What is Peripheral Edema?
The human body has different compartments that hold liquids. This includes the space inside cells and outside cells. The space outside the cells, also known as the extracellular space, holds about a third of your body’s water. This space is then divided further into the part that is inside blood vessels (25%) and part that is outside blood vessels but inside the body (75%).
The balance between the liquids in these compartments is maintained by different pressures described by a process called Starling forces. The permeability, meaning the ease with which substances pass through the walls of the vessels, and the lymphatic system, which is part of your circulatory and immune systems, are also crucial in maintaining this balance. The lymphatic system gathers liquid and proteins from the space that’s outside the blood vessels and returns them back into the bloodstream.
If this delicate balance is disturbed leading to more filtration out of the bloodstream or if the lymphatics fail to send the fluid back, it accumulates in the space outside the blood vessels, a condition called edema (swelling). This swelling can occur in any part of the body and can range from a small local swelling, such as in an insect bite, to a widespread, severe swelling called anasarca, an example of which can be seen in nephrotic syndrome, a kidney disease.
Except for localized swelling, edema does not become noticeable until the volume of fluid outside the blood vessels increases by about 2.5 to 3 liters. This is because the spaces outside the blood vessels can hold several liters of fluids quite easily. Thus, a patient’s weight can increase by nearly 10% before the swelling that leaves an indentation when pressed, known as pitting edema, becomes evident.
What Causes Peripheral Edema?
Peripheral edema, or swelling in your limbs, can be caused by a number of different factors relating to different bodily systems.
One key reason can be increased pressure inside small blood vessels, or capillaries. This can happen locally if, for instance, there’s a blood clot or damage to the veins. Conditions like this might include deep vein thrombosis or compartment syndrome, a severe swelling within certain sections of your limbs.
On a whole-body level, it might occur due to heart failure, inflammation of the heart’s lining (pericarditis), high blood pressure in the lungs (pulmonary hypertension), or liver failure.
Another cause could be an excess of fluid in the blood, due to pregnancy, before your menstrual cycle, kidney failure, heart failure, or some drugs.
Alternatively, an imbalance of protein in your blood could lead to swelling, either because proteins are being lost in conditions like preeclampsia (a condition affecting pregnant women) or because the body is not producing enough proteins, due to poor nutrition, liver failure, or certain vitamin deficiencies.
Swelling can also be due to an increase in the permeability, or “leakiness,” of your capillaries. This happens in circumstances such as after a burn, an insect bite, or an infection like cellulitis.
Another cause is a blockage in the lymphatic system, a part of your immune system that helps fight infections and drains excess fluid from tissues. This might happen due to certain diseases, because of cancers affecting the lymph nodes, or after surgery.
Then there are other conditions that don’t fit these categories, like “myxedema” in an underactive thyroid, a fat disorder called “lipedema”, or causes that are still unknown.
Lastly, some medications can cause edema as a side effect. Some common culprits include hormone drugs like glucocorticoids and estrogen, blood pressure medications like calcium channel blockers and vasodilators, and some antidepressants. Less common drug causes include antiparkinson drugs, and a type of medication known as proton pump inhibitors.
Risk Factors and Frequency for Peripheral Edema
Peripheral edema, or swelling, is most often seen in people over 50 due to venous insufficiency, which is a problem related to aging. However, there are also several other conditions that can cause this swelling, including heart failure, renal failure, liver failure, and trauma. These conditions can affect people of all ages. Additionally, peripheral edema is a common occurrence during pregnancy.
Signs and Symptoms of Peripheral Edema
Assessing a patient’s medical history and performing a physical examination is vital when diagnosing peripheral edema, which is swelling caused by the build-up of fluids in tissues of the body. The overall duration of the swelling, any changes in position, if it’s on one side or both, a person’s medicine history and any signs of systemic diseases are crucial for diagnosis. For instance, if swelling in the limb occurs within 72 hours, it could indicate conditions like deep vein thrombosis (DVT), skin infection, acute injury, or side effects from newly started medications. A gradual accumulation of more generalized swelling over days or months could be due to conditions such as congestive heart failure, liver disease, or kidney disease.
Various conditions lead to different types of edema. For example, venous insufficiency causes dependent edema, which typically improves when raised and worsens when dependent. Swelling due to decreased plasma oncotic pressure in conditions like malabsorption, liver failure, and nephrotic syndrome, usually doesn’t change with position. One-sided swelling could suggest local issues like DVT, skin infection, vein blockage, or lymphatic obstruction due to a tumor or radiation therapy. Conversely, swelling on both sides often suggests systemic diseases like heart failure, liver failure, kidney disease, or severe malabsorption syndromes.
