Section: CME Category: Vascular

Differential Diagnosis of Clinical Edemas

James McGuire, DPM, PT, LPed

James McGuire DPM, PT, LPed discusses basic principles of clinical edemas and describes various vascular tests and imaging that can assist with the diagnosis of fluid movement impairments.

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Goals and Objectives
  1. Describe systemic and localized causes of edema
  2. Describe components of the history and physical examination that can assist with differential diagnosis of the different types of edema.
  3. Describe vascular tests and imaging that can assist with the diagnosis of venous and lymphedema fluid movement impairments.
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  • CPME (Credits: 0.75)

    PRESENT e-Learning Systems is approved by the Council on Podiatric Medical Education as a provider of continuing education in podiatric medicine. PRESENT e-Learning Systems has approved this activity for a maximum of 0.75 continuing education contact hours

    Release Date: 03/28/2018 Expiration Date: 12/31/2020

  • Author
  • James McGuire, DPM, PT, LPed

    Director
    Leonard Abrams Center for Advanced Wound Healing
    Clinical Professor
    Department of Podiatric Medicine and Orthopedics
    Temple University School of Podiatric Medicine
    Philadelphia, PA

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  • Lecture Transcript
  • TAPE STARTS – [00:00]


    Speaker: Welcome to the stage our good friend, Dr. Jim McGuire and we are always honored to take the stage with him.

    Jim McGuire: It's nice. One of the people at back said, oh good some comedic relief. So I would like to think of this as medical information but whatever. Now, they have these -- these ladies have all these degrees by their names but what they don't have up there is that they have doctorates in niceness. You have to know them both personally and spend a little time with them and you want to surround yourself with people like those two people who are 100% positive and always nice and always kind and always helpful. And you have a much better life. So it's joy to work with people like that. I do speak for a lot of companies. I am at a university where we come in contact with a tremendous number of products. Now, we are just talking upstairs a second ago and we see products in our clinic that have not been -- they have been FDA approved but they are not on the market yet. So they are out getting information on them. So we get a chance to use things, work with things that nobody has tried before. So we get familiar with them and then we have had clinical experience with them and it's very helpful, I think, to go out and talk for companies about your clinical experience on products and when I like a product, I like to talk about it. I have no qualms about doing that and so all of these companies, they have products that I particularly like, that have worked for us and that we are happy to represent. And then we have research. Osiris and New Tech researches, both of them are actually going out now and we are starting a series of other researches that are really in biomechanical range and not so much in the wound bed and wound product range.

    [02:00]

    There is going to be kind of fun because I haven't done that type of research in a while. Objectives are to verbalize the systemic and localized cause of edema. Don't you like these words like they send you things and your objective should have the following power of words at the beginning. So when you take a power of words and say what are we going to verbalize. We are going to verbalize this, we are going to describe the components of the history and physical and you are going to be able to list the vascular tests, maybe. Epidemiology, there are a lot of venous ulcers. There are a lot of like leg ulcers. There are a lot of wounds associated with lymphedema, phlebolymphedema and other causes that affect the lower extremity. And you have to keep in mind that you are not necessarily just dealing with these. This little other component rears its ugly head everyday or every couple of days in our clinic. Sometimes thing come in that just isn't quite kosher. It's not quite right. It's something that we want to biopsy or that we want to do more extensive testing on and more evaluation on and it's not just these but almost every patient I see has these in there. It's not in there and that slide is what. Any kind of lymphatic insufficiency. Why because this is a classic old slide in epidemiology and this is exactly the way we were taught. It's exactly the way we are taught. We are still being taught and what should be in there is a percentage of patients with lymphatic involvement and it would be probably everybody with venous insufficiency, many patients with arterial, most of the patients with diabetes and edema problems and then all the other associated things which have lymphatic component in their wound. Up to 3% of the patients over 60 and 5% over their 80 have some sort of venous ulcer problem have a venous leg ulcer.

