What is the approach to investigating arm edema?

From the Guidelines

The approach to investigating arm edema involves a systematic evaluation starting with a thorough history and physical examination to determine the underlying cause, with a focus on identifying potential life-threatening conditions such as deep vein thrombosis or malignancy. Initially, assess for unilateral versus bilateral involvement, acute versus chronic onset, and associated symptoms like pain or redness. Key historical elements include recent trauma, surgery, cancer history, medications, and travel. Physical examination should focus on skin changes, temperature, tenderness, and palpation of lymph nodes.

• Diagnostic testing typically begins with ultrasound to evaluate for deep vein thrombosis, which is a common and potentially serious cause 1.
• If lymphedema is suspected, lymphoscintigraphy may be ordered to assess lymphatic function, as recommended by the American Cancer Society/American Society of Clinical Oncology breast cancer survivorship care guideline 2.
• For cases where malignancy is a concern, CT or MRI might be necessary, with MRI being the modality of choice for detecting superficial or deep fascial fluid or edema 3.
• Laboratory tests including complete blood count, renal and liver function tests, and inflammatory markers can help identify systemic causes.
• Measurement of the affected limb compared to the unaffected side provides objective assessment of severity and progression.
• Treatment depends on the underlying cause but often includes elevation of the affected limb, compression therapy, and addressing the primary condition, with early diagnosis being crucial to prevent chronic edema and its complications, as highlighted in a systematic review of rehabilitation and exercise recommendations in oncology guidelines 4.

From the Research

Approach to Investigating Arm Edema

The approach to investigating arm edema involves a comprehensive evaluation to determine the underlying cause.

• The chronicity and laterality of the edema guide the evaluation, as stated in the study 5.
• Medications, such as antihypertensives, anti-inflammatory drugs, and hormones, can contribute to edema, and their use should be considered in the evaluation 5.
• A basic metabolic panel, liver function tests, thyroid function testing, brain natriuretic peptide levels, and a urine protein/creatinine ratio can help identify potential causes of edema 5.

Specific Considerations for Arm Edema

• Lymphedema is a possible cause of arm edema, characterized by brawny, nonpitting skin, and can be primary or secondary to tumor, trauma, previous surgery, or radiation therapy 6, 7.
• The diagnosis of lymphedema is often clinical, but lymphoscintigraphy can be performed if the diagnosis is unclear 5.
• Validated decision rules, such as the Wells criteria, can guide decision-making regarding the possibility of venous thromboembolic disease 5.

Diagnostic Tests and Techniques

• Duplex ultrasonography with reflux can help diagnose chronic venous insufficiency 5.
• Compression ultrasonography or a d-dimer test can be used to evaluate for deep venous thrombosis 5.
• Bioelectrical impedance vector analysis (BIVA) is a noninvasive technique to estimate body mass and water composition, and can be used to assess hydration state 8.
• Echocardiography can be used to assess for heart failure in patients with pulmonary edema or elevated brain natriuretic peptide levels 5.