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Friday, July 8, 2011

A Curable Cause of Severe Chronic Leg Swelling

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A CURABLE CAUSE OF LEG SWELLING

    I had a patient recently, one of our Graeagle gentlemen, who even in his late 70s and after the usual accumulation of minor and major medical nuisances, was still very active, still working in fact, and had lots yet he still wanted to do. He came to see me in the office with a complaint of chronic severe swelling in both legs for several months.
     Leg swelling, or what we call 'edema', is a common and very annoying complaint. Your shoes don't fit. Your legs feel heavy and it takes more work to walk. In the heat they swell even more. There are several common causes of leg swelling. The most common for people middle aged and older is chronic weakness of the veins (venous insufficiency). This condition is often preceded by swelling of individual veins in the legs (e.g., varicose veins) and may gradually progress to diffuse edema fluid in the skin and subcutaneous tissue, which we then call edema. In the more chronic stages, venous insufficiency often declares itself by leaving little brown spots and dots like freckles all over the front of the legs. This is called "hemosiderosis" (too much iron in the tissue from the blood), which occurs as blood leaks out of weak veins and just sits in the tissue. Your body's defense system gradually eats up all the material from the red blood cells, but leaves the iron behind. In general, diuretic medications do not help chronic venous insufficiency that much. The big problem is that the stronger diuretics, which are needed, also take too much fluid out of the rest of your circulatory system, and leaves you feeling weak and dizzy. At this point you have to stop the diuretic. In the long term, once the veins have really failed, the only thing that may offer additional help is vein-stripping surgery.
     For younger women, pregnancy is a common cause of edema as the enlarging uterus puts pressure blocking the normal vein flow in the pelvis and causing back up of blood and tissue fluid in the legs. The same kind of thing can happen in older people, where a tumor (benign or malignant) can also put pressure on the veins and cause the same kind of edematous fluid back up. The good news is that in adults, tumors that block veins tend to occur on one side or the other but not both. Fortunately this is relatively rare.  In both these cases, a fluid pill (diuretic) will not help if the cause of the obstruction is not relieved. In pregnancy, you get that nice dramatic relief of obstruction when the baby is born.
     The most feared cause of chronic severe leg swelling is a heart problem--congestive heart failure. In this condition, which usually occurs in people who have already had coronary artery disease, a heart attack, or severe hypertension, the heart muscle becomes weak and is no longer able to pump out the normal amount of blood with each beat. Slowly fluid starts to back up in the veins. When it backs all the way up into the lung veins, then you get acutely short of breath in a condition called pulmonary edema. In less severe and more chronic cases the patient initially feels only severe fatigue, usually for months, and then may slowly developed a decreased ability to do their usual activities and they develop fluid and swelling in their legs, called 'cardiac edema.'  The good news is that this will respond promptly to diuretic therapy; the bad news is that this kind of heart failure is likely to recur from time to time. Congestive heart failure, and its related problem of chronic severe leg swelling, occurs overall in about 1% of the population.
     Another very rare form of chronic lower extremity edema is a genetic condition called "lymphedema." This is an unusual and very severe form of leg swelling. It is not really a true 'edema' as in the other conditions described, but rather is a 'lymphedema.' Here the problem is abnormal formation of the lymph vessels in growth and development with the result that the flow of lymph fluid is blocked and just slowly accumulates in the deep tissues of the leg. This kind of edema causes the feet to swell so that they look like wooden blocks at times, and the swelling tends to extend all the way up to the knees. This swelling also has a very different feel to it when you touch it; it is very hard and you can feel fibrous scarring in the subcutaneous tissue, whereas common edema is soft and leaves little impressions, indentations, when you press on it gently with your finger. The worst news of all is that there really is no satisfactory treatment for this condition. Probably specialized physical therapy and massage work the best; diuretics are not very effective, and surgery is not an option.
     So far, we have discussed a very common form of edema (mild venous insufficiency), and several rarer forms of edema (heart failure, pregnancy, tumor, and lymphedema [which, as you now know, is not really 'edema' at all].
     Now let's return to the gentleman described at the beginning of this article. His case is particularly important because it is fully curable. It turns out that he did not have heart failure (our biggest worry), nor did he have significant venous insufficiency (his veins weren't very prominent even though he had a little bit of hemosiderosis), and he certainly did not have lymphedema. The idea of a tumor was unlikely in view of the symmetrical severe swelling he had in both legs.  So we considered one more cause--medications. It turns out that he had been taking a very high dose of diltiazem (a common blood pressure medication) for years, and one of the common listed side effects is edema. In fact this applies to a number of high-blood pressure medications. The worst offenders are the group known as "calcium channel blockers" which include diltiazem, amlodipine, verapamil, and procardia. The "beta-blocker" group (metoprolol, inderal, labetalol, pindolol, carvedilol, etc.) can also do it, but usually less severely. 
     The thing that makes diagnosis hard is that patients can take these medicines for years, not have any problems, and then something tips them over into a full blown edema--from toes to knees. Thus considering this possibility, we slowly reduced his diltiazem by about 33% every 2 weeks and substituted another blood pressure medicine. After the first reduction in dose, we did not notice any change. Two weeks after the second reduction in dose his legs had returned to completely normal. He was cured. 
     Now that is a very gratifying result in this condition. This is the only form of chronic leg swelling that may offer you a complete cure if you are on one of these medications. So it's a cause of leg swelling worth remembering.