    [04:04]

    That's of fairly large number of patients in our population. Over the course of lifetime, 10% of the population will develop some kind of chronic wound. So that means in this room, how many people we have here, 100? 10 of you are going to the patients of ours, of yours, of all. I say to my students, I say when you see these number, this is job security. This is like one, it's why you went to medicine. Two, it's these people are going to be there no matter what they do with the insurances, no matter what they do with the world, patients are going to need you to care for them. It's important that you are there to do it and that no matter what the reimbursements are or the restrictions are on you that you figure out a way to make them better. You like to use fancy products all the time and cool new things, bells and whistles. We had to debate the other day about our saline dressings coming back because I don't think they are affordable for a lot of patients to have. Two million workdays are lost to VLUs alone. Two million days of work annually. There is a lot of people out there that suffer from this and the VLUs average about $4000 per month of cost and 16,000 per episode and the annual cost is estimated to be up to be 3 billion. It's kind of like diabetic ulcers of 3 billion, arterial ulcer of 3 billion, venous problems are 3 billion and if we added up the lymphatic, if we said how much billions are associated with lymphatic involvement, it probably will be 6. Probably, most of these patients would have it. Diagnosis, then take a good history and physical. Sit and talk with our patients. I know you don't have time anymore, I don’t have time. I have -- I guess it's like a privilege to have a students do histories, who are very, very careful to ask like every question they were ever taught to ask a patient.

    [06:01]

    Send them in the room and they ask everything like they could possibly ask and they come out and they summarize that for me. And patients love talking to a nice young student who is asking them questions and is talking to them and is really, really interested in them because you are the first guy that ever asked any questions to and they really do get a very detailed history, but it's important to take a good history so you get a feel for how long it has been going on. One of the things that Heather mentioned before was how long have patients been having a lymphatic or an edematous problem of their legs and didn't do anything. I mean I know when I grew up my mother had varicose veins, pretty bad that she got after me. She always reminded me. See that vein. That's because of you. So I looked down and lo and behold one day after wrapping my knee after football injury in high school, my mother had cursed me with a genetic predisposition to varicosity. So I had a varicose vein in high school. So I went to physical therapy school after college and learned all about how to take care of this stuff because that's the only place I ever heard about managing varicose veins. It was not much in podiatry school but it was in physical therapy school where we learned about stockings and compression and boots and all that kind of stuff. So I started wearing knee-high compression hose, which I have on now and I wear 24 hours a day almost, not quite, I don’t sleep in them but whenever I am up and walking around, I wear them all the time unless I go to beach. So I don't have half of the problems I could had at 66 years old. I have patients in their 50s that you saw pictures of that are just horrible lymphedema, phlebolymphedema, venous insufficiency, ulcers, varicosities, DVT, all these other things that could have been avoided if they had done aggressive early edema management when the problem was first noted.

    [08:05]
    So that's that. Soft tissue imaging, we are going to see some of that. It's available to you. Lymph vessel and lymph node imaging. You have seen some pictures. We will go through a couple more. Volume measurements, which are not done as much anymore but it's an older method for determining how much edema is in the leg. Electrical conductance is even older. Genetic testing, which is available for some genetic related problems, vascular imaging and then blood tests for other causes associated with genetic and illness related. So these are systemic and localized causes of edema. It's with this you just take the slide, ask her to blow this one up, one on a page and sit and read this. Down here is also where it comes from, so you can go to say pull up the paper and read it there. But it's everything from systemic to local causes. It's allergic reactions, urticaria like somebody that gets allergic reaction and anasarca, total body edema all over the place, hepatic disease with a backup pressure coming out of liver and then that's lower extremity edema associated with that. Cardiac illness we talked about. Sleep apnea, patients that are really, really heavy and have sleep apnea invariably develop some kind of you know that's actually lymphatic edema that kind of the abdominal compression. It also helps -- the heart's still pumping away and there is all those pressure on the veins, which collapse a little more easily. And then you have venous backup and more edema, renal disease. Renal disease is associated with severe healing problems and wound healing problems, microvascular illness particularly involving the skin of lower extremity. Localized problems are cellulitis and then the secondary problems are associated with cellulitis. They get like recurrent infections. Recurrent little inflammations, little vasculitis. Is it vasculitis or cellulitis? I don't know, is there a wound?

