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Probability diagnosis


  • dependency/gravitational

  • prolonged sitting, standing, walking

  • hot weather

  • pregnancy

  • mechanical (e.g. constricting clothing)

Chronic venous insufficiency (varicose veins)

Congestive cardiac failure

Drugs (e.g. calcium antagonists, NSAIDs)

Local trauma


Serious disorders not to be missed


  • deep venous thrombosis (DVT)

  • inferior vena cava thrombosis

  • thrombophlebitis


  • cellulitis

  • tropical infections (e.g. filariasis, hookworm)


  • obstruction from pelvic cancer

  • localised malignancy


  • kidney disease (e.g. nephrotic syndrome)

  • liver disease (e.g. cirrhosis)

  • skin allergy (e.g. angioneurotic oedema)

Pitfalls (often missed)

Idiopathic (periodic or cyclic) oedema

Protein-losing enteropathy (e.g. Crohn)

Lipoedema (fat and fluids) of legs

Lipidema (fat) of legs


  • malnutrition

  • lymphoedema: primary or secondary

Masquerades checklist


Drugs (multiple; see list)

Thyroid/endocrine (hypothyroidism, Cushing syndrome)

Key history

Past history (esp. liver, heart, kidney disease), travel, drugs, occupation, recent trauma. Circumstances of swelling (e.g. prolonged walking, long journey).

Key examination

  • Cardiovascular, abdomen (signs of liver disease), legs including circulation, varicose veins and evidence DVT

Key investigations


  • urinalysis (?albumin)

  • FBE


  • U&E

  • KFTs

  • serum albumin/LFTs

  • TSH

  • ultrasound (DVT screen)

  • CXR

  • pelvic ultrasound

  • other radiographs (e.g. CT scan, venogram).

Diagnostic tips

  • Not all swollen legs require investigation.

  • If the onset of oedema is acute (often <72 hours) suspect DVT.

  • Pitting oedema is a feature of venous thrombosis or insufficiency, not lymphatic obstruction.

  • The significance of leg swelling varies according to the age group, whether it is bilateral or unilateral and whether the onset is sudden or gradual.

  • Drugs that can cause leg and ankle swelling include calcium antagonists, NSAIDs, corticosteroids, glitazones, beta blockers.

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