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Friday, July 8, 2011

A Curable Cause of Severe Chronic Leg Swelling

The View from the Office


    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.