16 comments:

  1. Varicose veins symptoms in pregnant women also seem to become more important, although many of the symptoms disappear after the baby is born.

    veins

    ReplyDelete
  2. Thanks Doc! I really like your easy going and easy to understand style of communicating. Man, I wish all doctors could be like you.

    I really learned a lot just from this one article. Most of the information articles, well they might be longer than this one, but, only info about one possible cause. Too much info in many cases for a layman like me. Your style is brief, focused, and I like how at the end you will say 'diuretics will NOT (or will) help this'.

    I live in Sweden, speak only English, and keep getting doctors who are like weird African or eastern European and who speak a little english & swedish, but, not enough of either to get my message, or my 'interpreter'. It seems they are going down a checklist of 'possible' causes, not unlike your discussion up there. heart, liver, kidney, blah blah. I went to the doctor because I can't stop coughing (I have had on and off bronchitis cough problems for over a decade, but of course their first fear was heart failure because of the cough)

    I keep asking them to help me by treating my sinuses and my cough. I mean how long can one person cough all the time before it just damages their veins, heart, lungs, etc? I have been coughing so hard I tore the muscles in in back twice, and now my side.

    They don't sell dextromathorphan in Sweden! Or Benadryl. Usually I would just suppress the cough and dry up my sinus, and it goes away. Now my blood pressure is high, I'm getting redness & edema in my feet-ankles, and boy my throat HURTS and is raw from coughing. I don't know what to do. After 2 months and 3 doctors, I got some Nasonex. It only partially helps, can't dry up that post nasal drip.

    Anyway, can you believe all that? And the 3 doctors, is more than one visit per. I have been like 5 or 6 times. All tests come out NORMAL. Very frustrating.

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  3. Hi Doctor,
    I am 24 years old. Recently i had diagnoised that, I have venous insufficiency. And i have brown dots spreading all over in my foot. Am taking medication for venous insufficiency. But my doctors are not sure about the pigmentation. We have any solution to make the dots disappear? If its available, can you please prescribe the treatment? and also i want to know that can i get rid of this disease completely? Thanks in advance

    ReplyDelete
  4. Swelling of the legs, ankles or feet is a fairly common problem. It can have a number of possible causes, and often afflicts people who are on their feet many hours a day.

    Wobenzym

    ReplyDelete
  5. I have swelling of both legs for the past 2 years since my Mom died in my arms, and they are not only the leg but the swelling is also so very noticeable on the ankles and goes down to the toes. Only twice the swelling in both feet, ankled and legs dissipated, and my legs were normal and I could again wear my shoes, walk again, and my leg pain stopped, but that only lasted for 2 days. It seems the swelling and the edema occasionally comes and goes, and I have no idea why or how this is happening.

    My legs are always cold and from the knee caps downwards and appear to be quite red.

    Now I cannot even bed down to shave my legs and that is very upsetting. I can’t bend down to pick anything up from the floor and that is also nerve wracking.

    No shoes fit and I cannot buy new ones because the edema is so high in depth from the toes to the ankle and no wide shoe fits me. the only thing I can wear very uncomfortably is an old pair of sneakers which are really stretched out. they have the velcro closures but even those pop open when I walk.

    According to my electrocardiogram tests my physician stated I have no heart problems thus far, but I am asthmatic and take steroids when needed, and asthma inhalers.

    Also lasix I know can harm internal organs but I take it when they are so swollen I cannot stand without crying in pain, and my legs feel like I am carrying 100 lb. weights in each leg.

    I had those vein tests 5 years ago when I had health insurance, and even then they were very expensive.they said the swelling would go away by itself, and a few months later it did....until about 2 years ago when my mother died and I began grieving. then I noticed the edema in both legs.

    Now I do not have any health insurance and cannot afford any. I am too young for medicare, and do not qualify for medicaid.

    I am 62 years of age, white american female of greek heritage, living in the U.S.

    Btw my medical doctor said this edema condition comes with aging and I will have to ignore it and learn to live with it, but since i cannot really walk or do anything without constant pain and swelling it is something I am finding very difficult to learn to live with, but I also do not believe this is a common condition caused by aging.

    ReplyDelete
  6. Nice. I appreciate that you have shared this. Me and my chronic venous insufficiency treatment center likes this so much! We are now more aware of how and why is this happening. Thanks a lot!

    ReplyDelete
  7. Hi! Just tripped over your blog. It was an "aha moment." My husband, his siblings and his father have all had those brown dots from time to time. The family carries a lot of problems from their dad-easy bruising, heart disease, diabetes. Now I finally know what causes those spots, can't wait to tell the hubby! (When his own doctor was asked, he just shrugged and said, "I dunno.") I'd have fired him a long time ago!

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  9. I have severe foot swelling in both feet caused by a disease called Charcot's joint and i also have a severe case of osteomylitis caused by MRSA & Gram Negative rods that have spread into my blood causing me to have septicemia, I'm allergic to all antibiotics that are needed so there is no cure for me. Iwas put into hospice care and have been told I can die at any second. All they can do is give me pain meds and make me as comfortable as possible till I pass away. My question is #1 my feet swell so huge they rupture and make either a hole that drains blood and pus or a tear looking lesion that drains alot of blood and pus and looks like meat and veins are hanging out, is there a name for this, and is this normal?
    Question #2 - even with my condition and I am dying, I am in severe pain in my feet and legs (I cannot even walk or put weight on them , in a wheelchair) would getting my legs amputated be beneficial at this time or should I just leave them be? Thank you for all your help...

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