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Approach to Lower
Limb Oedema
Satyendra K. Tiwary
Editor
123
Approach to Lower Limb Oedema
Satyendra K. Tiwary
Editor
Approach to Lower Limb
Oedema
Editor
Satyendra K. Tiwary
Department of General Surgery
Institute of Medical Sciences, Banaras Hindu University
Varanasi, India
ISBN 978-981-16-6205-8 ISBN 978-981-16-6206-5 (eBook)
https://doi.org/10.1007/978-981-16-6206-5
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Singapore
Pte Ltd. 2022
This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether
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The registered company address is: 152 Beach Road, #21-01/04 Gateway East, Singapore 189721,
Singapore
Foreword
It gives me great pleasure to write the foreword for this text that has been put
together by the hard work of Dr. Satyendra Kumar Tiwary from the Banaras Hindu
University of Varanasi.
Many of us, as treating clinicians, are often confronted with how to manage a
patient with lower limb edema. This text very much reviews the issues of lower limb
edema, looking at not only the anatomy and physiology but also those issues that
confront the clinician looking after these patients. There is a worldwide group of
experts who have contributed to this text and looking at all the various investigations
and potential treatment pathways for this cohort of patients. I very much hope that
many practising physicians will be able to nd information in this excellent text that
will allow them to benet the large number of patients worldwide who suffer from
swelling in their lower legs.
Academic Department of Vascular Surgery AlunH.Davies
Imperial College London
London, UK
v
Foreword
Edema of the lower limbs is a very common clinical picture: people of every age,
from childhood to the elderly complain of it.
Edema has several causes and the origin is not always clearly and immediately
understood. For example, slight swelling in young teenagers, which disappear spontaneously, or local, limited, painful swelling of a foot, maybe sometimes of
unclear origin.
Commonly, edema is discussed as a clinical sign in a paper or in a chapter dedicated to a specic disease, like venous insufciency, but is not a single argument itself.
However, as the symptom is common, alternative diagnoses need to be considered if the cause is not clear. Several diseases, related to different specialties, maybe
the cause of limb swelling, requiring to have a multispecialty overview to nd out
the origin of edema. Moreover, some rare diseases, like vascular malformations, or
genetic disorders may be difcult to be considered as causes of swelling.
The result is that the patient is sent to different specialists, wasting time and
money, to get a correct diagnosis.
This book, which collects all the pathologies that may be the cause of lower limb
edema, is an important aid for the correct diagnosis and treatment of limb swelling.
It will help the physician not only to understand and update his own knowledge
about physiopathology of uid accumulation in the limbs but also to have available,
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viii
Foreword
in a single book, a series of chapters regarding all the diseases that may create
edema, including rare one which may be difcult to consider in unclear cases.
For these reasons, this book is an original and helpful publication that each physician, involved in lower limb diseases, should have in his library.
Center for Vascular Malformations RaulE.Mattassi
Clinical Institute Humanitas “Mater Domini”
Castellanza (Varese), Italy
Preface
Lower limb edema is the commonest peripheral edema affecting the legs, ankle, and
foot. The cause may be simple, sometimes like sitting for a long time in a plane or
standing for too long in the journey or work. Sometimes, it may be a result of more
serious underlying diseases like systemic diseases in the form of cardiac failure,
liver disease, or renal impairment, etc. It is a manifestation leading to consultation
from so many specialists like Surgery, Plastic Surgery, Orthopaedics, Neurology,
Vascular Surgery, Cardiology, Nephrology, Medicine, Radiotherapy, Physical
Medicine, and Rehabilitation. Despite patients consulting in so many specialties, I
have observed in my surgical practice of 20 years in university teaching hospital that
it is a complex clinical scenario for which the cause, cure, and complications need
very careful work up from the clinician as results and outcome may be difcult,
unpredictable, and limited, sometimes amidst uncertainties.
Lower limb edema may be trivial, temporary, transient, or terrible, not responding to treatment. Cellular uid balance disruption and accumulation in interstitial
space with gravitational pull effect driving uid in dependent part is the culprit in
lower limb edema. Peripheral edema is common in older adults and pregnant
women, but it can occur in any age group including children. It may affect one or
both legs and may be acute or chronic.
So many disciplines needed with overlapping and myriad manifestations of many
underlying pathologies in different patients make it difcult to work up and treat
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x
Preface
lower limb edema systematically and honestly by consultants of every discipline.