    [10:00]

    There is no wound but they are calling it cellulitis. Is it cellulitis? Are the cells inflamed or is it a vasculitis associated with this secondary to something else? I find those the most frustrating wounds, severely painful. They keep flaring up. You just get a handle on them, they are just getting better, you really don't want to use the steroid but it's just roll for couple of Medrol Dosepak and the patient really got lot better because those veins, those arteries just settled down and then they flare back up again and they are back right where they were. Most frustrating wounds that I take care of. Compartment syndromes are possible causes of edema. Complex regional pain syndrome, RSD, can result in that edematous, that kind of open vessels, that kind of just flow of edema into the wound. Iliac vein obstruction or May Thurner syndrome where you got the artery laying over the vein and it compresses the vein on the left side and you get unilateral left-sided edema, lipedema, lymph edema and May Thurner syndrome at the bottom again. This kind of walks you through unilateral lower extremity edema. Is it acute or chronic? If it's acute, there is a clinical probability of DVT, so look into the possibility of DVT and do ultrasonic imaging of the lower extremity. If it's low, you can just do D-dimer assay and if it's normal, just consider it like a cellulitis or some other cause of unilateral edema. If it's elevated, do an ultrasound and look for the presence of DVT. I can't tell you how many times I have done these and not found one and the one time somebody has given you this little nebulous symptom of my leg hurts a little bit. It's a little sore. You got vasculitis, you got edema. Don't worry about it, you are okay. That's the DVT. We had one just a week ago. You know I had DVT. You missed it. The first thing I said was that was not me, that's my associate.

    [12:00]

    He said that's true. It wasn't you. So I said don't blame it on me. She is the one you want to sue. No, I didn't say that. But the patients do sneak up on you and you have to be very careful. You have to always be thinking that the patient may have an arterial component. I have venous blinders. You look at and go like venous leg ulcer. And you immediately start doing compression and all those other things and the compression hurts and it's really painful and they are not getting any better and then somebody hits you on the head with something and goes, did you do any arterial testing? It's usually a student like what was his ABI. I didn't do it. So if you train yourself to do each component of each and every time you try not to forget it as much and always look into the arterial like what's the arterial status underneath all of this edematous problem that you see and make sure that they have good flow into the leg. So this is chronic edema. Is there a history of cancer and any kind of pelvic trauma or surgery? If none, you do a Duplex ultrasound and if there is, you might do a pelvic MRI to see if there is any kind of obstructive lesion in the abdominal region at all that would be causing that. So you can kind of go down through this. I don't think you have to go through the whole thing. This is bilateral edema or total body edema, anasarca and it's to look at you know like another way of going or is this a systemic disease by history? No. Is it acute? Is it medication induced? It's something they took to cause allergic reaction, which cause them to blow up everywhere and if it's not medication-induced, if the clinical exam suggest venous insufficiency, lymph edema, lipedema or something. I got blanked out, I forget what that one was.

    [14:02]

    I don't know why that's even in there. Took it out of mind. It creeps back after we moved this slide around. That little thing creep back in. And then you would confirm these tests like just keep the suspicion going all the way through that it might be something that you are not thinking of, like foot pain, lower extremity pain. Is it radiculopathy? Do they have a back problem associated with this? You know, lot of these patients have a huge abdomen. They have got lumbar lordosis. They kind of walk like this. They are not really moving around appropriately. A lot of them have back pain. They have done some disk disease and they have radiculopathy to the lower extremities. If they have central herniation, both legs hurt and they can be - just look for the radicular pattern in the pain syndrome that they have and make sure you pick that up and that's just a definition of anasarca. Basically, it's when the whole body is swollen up all over the place, usually an allergic reaction or medication reaction. Primary causes of that if you see it. There is a lot of things. My daughter went through one of these. She just had twins and went through like post-twin eclampsia and blood pressure problems and all kind of things, which we were very worried about but she is okay now. Everything is fine. We see a lot of hookworm. Not really. At Philadelphia, we see a lot of worms, but it's not hookworm. Liver failure due to cirrhosis. That's much more common in the Phili area. Major cause of edema in Philadelphia is lipedema associated with hoagies and liver disease. Kidney disease or kidney failure where they build up of fluid in lower extremity. POEMS syndrome, you know like when you get, I am like going. I don't remember.

