Leg Swelling and Venous Disease
Swelling of the legs, clinically known as peripheral edema, is a common disorder in the general population and its occurrence increases with advancing age eventually affecting approximately 50% of the population. There are a number of underlying diseases that can cause leg edema such as heart failure, liver disease, kidney disease and lymphatic disorders. It can also occur with the use of certain medications. However, the most common cause is primary disease of the veins in the legs.
Blood is pumped to the legs from the heart through blood vessels known as arteries and the blood returns to the heart through vessels called veins. When the veins become diseased and malfunction, the flow of blood back to the heart is compromised and blood pools in the leg veins. Because of the dilation of the veins and increased intravascular pressure, the clear portion of the blood known as serum, leaks from the veins into the soft (subcutaneous} tissue under the skin causing edema. Because of gravitational force, the fact that blood can return to the heart from the legs is a physiological miracle that equates to “water flowing up-hill”.
There are two systems of leg veins: superficial veins (those that are close to the skin) and deep veins that are in the muscles of the legs. Within the lumen of the veins are numerous valves that open and close in a coordinated fashion to cause unidirectional flow of blood back toward the heart. Additionally, there is a calf muscle pump system that contracts when the valves are open squeezing blood toward the heart and during muscle relaxation, when the valves are closed, prevent the back-flow of blood toward the feet. When these valves become diseased and incompetent, blood pools in the legs increasing pressure within the veins causing them to stretch and dilate. The valves in dilated veins become more dysfunctional resulting in a snow-ball like affect. The dilated veins close to the skin are small string-like vessels that are reddish-brown in color and known as spider veins or telangiectasia. The larger dilated veins are known as varicosities or varicose veins.
Pressure in the veins can increase for a number of reasons including: an inherited defect of the valves in the veins; leg trauma or surgery; obesity or weight gain (as in pregnancy); standing in one spot or sitting for prolonged periods of time. Lack of muscle activity eliminates the all- important pumping that propels blood to the heart. We frequently see patients in the office with marked leg edema after prolonged travel.
The enlarged veins from CVD are unsightly but they can also become inflamed and painful (phlebitis). Stagnant blood tends to clot easily and when this occurs the condition is known as thrombophlebitis. These clots are not only uncomfortable but they block blood flow worsening edema and can be dangerous if they grow and break off. A clot floating free in the veins is known as an embolus and an embolus can travel to the lungs and block blood flow to lung tissue. This can be a deadly event and clinically is known as a pulmonary thromboembolism-a medical emergency.
The pooling of blood in the veins if left untreated for a period of months can cause the skin to become pigmented, turning a reddish-brown color. Early on, this most commonly occurs on the inside of the ankle. These skin changes can create susceptibility to developing open non-healing sores and these ulcerations are subject to bacterial infections. Because of the poor blood flow and edema, these lesions are difficult to heal.
CVD is a mechanical disease and the mainstays of treatment are mechanical: elevation, exercise, and compression. Simply elevating the legs to heart height for 30 minutes 3-4 times daily helps relieve the swelling. Elevating them to heart height is very important and not simply propping them up on a foot stool. Also, if elevating using a recliner, be careful to keep pressure off of the calves by putting pillows under the heels. Regular exercise, such as walking, concentrating on the muscles in the legs is very helpful. Good muscle tone helps propel the blood to the heart. With prolonged sitting, exercise the ankles by pointing the toes up and down several times every 30-60 minutes. Finally, the most important treatment is consistent use of compression stockings. The stockings can be knee high because modern products incorporate graduated pressure support. The pressure is highest at the ankles and gradually decreases up to the knee. It is best to obtain custom stockings by getting measured. The measurements should be taken early in the day when edema is at its best. Please remember that compression stockings are prevention not treatment. The stockings will not push the edema back into the circulation. Put the stockings on as soon as your feet hit the floor in the AM.
Dr. Tippett is the founder of Comprehensive Quality Healthcare Providers, a concierge internal medicine practice located at 1210 Commerce Dr. Suite 106 Greensboro, Ga. 30642. He can be contacted at 706-510-3695. Visit his webpage at www.drtippett.com