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Water Pills (Leg Edema)

By Dr. Peter W. Kujtan, B.Sc., M.D., Ph.D.

Article published on page 20 in the December 15-16, 2007 issue
Reprinted under "I Need Water Pills & a Shot for the Road!"
on page 10 in the January 12-13, 2008 issue,
on page 10 in the September 26-27, 2009 issue, and
on page 34 in the September 15, 2010 issue of
The Mississauga News under the feature: Health & Beauty, Medicine Matters.
Portrait of Dr. Peter W. Kujtan, supplied 2005
Dr. Peter W. Kujtan

Swelling of the lower legs without redness or fever is a common entity seen in medical practice. It is much more common amongst older adults. If one or both of your legs tend to swell, there is a greater tendency to develop ulcers or skin infections called cellulitis.

When we see swollen ankles, we first try to decide whether it is acute or chronic. Acute refers to a sudden new swelling that appears within a few hours. It is also important to decide whether it affects one or both legs. Leg edema tends to fall into two broad types. Oxygen rich blood flows down to our legs in arteries, but returns two ways. It can travel through capillary beds and then into veins, or it can flow through spaces between tissues called lymph flow. When the capillaries cannot filter and return fluid fast enough, it seeps into the areas around them. It contains little protein, and pushing on the area can cause an indentation by squeezing fluid to the side. We call this "pitting edema." Lymphedema is generally due to a problem with some sort of blockage preventing lymph from draining out of the legs and tends to be more serious. Cancer needs to be ruled out in these cases.

The veins in our legs carry blood back to the heart in an uphill fashion. They contain littl valves that resemble saloon-doors, and allow blood to flow in one direction only. hen we are active, our calf muscles also help the blood flow. This whole mechanism tends to function less efficiently as we age. Some people are more prone to varicose veins. This is a condition in which the veins enlarge due to poorly functioning valves. Varicose veins should not be confused with leg edema.

Venous stasis is a chronic type of vein insufficiency that tends to bother older folk. It can be totally harmless or can be an indicator of heart failure. It tends to get worse through the day and is helped with elevation or compression stockings. There tends to be no shortness of breath or chest pain. If the swelling is chronic, you may notice a browning of the skin caused by hemosiderin deposits. In simple terms, this is the result of our body doing a chronic cleanup of debris that has accumulated in the area.

The one emergency situation that we are always on the look out for is a sudden painful unilateral leg swelling suggesting a blood clot. Technically, it is called a DVT (Deep Vein Thrombosis). It requires urgent diagnosis and treatment to avoid the rare complication of a pulmonary embolism. These clots can break off their footings and travel to the lungs. Blood is a very responsive medium. It tends to clot when smooth flow stops. This can occur at the side of a cut or during long periods of leg inactivity such as on plane or car rides. The standard treatment was to prevent further clot formation by injecting heparin, but this has been replaced by newer more efficient drugs such as Lovenox.

Sometimes leg edema is the result of medication. Some drugs, particularly calcium channel blockers, can modify the response of blood vessels to changes in posture. One way to control hypertension is to move fluid "away from the heart." For this reason, I often caution patients who feel "water pills" are a quick solution for all types of leg swelling. The concern I sometimes harbor is that when the infamous "water pill" helps one person they sometimes cannot help but advocate it to anyone encountering with swollen legs. Some people even offer free samples. Other people turn to herbal preparations with known mild diuretic effects such as horse chestnut. Self-treatment is not defined by the source in my mind.

As our population ages, we are diagnosing more people with sleep apnea. In this group of patients who also develop leg swelling, it is vital to rule out a potentially serious condition called pulmonary hypertension.

Elevating the legs as much as possible, wearing compression stockings and regular walking can relieve chronic leg edema. If you notice new leg swelling it is best to get it checked by a medical professional. Sudden onset of swelling deserves urgent assessment. Lovenox (Enoxaparin) is a newer blood thinning drug that is being used to prevent blood clots not only in surgical patients, but is also starting to be used in cancer patients. Snowbirds engaging on those southern migrations in cramped cars may also consider discussing its use during travel. I would be very cautious about water pills. They often help many types of swelling but without an appropriate diagnosis can mask a more serious problem. It is dangerous to share or sell any prescription dispensed to you.

Related resources:

Lower Leg Edema from MedlinePlus.
Deep vein thrombosis (DVT) from Bupa. Factsheet: Deep vein thrombosis (DVT) is a condition in which a blood clot forms in one of the deep veins, usually in the leg. DVT can cause pain and swelling and may lead to complications such as pulmonary embolism.
Lymphedema Fact Sheet from American Physical Therapy Association. "Edema, or swelling, may occur when there is an increase in the amount of fluid, proteins, and other substances in the body tissues. Lymphedema occurs when the normal drainage of fluid is disrupted. It may be caused by a blockage or cut in the lymphatic system, usually the lymph nodes in the groin area and the armpit."
Edema from InteliHealth. What is it? Symptoms, Diagnosis, Expected Duration, Prevention, Treatment, Prognosis.
Foot, leg, and ankle swelling from National Institutes of Health (NIH). "Painless swelling of the feet and ankles is a common problem, particularly among older people. Abnormal buildup of fluid in the ankles, feet, and legs is called peripheral edema."
Edema (Pitting and Non-Pitting) - Causes, Diagnosis, Symptoms, and Treatment from MedicineNet.
Leg Swelling - Symptoms and Signs from MedicineNet.
UpToDate Patient Information: Edema by Burton D Rose, MD.
Causes of Edema and Common causes of Leg edema from WrongDiagnosis.com.
UpToDate Patient Information: Lympedema by Emile R Mohler, III, MD.
Diuretics from Healthline. Diuretics, also called water pills, belong to a class of medications that are designed to increase the loss of water and salt from the body.

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