    [16:00]

    I looked at it and I went [indecipherable] [16:01] and I don't remember. I don't remember that. So you could look at POEMS syndrome. Do you know? You know everything. You have to work with these ladies to know that they are extremely knowledgeable. So I usually go like, Heather, what's that? She just goes and she knows the answer and in this case none of us do. Does any of this room know what POEMS syndrome is? This is called you are screwed syndrome. [indecipherable] [16:56]. Okay, alright. Malnutrition is another one. Sometimes, we don't pay attention to what their protein balance is. Whether they have appropriate protein supplementation that they are getting amount of proteins they need but malnutrition can lead to the development of edema. You know anasarca like the total body edema, extreme protein. Amyloidosis associated with thyroid disease and then systemic capillary leak syndrome or Clarkson syndrome, which again I never seen but it's one of these things that put in because that's to be complete. Medications that can produce edema for your patients. Antidepressants, some of them that they take. Trazodone is one of them, can produce edema of the lower extremities. Antihypertensive, particularly, beta-blockers and other things can result in lower extremity edema. So whenever a patient has like just that their legs are swollen out of nowhere, I usually first think heart.

    [18:04]

    Make sure their heart is okay and we are always doing pulses and looking for kind of weird beats that kind of develop in these patients because their heart are under a lot of stress and checking that first. Checking kidney is next and then starting to look for things like medications that they are on and just going over one mediation at a time and trying to find out. Sometimes we have to look them all up. I don't remember all these stuff. See if edema is some sort of secondary complication of that medication. Antivirals, you know acyclovir. I didn't know that produced edema. Chemotherapeutic agents, many of them are associated with edema. Cytokines that are out there that granulate colony stimulating factors. Some of these things that we used for wound care or wound management may produce lower extremity edema. Certain hormones, if patients are on hormone therapy, they may have fat deposition, they may have weight gain, they may have edema problems. And then non-steroidal anti-inflammatory drugs, which everybody is taking. Everybody has got -- you know what you take for the pain, Motrin and now in Pennsylvania with the new push for this opioid like oversight where I got to check out -- if I have to write for any pain medicine, I go like somebody is monitoring me all the time. I basically tell patients anymore -- I don't see anybody here is a primary doctor, which is really good because all I ever say now is if you need serious pain medicine, you need to talk to your primary. Because the only I give, the biggest thing I ever gave is Tylenol 3 and if you can't live with that, you got to see pain specialist because I don't want to be responsible for the state coming in one day and saying you are writing for all these pain medicines. One, I think it's horrible because patients that do have vasculitis and severe limb pain associated with lot of these wounds and you will see a couple in here that will -- you would want pain medicine. Everybody is reluctant to use what I would consider adequate pain control.

    [20:02]

    Short-term use of these opioids I think is not a problem, but we have been made to feel like we are guilty to prescribe them and everybody is afraid to use them. This is just something that we are going to have to work through. In the next few years, I think we will figure our way around this. These are the causes of leg ulcers. Vascular, neuropathic, metabolic, hematologic, trauma, tumors, infection, panniculitis, pyoderma and then other special causes. There really are almost unlimited reasons why you have an ulcer. One we are dealing with right now is my mother-in-law and a patient they are like mirror images of each other, had one of these leg traumas where they had a big deep black hematoma that nobody wants to drain. I would encourage you drain them immediately so they don't build up all that big hole, that huge hematoma under the skin that allows the whole area to kind of break down. Differential diagnosis of edema in the lower extremity, we have looked at a lot of them. Malabsorption. This is kind of just goes over all over again, so we don't have to do it twice. In your H&P, what's the onset of the edema? Did it crawl on? Is it real slow? Has something happened overnight? Is it rapid onset of edema? Is it one leg, both legs? Is it more than just a leg? Does it have that fat deposition pattern that leads you to think this is a lipedema and did they have that first? I had this when I was a teenager but now I have this other problem associated with it. So is it lipo-lymphedema or problem associated with that? Check meds again. Go over the course of the disease process like how is it manifesting itself. It comes and goes, stays around. It was unilateral, now it's bilateral and then start to look about some of these things that we mentioned already that may cause the problem.

