Depressed ejection fraction, image from The POCUS Atlas

An 44 year-old male with no reported medical history (though limited access to medical care) presents with lower extremity swelling. He states that the symptoms have been gradually worsening over the past 3 months. He notes occasional fatigue while at work but denies chest pain, shortness of breath, leg pain or changes in urination.

A point-of-care ultrasound is performed showing decreased left ventricular ejection fraction. The patient was admitted for further evaluation and management of new-onset congestive heart failure.

Algorithm for the Evaluation of Lower Extremity Edema with Ultrasound

Gallery

The POCUS Atlas
The ultrasound images and videos used in this post come from The POCUS Atlas, a collaborative collection focusing on rare, exotic and perfectly captured ultrasound images.

• DVT
• Cirrhosis
• Soft Tissue

Nodular liver contour, ascites

Ascites

Cobblestoning

Cobblestoning

Longitudinal view of a ruptured Baker cyst

References

1. Trayes KP, Studdiford JS, Pickle S, Tully AS. Edema: diagnosis and management. Am Fam Physician. 2013;88(2):102-110.
2. Goyal A, Cusick AS, Bhutta BS. Peripheral Edema. [Updated 2022 Nov 19]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK554452/
3. Smith, C. Clinical manifestations and evaluation of edema in adults. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed 2/11/2023.

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Meningococcemia

• Epidemiology: <20yo, dorm, military barracks
• Appearance: diffuse petechiae, palpable purpura
• Management: antibiotics, steroids

Necrotizing fasciitis

• Symptoms: POOP, rapid progression
• Appearance: bullae, crepitus, systemic toxicity
• Management: surgery, antibiotics

RMSF

• Symptoms: flu-like
• History: tick bite, camping/hiking
• Appearance: wrist/ankle spreading inward (centrifugal), petechiae
• Diagnosis: clinical, titers
• Management: doxycycline (increased mortality if not treated)

PV

• Epidemiology: 40-60yo
• Pathophysiology: autoantibodies (desmoglein), causes superficial epidermal separation (pemphigus for superficial)
• Symptoms: painful oral blisters, small bullae
• Findings: +Nikolsky
• Management: steroids (methylprednisolone 1g IV), burn center

BP

• Epidemiology: >70yo
• Pathophysiology: autoantibodies, deeper dermal layer (pemphigoid for deep)
• Symptoms: not painful, no oral lesions
• Findings: large, tense, unruptured bullae
• Management: steroids

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Appendicitis

Non-compressible tubular structure in the RLQ of a patient with focal abdominal tenderness. >6mm in diameter.

Common Bile Duct

A tubular structure typically anterior to the portal vein without flow. Normally measures <4mm, increases by 1mm per decade after 40yrs.

Cellulitis

"Cobblestone" appearance of soft tissue suggesting infection/edema.

Fetal Heart Rate

Placing the M-Mode marker over the most visibly active portion of the fetal heart allows for measurement of the fetal heart rate.

Free Fluid

Free fluid in the hepatorenal recess.

Hydronephrosis

Severe hydronephrosis.

Thoracic Aorta Aneurysm

Subxiphoid view of thoracic aorta, markedly dilated (>3cm) with thrombus.

Pericardial Effusion

Mild pericardial effusion in a patient with pleuritic chest pain.

Inferior Vena Cava

IVC without significant respiratory variation.

B-lines

B-lines extending deep from pleura suggestive of interstitial fluid accumulation (pulmonary edema).

"Shred" sign

Irregular, "shredded" pleural line suggestive of consolidation.

Pneumothorax

Transition point with loss of lung sliding in a patient with a small spontaneous pneumothorax.

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51 year-old male with a history of HTN, DM and chronic alcohol abuse presenting with lower extremity swelling. He notes one month of progressive, bilateral lower extremity swelling, in the past two weeks associated with increasing pain and redness and is now no longer able to ambulate due to pain. He denies fevers/chills, chest pain or shortness of breath. He also denies orthopnea and paroxysmal nocturnal dyspnea. He states that he has not had these symptoms prior to one month ago. On review of systems he denies nausea/vomiting, abdominal pain, and changes in bowel or urinary habits. He has a history of GI bleeding (unknown treatment) but denies hematemesis, hematochezia or melena. He has previously experienced alcohol withdrawal, which manifested as tremors, but no hallucinations or seizures.

Physical Exam:

Labs/Studies:

• CBC: 7.4/13.1/39/180
• Creatinine: 0.84
• Albumin: 4.3
• BNP: 28

Imaging:

Venous Lower Extremity Ultrasound

1. No DVT.
2. Pulsatile flow in bilateral EIV (external iliac veins) suggestive of elevated right heart pressure.

Assessment/Plan:

51M with HTN, DM, EtOH abuse presenting with lower extremity edema. Chronic bilateral lower extremity edema likely secondary to chronic venous insufficiency perhaps related to OSA given ultrasound findings of pulsatile flow in EIV’s. Doubt systemic cause: no evidence of heart failure on exam and normal BNP, no stigmata of cirrhosis and normal albumin, normal creatinine. Also, no evidence of DVT on ultrasound though bilateral DVT unlikely. Bilateral cellulitis also unlikely as the patient is afebrile without leukocytosis, however the patient was started on antibiotics including ceftriaxone and TMP/SMX given erythema, warmth and tenderness to palpation. The patient received benzodiazepines which eased withdrawal symptoms and he was admitted for continued treatment.

Mechanisms of Lower Extremity Edema: ¹

Differential Diagnosis of Lower Extremity Edema: ^1,2

Evaluation:

History ^1,2

• Duration: acute (<72h) vs. chronic
• Pain: DVT, CRPS, less severe in venous insufficiency
• Systemic Disease
  • Cardiac: orthopnea, PND
  • Renal: proteinuria
  • Hepatic: jaundice, ascites
• Malignancy: lymphedema
• Improvement with elevation/recumbency: venous insufficiency
• OSA: snoring, daytime somnolence
• Medications: B-blocker, CCB, hormones, NSAID’s

Physical Exam ^1,2

• Distribution: unilateral, bilateral, generalized
• Quality: pitting, non-pitting
• TTP: DVT, cellulitis
• Varicose veins: venous insufficiency
• Kaposi-Stemmer: inability to pinch dorsum of foot at base of 2nd toe (lymphedema)
• Systemic Disease
  • Cardiac: JVD, crackles
  • Hepatic: ascites, scleral icterus, spider angiomas
• Brawny, medial maleolar involvement: venous insufficiency

Key Features Distinguishing Cellulitis: ³

• Typically unilateral and acute
• Often with systemic symptoms (fever, leukocytosis)
• Risk Factors: immunosuppression, previous episodes, DM, PVD

References:

1. Trayes, K. P., Studdiford, J. S., Pickle, S., & Tully, A. S. (2013). Edema: diagnosis and management. American family physician, 88(2), 102–110.
2. Ely, J. W., Osheroff, J. A., Chambliss, M. L., & Ebell, M. H. (2006). Approach to leg edema of unclear etiology. Journal of the American Board of Family Medicine : JABFM, 19(2), 148–160.
3. Keller, E. C., Tomecki, K. J., & Alraies, M. C. (2012). Distinguishing cellulitis from its mimics. Cleveland Clinic journal of medicine, 79(8), 547–552. doi:10.3949/ccjm.79a.11121
4. WikEM: Pedal edema

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