Bilateral leg edema in an older woman

Abstract

Bilateral leg edema is a frequent symptom in older people and an important concern in geriatric medicine. Further evaluation is frequently not performed and simple therapy with diuretics is prescribed. Particularly in older patients, long-term use of diuretics can lead to severe electrolyte imbalances, volume depletion, and falls. In this case report we want to focus the physicians' attention on the necessity to determine the cause and show a correspondingly effective treatment for bilateral leg edema in older people. A thorough approach is required to recognize diseases and to avoid adverse drug events as geriatric patients often show an atypical presentation or minor symptoms. The cause of swollen legs is often multifactorial; therefore, the patient's individual history and an appropriate physical examination are important. Depending on the clinical symptoms, evaluation including basic laboratory tests, urinalysis, chest radiography, and echocardiogram may be indicated. The most probable cause of bilateral edema in older patients is chronic venous insufficiency. Heart failure is also a common cause. Other systemic causes such as renal disease or liver disease are much rarer. Antihypertensive and anti-inflammatory drugs can frequently cause leg edema, but the incidence of drug-induced leg swelling is unknown. With the help of this special case we tried to develop an approach to the diagnosis of symmetric leg edema in older patients, a problem frequently neglected in geriatric medicine.

Development of a Minimum Data Set Registry for Chronic Venous Insufficiency of the Lower Limbs

“…With these 39 documents, we developed an MDS for the prevention, diagnosis, and treatment of CVI, with a total of 125 items grouped into seven categories, as follows:Patient examination [3,4,5,6,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55] (Table 1), with two sub-categories, as follows: Risk factors, with 15 items covering personal circumstances that increase the likelihood of CVD. These items include age, sex, and family history of CVI.Leg conditions, with 22 items related to the signs and symptoms of venous disease of the lower limbs such as cramps, heaviness, and varicose veins.Diagnostic studies [6,21,23,26,27,28,29,30,31,32,33,34,35,36,38,39,40,42,43,44,47,49,…”

“…Venous disease scoring and classification systems consisted of the Villalta scale, the Venous Clinical Severity Score (VCSS) and the CEAP.Ulcer examination [30,31,33,34,39,42] with seven items to describe ulcers, including photography, signs of infection, and pain.Different treatments at the various stages of venous disease (Table 3). This category has four sub-categories, as follows:Compression therapy [6,19,21,26,27,29,30,31,32,33,34,35,36,38,39,41,42,44,46,47,49,50,51,53] with seven items covering different limb compression methods, including the Unna boot, graduated compression hosiery, and the multi-layer compression bandage system.Drug treatment [6,21,29,33,35,36,39,42,43,44,46,52,53] with ten items related to recommended drugs in venous disease, such as oral anticoagulants, flavonoids/phlebotonics, and pentoxyphylline.Surgical treatment [6,19,21,23,26,28,40,43,44,45,47,49,50,53,54,55] with nine items, including mechanochemical endovenous ablation (MOCA) and endovenous thermal ablation (EVTA).<...>…”

Diagnostic approach to lower limb edema

“…Previous abdominal or pelvic surgery, malignancy, or radiation history is also important as an antecedent to both venous and lymphatic etiologies of edema. [2][3][4][5] Assessment for systemic diseases is necessary, particularly in older patients with multiple comorbid conditions that could be contributing to their primarily bilateral leg edema. New onset or exacerbations of cardiac, renal, hepatic, endocrine issues may be a cause.…”

“…Previous abdominal or pelvic surgery, malignancy, or radiation history is also important as an antecedent to both venous and lymphatic etiologies of edema. 2 – 5 …”

“… 1 Symptoms can be debilitating and subsequently impact quality of life with significant costs to society. 2 – 5 Recent work has demonstrated that chronic edema negatively impacts physical and psychological health and reduces quality of life. 6 As such, in this opinion article, we propose a practical diagnostic approach to accurately and efficiently identify the causes of chronic edema in affected patients and to institute appropriate therapy.…”