    [22:02]

    Thrombogenic events, leg fractures, trauma. When you have had a traumatic event to the lower extremity. One the things that crept up on me, it was not exactly a trauma but patients that have DJD of the knee like severe knee arthritis. What do they get? They get those little out pouching of the capsule in the back of the leg, right? Puts pressure on the lymphatics and on vein and leg will swell up associated -- every time they have the knee drained, their leg goes down. So what they really need is somebody to address the knee problem. Yes. Thank you. Yes. Good. I want to shout it out. That's Baker's cyst. No. Because another word popped into my head and I went right away it's not that. It's not a Baxter's cyst. I want to Baxter's neuroma because I am a podiatrist and so now I am just going to describe it. That's why I tell my students if you don't know the guy that they named it after just describe what it is. It's an outpouching of the posterior aspect of the capsule of the knee. I got that. I will give you my name for that. They don't need to know it's a Baker's cyst unless you are really smart. Okay. Is there malignancy involved? Is there any kind of cancer causing vascular diseases? You will see a couple of pictures. I don't know. I don't think I have any of those examples but patients that have rheumatoid vasculitis or connective tissue disease and some of the things that does to the lower extremity, the wounds that are created are associated with that and then the secondary edema, which is often a lymphedema when you have an overwhelming of the lymphatic system because of the trauma and vasculitis and inflammation associated with the wounds, that are there. Pyoderma gangrenosum, weird kind of wound. We see a few of them because Dr. Popovic [phonetic] who I worked with, who is sort of recognized expert in managing pyoderma and so we see more of those in lot of other places and then sickle cell or any of the blood dyscrasia that are associated with coagulation, associated with wounds.

    [24:14]

    You don't think of that necessarily creating edema but once you have the wound, you have trauma, inflammation, fluid buildup, overload and you can have secondary edema associated with it. Insect bites, lymphangitis, we see a number of patients in the Phili that will come in with either bedbug bites or flee bites that have become secondarily infected and they have a cellulitis associated with multiple flee bites or multiple bedbug bites. I work with a bug creep. You know people are like really, really scared of bugs. So they see like a beetle and they go bananas thinking it's a bedbug and they have like infection control and disease management and they shut the whole clinic down for like a beetle. And I don't want to say anything but I wish you would like to take an insect course on exactly what a bedbug is so you know and you don’t freak out when you see a cockroach. Cockroaches don't hurt anything. They are just dirty, nasty things. My favorite cockroach story was -- who does home care nursing? Anybody do home care nursing? Okay. The nurse came to me and she called me on the phone. She says I am sorry, I can't go see this patient anymore. She said this is the filthiest house I have ever been in. And she said, have you ever seen a cockroach running across the floor with the potato chip that looks like a sail? Literally, can you visualize it? It's running with the little potato chip. I said, alright, see if we can get another nurse to go in. I don't know what else to tell you. These are the people I treat. Again, these are just more of the medications that produce edema.

    [26:00]

    So when you get edema, you get, you know, your leg start to get tired all the time. I try to tell my students, one of the nicest things you can do for yourself is start wearing compression stockings when you do surgery. And they are available to everybody now in a cool form because you can buy athletic socks. That are basically compression stockings but they have like colors on them, so lightening bolts on the side to make you feel cool but fine. As long as you wear them, your legs will feel better. When you have to stand up for long periods of time. Doctors who see patients and are standing for long periods of time, should wear some kind of compression hose. If you sit with your knees bend all day, one, walk but two, wear compression hose so you don't have that edematous buildup in lower extremity. Burning, swelling, throbbing, cramping, muscle cramping associated with lack of fluid movement in the extremity, aching, heaviness and restless leg. Restless legs can be all vascular but sometimes that's also spinal stenosis. For me when I hear restless leg, the first thing I look for is spinal stenosis when people at night their legs are popping around, I think they have had pressure on those nerves and when they decompress, they're just having restless leg syndrome and it's proved true more times than not. They begin to develop varicosity, you see hyperpigmentation at leg and that's at SIP. We go through the SIP -- did you go through that already when I was gone? Okay. It's so great when you find out you are scheduled to do two things at the same time and it literally was exactly the same time until we move ourselves around a little bit. Did you tell them that? I have to always confess. My wife says, you will never have an affair because you just come back and tell me it happened. I am like I am so burden by that. I just kind of talk to people by the way. Okay. Venous dermatitis, chronic dermal disruption ulceration. I like that term, you know, like when the whole leg is just and you called it like lymphedema, like generalized leg lymphopathy, dermal disruption, ulceration.

