Dear doctors: My wife, who is 77 and a Type 2 diabetic, suffers from severe edema in both legs. Her heart, liver and kidneys recently all checked out fine. She had an ultrasound on her legs, and had no blood clot. We've had three doctors tell her the only thing that can reduce the swelling is to wear compression hose and keep her legs elevated, but to be blunt, it "ain't workin'." Are there medicines, surgery or something else she can try?
R.H.
Edema is swelling, and it's common in the legs, particularly as we get older.
Fluid retention occurs when the forces pushing fluid out (mostly vein pressure) are higher than the forces keeping fluid in (mostly by proteins).
You mentioned three common causes. In heart failure, the heart is weak and unable to effectively pump all the blood needed by the body. This causes fluid to "back up." Kidneys filter the blood to remove waste products and retain proteins, and they can cause edema by letting too much protein out. The liver can fail to make enough protein to keep the fluid in veins.
But in your wife's case, as in most, none of these is the issue. So, what is?
Most commonly, the problem is leakage through the capillary walls. Veins have valves, but if these valves leak, that increases edema flow into tissues.
With time, the vessels are damaged further and fluid stays in the tissue longer.
For the majority of people, the lymphatic system will suck up the extra fluid, especially when the legs are raised at bedtime. By the morning, the extra fluid in the legs is gone. This is not the case with your wife.
There is no cure. Diuretics such as Lasix don't work for more than a few days.
Surgery tends to make it worse. But support stockings and elevation are helpful; so is exercise. Support hose need to be the appropriate size and strength, and that means careful measurement and possibly custom-made stockings.
Elevation needs to take place at least three times a day, and the legs should be raised above the heart. This is more than propping your feet on a chair; your wife must lie down. And exercise uses muscles to take fluid out of the legs and bring it back to the circulation.
A supplement called horse chestnut extract has been shown to be helpful; however, my experience with it in my patients has been less than spectacular.
