Makindo Medical Notes

📖 Introduction

Peripheral oedema and ankle swelling are common clinical findings across all age groups, particularly in the elderly. They result from an imbalance between capillary filtration and lymphatic drainage. Oedema may be localised (e.g., DVT, cellulitis) or generalised (e.g., heart failure, cirrhosis, nephrotic syndrome). A careful history, examination, and targeted investigations are essential to identify the underlying cause.

⚙️ Basic Physiology of Oedema Formation

• 💧 Starling Forces: Fluid movement across capillaries is governed by the balance between:
  • Hydrostatic pressure (pushes fluid out of capillaries).
  • Oncotic pressure (albumin pulls fluid back in).
• 🦵 Lymphatic Drainage: Removes excess interstitial fluid and proteins → blockage or failure causes lymphoedema.
• 🩸 Balance: When filtration > reabsorption + lymphatic drainage → oedema develops.

🧬 Aetiology of Peripheral Oedema

• 🫀 Cardiac: Right-sided heart failure, constrictive pericarditis, pulmonary hypertension → ↑ venous pressure.
• 🍺 Hepatic: Cirrhosis → ↓ albumin (low oncotic pressure) + portal hypertension.
• 🧬 Renal: Nephrotic syndrome, CKD → proteinuria + salt retention.
• 🩸 Vascular: DVT, chronic venous insufficiency, varicose veins.
• 🧠 Endocrine: Hypothyroidism → myxoedema (non-pitting).
• 🦵 Lymphatic: Primary (congenital) or secondary (cancer, surgery, filariasis).
• 💊 Drugs: Calcium channel blockers, NSAIDs, steroids, pioglitazone.
• 👶 Other: Pregnancy, immobility, prolonged standing, idiopathic oedema.

📝 History Taking

A careful history is crucial in determining the underlying cause of peripheral oedema or ankle swelling. Think: 🫀 cardiac, 🩸 vascular, 🧬 renal, 🍺 hepatic, and 🧠 endocrine causes.

• ⏱️ Duration: Acute (<72h) vs chronic (weeks/months).
• 📍 Location:
  • Unilateral → local (e.g., DVT 🩸).
  • Bilateral → systemic (e.g., CHF 🫀, nephrotic syndrome 🧬).
• ⚠️ Associated Symptoms:
  • Dyspnoea, orthopnoea → heart failure 🫀
  • Pain, redness, tenderness → DVT 🩸
  • Weight gain, foamy urine → nephrotic syndrome 🧬
  • Long standing, varicosities → venous insufficiency 🦵
• 📖 Medical History: Heart disease, HTN, CKD, cirrhosis 🍺, DVT, hypothyroidism 🧠.
• 💊 Medications: Calcium channel blockers, NSAIDs, steroids – common culprits.

🩺 Physical Examination

• 👀 Inspection: Distribution (uni vs bilateral), symmetry, skin changes.
• 🦶 Pitting vs Non-Pitting: Pitting → CHF/nephrotic; Non-pitting → lymphoedema, hypothyroidism.
• 🫀 CV exam: JVP, murmurs, displaced apex (CHF).
• 🍺 Abdomen: Ascites, hepatomegaly, jaundice (cirrhosis).
• 🦵 Calves: Tenderness, redness, swelling → DVT.
• 🩹 Skin: Venous stasis (pigmentation, ulcers), cellulitis/infection.

📊 Causes, Features & Management

Cause	Clinical Features	Key Investigations	Management
🫀 CHF	Bilateral oedema, dyspnoea, orthopnoea, fatigue	CXR (congestion), BNP ↑, Echo (EF ↓)	Diuretics, ACEi/ARB, β-blockers, fluid/salt restriction
🦵 Chronic Venous Insufficiency	Ankle swelling, varicose veins, pigmentation	Doppler US (reflux), exam	Compression stockings, leg elevation, venous surgery
🩸 DVT	Unilateral swelling, pain, redness, warmth	D-dimer, Doppler US, Wells’ score	Anticoagulation, stockings, ± thrombolysis
🍺 Liver Cirrhosis	Bilateral oedema, ascites, jaundice, spider naevi	LFTs, albumin ↓, US (ascites, cirrhosis)	Spironolactone ± furosemide, low Na diet, paracentesis, transplant referral
🧬 Nephrotic Syndrome	Periorbital + peripheral oedema, foamy urine	Urine protein >3.5g/day, albumin ↓, renal biopsy	Steroids (if responsive), ACEi/ARB, diuretics, salt restriction
🧠 Hypothyroidism	Non-pitting oedema (myxoedema), fatigue, cold intolerance	TSH ↑, T4 ↓	Levothyroxine
🦵 Lymphoedema	Non-pitting swelling, skin thickening	Clinical ± lymphoscintigraphy	Compression, massage, exercise, ± surgery

🧪 Initial Investigations

• 🩸 Bloods: FBC, U&E, LFTs, TFTs, BNP.
• 🧪 Urinalysis: Proteinuria → nephrotic syndrome.
• 🩻 CXR: CHF suspicion.
• 🦵 Doppler US: To confirm/rule out DVT.

🔎 Specific Investigations

• 🫀 Echocardiogram → CHF.
• 🍺 Abdominal US → cirrhosis/ascites.
• 🧬 Kidney biopsy → nephrotic syndrome.
• 🦵 Lymphoscintigraphy → lymphoedema.

🛠️ General Management Principles

• 🦵 Leg elevation – improves venous return.
• 🧦 Compression stockings – venous/lymphatic causes.
• 💧 Fluid & salt restriction – CHF, cirrhosis, nephrotic syndrome.
• ⚖️ Treat underlying cause – essential for long-term resolution.