    [28:08]

    There is just lots of little ulcers and they are all just draining everywhere. Lipodermatosclerosis where after long periods of time you use that kind of heavy, alligator skin appearance of skin with the swelling of all the dermal papilli, the hyperkeratosis of the leg, ankle flare, which is just kind of buildup of small venules and little tiny varicosities around the ankle and then the characteristic location of the ulcers whether they are medial or lateral or around the leg whether they happen to be on -- one of the more difficult venous ulcers we have ever treated is one on the dorsum of the foot, which is popped up. It's venous kind of but he is definitely swollen. He definitely has venous disease. He keeps infecting from his interspaces because he is not bathing effectively, so he doesn't really clean up his interspaces. The nails have multiple biofilms associated with them and he just keeps bacterially seeding everything that opens up on them. There are Stemmer sign. You already had that presented but just do the test and look and see if there is significant lymphatic component. See if you can tent that skin on the foot. If you can, there is a lymphatic component associated with the edema that you see. So here is a SIP classification, which I like for looking at the progression of venous related skin changes and disease in the lower extremity. It was developed by the American Venous Forum that gets together every couple of years and goes through this and has come up with this classification. The only thing I don't like about it and what I really want is some sort of classification system for the venous ulcers because C6, which is the highest classification, is you have got an ulcer. Yeah, that's everybody I see. So now what? Is it lymphatic related, is it venous related, is it arterial venous combination, is it traumatic, is it why that they have it and where it's? And that sort of thing.

    [30:08]

    I also would take healed venous ulcer and put it down here because in the order of progression, you can't have a healed ulcer till you have one but that's just me. You know like C5. Yeah, I got this. A healed ulcer. I am about to break out any day now. And I will be a C6. A graduate. And they look at symptoms, whether they are symptomatic or asymptomatic, they get a designation of S or A. And then they get one with -- there is another one whether they are congenital or not. This is a location. So which veins are related? They literally have telangiectasia and reticular veins all the way down to saphenous and non-saphenous and all the deep veins and depending on the vein that's involved, they will give that the primary designation based on that number. So it's like a 10. It's pelvic. We are going to gonadal edema. Differential diagnosis. Again, when you are looking at the wound, think how long has it been there? How long the wound been present? Is it something that deserves a biopsy? And when you biopsy a wound, don't just biopsy one place on these larger wound, take a few biopsies in a few locations. I would say at least three and don't take too small a biopsy. Try to take one that's at least a 4-mm punch I think and if you can, I like incisional. Just take a little incisional biopsy and what will happen. Every time you take a biopsy unless they are pathergic, it will heal around. It will look great around the healed wound where you took the biopsy because you created an acute situation and immediately it goes into a healing phase to heal the incision that you just made and that little area starts to look better.

    [32:00]

    Cellulitis, contact dermatitis. I have already talked about that too much that they come in contact with certain substances, dyes, shoes. Some other things they put in the tanning people allergic to. They use a lot of heavy metals in tanning leather, so you might see some approach to that. The cardiac disease, renal disease, erysipelas, they have an infection, they have strep, telangiectasias. Essential telangiectasia is just a skin disease involving the small vessel, Klippel Weber syndrome, squamous cell carcinoma, which could be present and should be looked for basal cell and squamous cell. And then stasis dermatitis and there is a traumatic component. They hit it and that got the process started. Pitting edema, we have already really talked about these, lymphatic edema due to other things and then these are some of the tests you can do. First one is Duplex ultrasound and the study of choice for DVT is if the patient has suspected DVT, has ordered Duplex ultrasound, real-time B-mode sonographic -- I never know what to write. I just write ultrasound. Ultrasound for DVT, hopefully they make the right choice. It's considered the gold standard. I never know what the hospital wants anymore. Like I write -- here is the most frustrating thing in my life. I send the patient up for an MRI or scan, some sort of scan where they have to have an injection. So what do they want? Kidney function. So I send them to an MD who needs a kidney test done in order to do the test that I ordered. So they cancelled the patient, send them back and asked me to order a kidney test. They are right there at the hospital.