Examining the physical features of the swelling can help differentiate underlying causes. For example, signs of heart failure could include jugular vein distension, shortness of breath, bilateral crackles and a history of heart disease. Liver disease may present with yellowing of the skin and eyes (jaundice), fluid in the abdomen, history of hepatitis, and alcohol use disorder. Kidney disease may be indicated by protein in the urine, reduced urine production, and history of poorly controlled diabetes and high blood pressure. Thyroid disease symptoms could include fatigue, anemia, weight gain.
- Swelling needs to be assessed for indentation when pressed (pitting), tenderness, and skin changes.
- Early stages of lymphedema, swelling caused by damage to the lymphatic system, results in pitting due to protein-based fluid accumulation.
- Conditions like cellulitis and DVT may cause swelling tenderness, while systemic diseases like heart failure, kidney, and liver disease usually don’t.
- Acute DVT and cellulitis can raise the skin temperature of the affected area.
- Chronic venous insufficiency often causes a reddish-brown skin color due to iron deposition.
- Late-stage patients can develop wounds that might turn into deep, oozing erosions.
Myxedema, a condition resulting from severe thyroid deficiency, may present with thickened skin with a yellow to orange discoloration and nonpitting swelling around the eyes. In lipedema, a disorder characterized by the abnormal accumulation of fat cells in the legs and arms, the feet are generally unaffected.
Testing for Peripheral Edema
Doctors will first try to determine if major issues like heart failure, liver failure, or kidney failure are causing your symptoms. This is why a detailed medical history and physical exam are essential. This helps to avoid unnecessary tests. If they suspect heart failure due to CHF (a type of heart disease), they’ll perform a chest x-ray, EKG (a test to check the electric activity of your heart) and conduct a blood test for BNP (a hormone that increases when heart failure is present).
If your symptoms seem to be coming from kidney problems, the doctor will need to check your metabolism and kidney function through tests. A urine test will also be done to check for protein, which might indicate kidney disease. If they strongly suspect kidney disease, they may recommend a kidney ultrasound to check for any issues like kidney stones or tumors.
If liver disease is suspected, the doctor will conduct liver function tests and check your albumin levels (a type of protein made by the liver). If these tests come back abnormal or if they suspect liver disease, an ultrasound of the liver may be done.
If they think your symptoms might be due to hypothyroidism (an underactive thyroid), tests will be done to check how well your thyroid is working. This may be followed by an ultrasound if necessary. If they suspect DVT (a blood clot in a deep vein, usually in the leg) or chronic venous insufficiency (a condition where the veins in your legs have problems sending blood back to the heart), Doppler ultrasonography (an ultrasound that measures the speed and direction of blood flow) may be used. This can help diagnose these conditions.
Treatment Options for Peripheral Edema
The treatment for swelling, or edema, is usually based on what’s causing it. Pulmonary edema, which is swelling in the lungs, can be life-threatening and requires urgent treatment. But for most other kinds of swelling, the excess fluid buildup can be removed slowly because they are generally not as dangerous.
If you have heart, liver, or kidney disease, your doctor may prescribe water pills known as diuretics to help your body get rid of excess fluid. In particular, loop diuretics are often effective. However, because they don’t last long in the body, you generally need to take several doses throughout the day. If you have liver cirrhosis, which is often accompanied by an excess of a hormone called aldosterone, your doctor may prescribe a type of diuretic called spironolactone along with another diuretic called furosemide.
However, with liver cirrhosis, it’s critical not to remove fluid too quickly, especially in those patients who don’t have much peripheral edema or swelling in the limbs. This is because rapid removal of fluid can worsen kidney function and lead to serious complications such as low blood pressure. If you have ascites, or fluid buildup in the abdomen, your doctor may perform a procedure called paracentesis to remove the excess fluid. This can reduce the need for high doses of diuretics and help prevent electrolyte imbalances in the body.
Some people with unexplained edema may already be taking diuretics. In these cases, the usual treatment is a low-salt diet and stopping the diuretics for a few weeks. If someone does not respond to stopping diuretics, or they aren’t taking diuretics at all, a diet that is low in salt and carbohydrates may help get rid of the swelling.