Dedicated books as well as a focus on specic limb edema during teaching and training are lacking in literature as well as custom. Considering that so many patients of all
age groups, children, middle-aged, old, pregnant, are affected and lack of very lucid
clinical approach with targeted treatment in lower limb edema led me to the concept
and completion of this book. With 23 chapters contributed by competent consultants
in their eld covering every aspect of lower limb edema, comprising anatomy, physiology, etiology, pathogenesis, investigations, differential diagnosis, clinical manifestations, genetics, local causes, systemic causes, acute edema, chronic edema,
compression therapy, and quality of life. A lot of ow charts, gures, tables, and diagrams have been included in chapters as per requirement to clear the clouds of confusion and construct a complete clinical concept for consultants.
This book has been framed with contents to answer the queries in lower limb
edema, whether that is acute or chronic, unilateral, or bilateral, local, or systemic,
trivial, or terrible, persistent, or progressive. It fullls the gap in scientic knowledge
helping general surgeons, plastic surgeons, orthopedician, neurologist, vascular surgeons, cardiologists, nephrologists, family physicians, and helping trainee and fellows
in different disciplines once they come through a case of lower limb edema.
I acknowledge the help of Dr. Naren Agarwal, Ms. Jagjit Kaur Saini, and Ms.
Beauty Christobel Gunasekaran from Springer Nature to bring out the book in its
present form with their valuable inputs and suggestions till the nishing of the project. I am highly indebted to Mrs. Sangita Yadav (Chandrapur) for continuous and
valuable suggestions in English, grammar, and corrections to shape the book nally
in publication. I am indebted to my family Hema, Apoorva, and Advaita who provided me all the moral support and will forgive me for any negligence which was
unavoidable.
I dedicate this book to all the patients managed during my entire career who were
the resource as well as inspiration in the management of this complex manifestation
of lower limb edema.
It is my earnest desire that this book becomes a valuable source of understanding
and management of common to complex clinical condition of lower limb edema to
the students, trainees, fellows as well as clinicians who may have difculty at any
point getting corrected with aid of this resource.
I conclude my words here with a quote from the most ancient scientic literature
of the world, Rigveda told about 5000 years back. Have you ever wondered—what
did the seers () of the Vedas yearn for?
In a hymn addressed to the Visvedevas () in the Rig Veda, they prayed for
noble thoughts from all directions.
: |– – 1.89.1
(āno bhadrāḥ kratavo yantu viśvato)
|
Let noble thoughts come to us from all directions.
– Rig Veda 1.89.1
Varanasi, India SatyendraK.Tiwary
Contents
1 Introduction of Lower Limb Edema . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Satyendra K. Tiwary, Vivek Kumar Katiyar, and Ankush
2 Anatomy of Lower Limb . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Marian Simka
3 Physiological Basis of Lower Limb Edema. . . . . . . . . . . . . . . . . . . . . . . 25
Sanjeev K. Singh and Ravindran Revand
4 Aetiopathogenesis in Lower Limb Oedema . . . . . . . . . . . . . . . . . . . . . . 45
Vaibhav Pandey and Mohammad Imran
5 Clinical Examination in Lower Limb Edema . . . . . . . . . . . . . . . . . . . . 55
E. Menegatti, M. Tessari, and S. Gianesini
6 Investigations of Lower Limb Edema . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Alberto Caggiati and Lorenza Caggiati
7 Differential Diagnosis of Lower Extremity Oedema . . . . . . . . . . . . . . . 77
Sandeep Raj Pandey and Moorooteea Mehta Raaka Rai
8 Complications of Lower Limb Edema . . . . . . . . . . . . . . . . . . . . . . . . . . 91
Satendra Kumar
9 Chronic Lower Limb Edema . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
Ram Niwas Meena, Vipul Srivastava, Akanksha, and B. R. Akshay
10 DEEP Vein Thrombosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
Patrick Harnarayan, Dave Harnanan, and Vijay Naraynsingh
11 Chronic Venous Insufficiency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141
Varun N. Kumar and Ramesh K. Tripathi
12 Compression Stockings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159
Matthew Machin, Ankur Thapar, and Alun H Davies
13 Imaging Assessment of Lower Limb Swelling . . . . . . . . . . . . . . . . . . . . 179
Amit Nandan Dhar Dwivedi and Jyoti Dangwal
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