    [34:00]

    All I have to do is get the test. You are an MD, you need the test, why do I have to -- I don’t need the test. He needs the test or she needs the test. I don't need to know. I have already known what their kidney function is. I just didn't send the number over. He needs to know and they never call you. It's like a date. They never call back. MRI, it's a fairly sensitive test for looking at veins. You can get a nice --there is a nice picture that you get from the vein. MRI is lot more expensive. It's probably not the test of choice for lower extremity veins. Direct contrast venography where you actually inject the veins and put a dye in the veins and kind of trace it up through and watch it move up through. It's a little labor intensive. It's invasive. Patients don't like being injected with things unnecessarily, so if you can do the ultrasound and basically the same advice. You do CTs, really fancy CTs that will pick up all arteries and veins and kind of give you the whole vascular structure of the extremity. Most of the time, these are things that vascular guys are ordering after I have determined -- I was only a podiatrist, so I determined that's a vascular problem. I am not taking care of that. It's going to somebody that does that on a regular basis. So lymphoscintigraphy is available where you can inject into the radioactive substance into the lymph system and kind of watch it migrate through the leg and take pictures as it goes along. Detect slow or absolute flow, areas of reflux. You can kind of see the lymph drainage associated with it, where is it. Where does the lymphatic flow go? Where are places of restriction? Does it have to make some sort of squarely turn to get out of the leg and maybe that could be facilitated. You can locate sentinel nodes. There are some areas that's really infected or inflamed or whether you have cancer or something you might see that.

    [36:01]

    And then center for congenital lymph edema determining whether the patient has a congenital problem. Indocyanine green, I don't have a green picture but you have already seen one. Not a lot of facilities have this but it's a really nice picture for places that have it available to order. It's a real time dynamic study. You actually kind of see the lymphatic material move up through the leg. It's very dramatic. You can also use, there is a similar technique now that's done for arterial flow into the limb to kind of see what -- look for areas for debridement or amputation or to kind of see how your treatment is affecting the lower extremity. It's a very valuable test that can be done. These are kind of unusual measures of volume. Tape measurements, like this is what we do pretty much in the clinic is measure them from week to week and see how they are doing and just record the measurement. Polarimetry with infrared optical scanners. I don't have one. Anybody have an infrared optical scanner for the measurement of lower extremity edema? Good, I feel better. And then water displacement where you have a big tub and they hop in and you measure the water that comes out and that's how much displacement is there measures the displacement of any one limb to the next. You could determine how much edema was in one leg. Then there is a bio-impedance spectroscopy. Anybody ever do that? I never did it. It's like historical. Historical testing but you can measure the electrical flow through the tissues and lymphatic tissues that are involved with lymphedema have a different electrical conductivity tissues that have fluid in them have a different electrical conductivity and you can kind of measure that. Physical findings. When you look at the skin, feel it. Is it indurated? Does it pit? Is there fluid that can move? Is it hard? Is it painful?

    [38:00]

    Is it lumpy, bumpy? Does it have nodules underneath the skin? Look at that. There is a way to measure skin texture and resistance with tonometry and then the dielectric constant also measures kind of the flexibility and hardness of the skin. Genetic testing can be done pretty much with the children with edema. You want to find out is this -- lymphedema has -- tendency to develop lymphedema or become edematous and develop a lymphedema problem has a genetic component. Almost all of them have something that you inherit and that makes you likely to develop that if you are put in the same circumstances. But these are things which children are born with. Some deficiencies that are genetic related to the development of edema. And there is traditional vascular and that's just to reemphasized that you really should do regular arterial testing on these patients to make sure that they have this support vascularity arterial support to heal the things that you are trying to heal and you don't concentrate just on edema. And it's nice to know your ABIs because if they have adequate ABI, then you can feel pretty good about compression and if their ABIs are low and you know that they are falsely elevated in patients that have diabetes and calcifications of the arteries, but if their ABIs are low and if you suspect an arterial component, you have to watch how much compression you use. Now, does that mean you can't use any compression? No. It just means that when you are 0.5 or above, you know, like below 0.5, you got to watch it with any kind of compression at all. But when Heather goes through the techniques that you see for lymphatic drainage, that's not precluded in any arterial condition and it does move that fluid without the compression necessarily. So you should be able to facilitate that little bit but you can use compression really 0.5 or above, you just have to be very, very careful with how much compression you use. In this particular guideline, no compression above that.


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