How to know if the swelling in your leg or ankle is normal
36-year-old Prisha Singh noticed a strange swelling in her legs and ankle when she couldn’t fit into her sneakers. She dismissed it believing it was water retention or tiredness but when the swelling didn’t subside even after many days, she booked a doctor’s appointment. Turned out her kidneys needed attention.
Swelling of the feet otherwise known in medical terminology as edema is a common problem encountered by people. Many of us would have experienced some swelling of the feet usually after a period of long exertion or after a strenuous journey. “As most of us are aware, edema of the feet may be a simple benign thing or a harbinger of serious organ dysfunction which warrants medical attention,” explains Dr. Subhash Chandra, Assistant Professor, Internal Medicine, Amrita Hospital, Kochi.
Dr. Allwin James D , MD.,( Gen.Med) DM.,(GE)– Consultant, Meenakshi Mission Hospital & Research Centre adds, “Mild edema normally clears up on its own, especially if you speed things up by elevating the affected limb above your heart. Drugs that help your body eliminate excess fluid in the form of urine may be used to treat more severe edema (diuretics). Furosemide is one of the most commonly prescribed diuretics. However, based on your unique medical history, your doctor will assess whether these sorts of medications are an appropriate fit for you.”
But sometimes this swelling is not benign and may be an indicator of a
bigger underlying health issue. Dr. Varun Verma, Associate Director –
Nephrology, Max Hospital, Patparganj shares, “Ankle swelling can be a
marker of kidney disease. It usually denotes protein leakage in urine.
It is possibly the first sign of renal disease.” However, patients with
heart failure, CLD or hypothyroid state can also have such swelling, but
history and labs can differentiate between these conditions. “I would
recommend a visit to your doctor and appropriate evaluation if you have
this symptom. If you have any such findings, kindly get your urine
evaluated. I would recommend a urinalysis along with urine spot protein
creatinine ratio. I would also recommend a detailed kidney function test
and ultrasound of the abdomen. I would also suggest thyroid profile,
HBA1C, liver function tests as well as 2 D echo.”
Harmless swelling of the feet may also be due to certain
medications, especially drugs used for the treatment of hypertension
like calcium channel blockers Amlodipine, cilnidipine and vasodilators
like prasozin and hydralazine. Mild lymphatic dysfunction due to
congenital causes can also produce a mild edema of the feet.
Warning signs that the swelling of the feet is ominous include
feeling of breathlessness associated with the edema, reduction in the
amount of urine you are producing, distension of the abdomen which
occurs along with the edema and that associated with yellowing of the
eyes and urine. Some other signs that the edema is dangerous include
edema in one limb occurring after a surgery or a prolonged travel. Edema
accompanied by pain and redness of the leg which is painful to touch
could indicate an infection in the legs called cellulitis, adds Dr
Chandra.
Is your swelling linked to water retention?
Retention of water is usually a result of water intake in excess of
our urine output. This may be the scenario in patients with chronic
renal impairment who have decreased urine output but mistakenly consume
large quantities of water in the belief that they are helping their
kidneys. Reductions in urine output can also be due to non compliance
with medications designed to increase urine output like diuretics which
may have been prescribed by your doctor. Highly reduced salt intake in
diet can also lead to water retention as kidneys require a minimal
amount of salt for the excretion of water in urine.
The link between swelling and cardiac, renal or liver dysfunction
Swelling of both legs may indicate serious cardiac, renal or liver
dysfunction. People who have a history of having chest pain or having
suffered from heart attacks may develop edema at a later time due to
cardiac failure. Such edema is accompanied by significant fatigue,
breathlessness on exertion and swelling of the abdomen. This edema
occurs due to the failure in the pumping mechanisms of the heart leading
to significant back pressure and overloading in the venous circulation
which in turn produces edema. Also this edema occurs after a period of
exertion and can be seen mainly towards the evenings, adds Dr Chandra.
Another mechanism of edema is an under-filling of the arterial
circulation due to cardiac pump failure which activates certain hormones
in the kidney called the renin angiotensin system. The activation of
this system leads to sodium and water retention by the kidneys and
ultimately edema.
Edema can also occur due to renal
failure. This edema is usually accompanied by facial swelling more
towards the morning. The signs that edema is renal related include a
reduced urine output, very high blood pressures and significantly frothy
urine especially in the mornings. Sometimes blood in urine may also be
indicative of renal causes of edema. Edema may be seen in patients with
chronic renal failure where the basic excretory function of the kidney
is severely reduced so that it cannot eliminate urea and other toxic
metabolites as well as get rid of excess water. Renal edema also occurs
in a condition called nephrotic syndrome where large amounts of protein
are lost in the urine especially albumin. This protein is what maintains
oncotic pressure in the blood vessels which keeps fluid within the
blood vessels. With the loss of the oncotic pressure the fluid seeps
outside the blood vessels causing edema. A similar mechanism occurs in
cirrhosis and liver failure where the protein is not produced in
sufficient quantities by a failing liver. Edema due to liver dysfunction
may be accompanied by jaundice where there is yellow discoloration of
eyes and of urine. Patients with history of heavy alcohol usage, obese
individuals and people with hepatitis B and C infections are people most
likely to develop liver damage related edema.
Tests to rule out health concerns
Patients with edema with the above
mentioned symptoms need to undergo testing to ascertain whether they
suffer from organ dysfunction or other problems. Routine blood
investigations would include a complete blood count to assess if the
patient has significant anemia as very low haemoglobin can itself cause
cardiac failure. Other investigations include renal function testing
which include blood urea and serum creatinine. Urine routine can show
presence of blood or protein in the urine as well as a 24 hour urine
protein or a urine protein creatinine ratio can tell us about heavy
proteinurea as the potential cause.
Liver function testing is done to
check for albumin and globulin levels as well as liver enzymes like
SGOT, SGPT and Alkaline phosphatase which may throw light on ongoing
liver injury. ECG and 2D ECHO are also done to assess for the pumping
capacity of the heart, Ejection fraction, structural abnormalities,
regional wall motion abnormalities contributing to cardiac edema. Blood
tests for cardiac failure including BNP or brain natriuretic peptide are
also done where high levels indicate cardiac dysfunction. Other tests
include a thyroid function test as hypothyroidism is another common
cause of edema of both legs.
A unilateral swelling of one leg
requires investigations like an Ultrasound venous Doppler to look for
thrombosis within the deep veins of the leg, a dangerous condition
called DVT or deep vein thrombosis. Other tests done in unilateral
swelling would include a blood count to rule out infection especially if
there is pain and redness over the swollen foot. In Kerala, unilateral
swelling of the feet may also be due to filarial infection which leads
to a lymph vessel dysfunction which helps in carrying fluid back to the
chest. This warrants investigations like lymphoscintigraphy which tell
us about any lymphatic dysfunction in the limbs, elaborates Dr Chandra.