If your swelling is due to a blood clot in the veins, or deep vein thrombosis (DVT), your doctor may prescribe blood thinners, such as low molecular weight heparin or newer medications like rivaroxaban or apixaban. Compression stockings are also often used to prevent conditions such as post-thrombotic syndrome, which is a complication of DVT that can lead to ongoing swelling and discomfort in the affected limb.
If you have chronic venous insufficiency, which can also cause swelling, elevating your legs and wearing compression stockings can help. However, if you have disease in your arteries, compression is not usually recommended, because it might restrict blood flow even further. In cases of lymphedema, a swelling condition caused by blockage in the lymph vessels, therapy often involves physically massaging the area and wearing multilayer bandages. Over the longer term, wearing compression stockings or using devices that apply pressure to the area can help. And, of course, if you have swelling due to certain medications, your doctor would likely switch you to a different drug.
What else can Peripheral Edema be?
Peripheral edema, or swelling in the body, can result from various health conditions. Here are some potential causes:
- Congestive heart failure: This condition, marked by the heart’s inability to pump blood effectively, can cause fluid buildup in the lungs (pulmonary edema) and throughout the body (peripheral edema). The swelling is usually even on both sides of the body.
- Liver disease: Specific liver-related issues can cause bilateral edema, or swelling on both sides of the body, due to increased vein pressure and changes in blood protein levels.
- Renal disease: Certain kidney issues, including the nephrotic syndrome, can cause edema by increasing the amount of protein loss and fluid buildup in the body.
- Venous insufficiency: A condition where the veins struggle to send blood from the limbs back to the heart can cause swelling, often evenly distributed on both sides of the body.
Some other specific causes of peripheral edema include:
- Deep vein thrombus: This is a blood clot in a deep vein, typically in the leg. It can cause sudden, one-sided swelling.
- Lymphedema: This chronic condition, which can result from injury or surgery, often leads to swelling in the arms or legs.
- Myxedema: This is linked to severe hypothyroidism, causing soft tissue swelling alongside other symptoms like slow heart rate, constipation, and weight gain.
- Angioedema and urticaria: These conditions, which can be caused by allergies to things like bug bites or drugs, can cause swelling.
- Cellulitis: This skin infection can cause swelling along with fever and increased white blood cell count. It’s most common in people with obesity or chronic conditions like diabetes.
- Lipedema: This chronic condition often starts in or after puberty, mainly affecting thighs, legs, and buttocks but not the feet, ankles, or torso.
- Medication-induced edema: This type of swelling develops weeks after starting a new medication and quickly resolves once the drug is discontinued.
- Obstructive sleep apnea: Chronic swollen areas may also be a symptom of this condition, which is associated with pulmonary hypertension. It typically affects individuals who experience daytime fatigue, snoring, and obesity.
What to expect with Peripheral Edema
Peripheral edema, or swelling in your arms or legs, is a common symptom that can result from several health conditions. It may mean anything from severe conditions like heart failure and liver disease, to localized swelling due to an allergic reaction. Because peripheral edema can stem from many different issues, how it affects someone’s health in the long term will depend on what is causing it.
Possible Complications When Diagnosed with Peripheral Edema
Swelling in your extremities, a condition known as peripheral edema, can be an early warning sign of several severe diseases. These conditions can cause serious health issues, and in some cases, even death if they are not detected and treated promptly. The main diseases that doctors need to exclude are heart, liver, and kidney diseases. Hence, it’s crucial for these patients to undergo a detailed medical history examination, a physical check-up, and further necessary tests. All these steps can help to mitigate complications.
Main Points:
- Peripheral edema serves as an early warning sign for multiple severe diseases.
- These diseases can cause serious health problems and even lead to death if not treated early.
- Doctors primarily need to rule out conditions related to heart, liver, and kidneys.
- Detailed medical history, physical check-up, and necessary tests are essential to prevent complications.
Preventing Peripheral Edema
Educating patients is very important when dealing with conditions like peripheral edema, as well as other diseases. To explain, peripheral edema is a condition where there is an excess buildup of fluid in your body’s tissues, often causing swelling. This is common in cases like congestive heart failure, where the heart is unable to pump blood efficiently and fluid builds up in the body.
In congestive heart failure, one major part of the treatment plan is following a low-salt diet. This, along with medication to remove excess fluid (diuretic therapy), can help manage the condition.
Generally, it’s essential for patients to understand the importance of maintaining a healthy lifestyle. This includes regular exercise, a balanced diet, and routine medical check-ups. These check-ups are particularly important as they can help diagnose any underlying conditions early on, which can help to prevent serious complications down the line.
