhosis, renal failure, nephrotic syndrome, chronic venous insufficiency, and medication-induced edema<ref>Kay A, Davis CL. Idiopathic Edema. American Journal of Kidney Disease. 1999; 34(3): 405-408.</ref>

==Management==
===General===
*Treat underlying cause
*Sodium restriction
*Leg elevation
*Compression stockings for chronic venous insufficiency

===Heart Failure===
*See [[Congestive heart failure|CHF]] for detailed management
*IV [[furosemide]] for acute decompensation with pulmonary edema
*[[Nitroglycerin]] for preload reduction if hypertensive

===Cirrhosis===
*Sodium restriction, [[spironolactone]] +/- [[furosemide]]
*See [[Ascites]] management

===Nephrotic Syndrome===
*Loop diuretics, sodium restriction
*Nephrology consultation

===Medication-Induced===
*Identify and discontinue or reduce offending agent if possible
*Idiopathic pedal edema need not be treated with diuretics

==Disposition==
===Admit===
*New diagnosis of heart failure
*Acute decompensated heart failure
*Respiratory compromise from volume overload
*Acute renal failure
*New diagnosis of cirrhosis with complications
*Concerning laboratory findings (severe hypoalbuminemia, elevated creatinine, new anemia)

===Discharge===
*Chronic stable edema with known cause
*Medication-induced edema with plan for medication change
*Chronic venous insufficiency
*Patients should be followed up in outpatient clinic for further investigation and care
*Return precautions: worsening swelling, shortness of breath, chest pain, decreased urine output, weight gain >2-3 lbs/day

==See Also==
*[[Unilateral leg swelling]]
*[[Congestive heart failure]]
*[[Cirrhosis]]
*[[Nephrotic syndrome]]

==External Links==
*[http://ddxof.com/lower-extremity-edema/ DDxOf: Differential Diagnosis of Lower Extremity Edema]

==References==
<references/>

[[Category:Cardiology]]
[[Category:FEN]]
[[Category:Symptoms]]