A bad leg
Your senior house officer visited a 74 year old man in the emergency department. He shows you a photograph of his right lower leg taken after he had examined it (figure).
The man's lower right leg
Questions
- Name the clinical sign?
- List three common causes of this problem?
- The patient's abdomen was also grossly swollen and tense; what is this most likely to be due to?
Answers
- Pitting oedema
- Any three of heart failure, deep vein thrombosis, cellulitis, renal disease, proteinuria, cirrhosis, carcinomatosis, thrombophlebitis, malnutrition, lymphoedema, and immobility
- Abdominal ascites
Discussion
We are given little history with the photograph--only that the man is 74 years of age and presented to the emergency department. The obvious abnormality is the swelling of the lower leg with indentations from examining fingers--this is called pitting. For pitting to be apparent, it usually takes 30 seconds of sustained pressure to the tissues. Severe pitting oedema will be obvious long before this.
Oedema is an accumulation of tissue fluid in patients in whom a lymphatic abnormality has not been confirmed. Fluid tends to accumulate from the lower limbs upwards due to gravity. The available information from the photograph shows only one leg, but you should always compare both. This will enable you to distinguish if it is caused by a problem resulting in unilateral or bilateral oedema (box).
The causes of unilateral pitting oedema tend to relate to focal pathology or localised factors. Infection and inflammation causes oedema through the tissue response via the immune system. It can also result from impaired fluid drainage, namely of venous blood or lymph fluid. Blockage of outflow, leakage of vessels, or immobility and failure of muscle pumps can all lead to unilateral oedema.
Bilateral causes tend to be due to systemic pathology. Cardiac failure is a failure of the heart muscle pump. Renal hypoperfusion leads to volume retention via the rennin-angiotensin-aldosterone mechanism. Pump failure and fluid retention leads to venous volume overload. Dependent pitting oedema, pulmonary oedema, ascites, and raised jugular venous pressure result.1
Hypoproteinaemia results from nephrotic syndrome (loss of protein in the urine due to glomerular damage) and hepatic disease, such as cirrhosis (protein production failure). Colloid osmotic pressure is therefore reduced and unable to maintain vascular volume. Excessive accumulation of interstitial fluid occurs producing pitting oedema.
| Types of pitting oedema |
| Unilateral pittingoedema |
Bilateral pitting oedema |
| Deep vein thrombosis |
Cardiac failure |
| Superficial thrombophlebitis |
Renal failure |
| Cellulitis |
Nephrotic syndrome |
| Extrinsic compression of deep veins |
Cirrhosis |
| Lymphoedema |
Nutritional Carcinomatosis |
| Immobility |
|
Ascites is the accumulation of fluid in the peritoneal cavity. As explained above, this can result from cardiac failure; hypoproteinaemia, as in nephrotic syndrome; cirrhosis of the liver; or malnutrition. It can also result from intra-abdominal malignancy.2
Unfortunately systematic investigations showed that this person had a pancreatic carcinoma with peritoneal secondary metastatic deposits. He has been counselled about the care options available.
Steven Kennish, senior house officer in general surgery, Pinderfields Hospital, Yorkshire School of Surgery
Email: email
studentBMJ 2005;13:45-88 February ISSN 0966-6494
- O'Neill P, Dornan T, Denning DW. Medicine: a core text with self-assessment. 1st ed. London: Churchill Livingstone, 1999:165-72.
- Grace PA, Borley NR. Surgery at a glance. 1st ed. Oxford: Blackwell Science, 1999:18-9.
