Edema: When is swelling a sign of something more serious?

Published on Friday, September 1, 2023

By: Andrea Wright Dilworth, awdilworth@umc.edu

Three weeks after a bout with COVID-19 last June, Irvin “Rocky” Holston III couldn’t breathe and started retaining fluid. By September, he had gained 55 pounds, his legs and ankles so swollen he couldn’t walk. Normally a size 8.5 or 9, the only shoes he could find that fit were a size 13 pair of Crocs.  

“I thought I was going to die,” said Holston, 70, a retired preacher. “I had gone from walking to being in a wheelchair three months later. I couldn’t breathe, and my legs had begun leaking fluid. Even if I didn’t drink, I wouldn’t stop gaining fluid.” 

Holston was diagnosed with edema, visible swelling of the skin caused by too much fluid trapped in the body's tissues, a result, in his case, of heart failure. He was prescribed a drug to treat fluid retention. When his condition continued to worsen, he was referred to the University of Mississippi Medical Center.  

When he arrived at UMMC, a heart failure physician, who had already reviewed his case, admitted him and immediately began administering a cocktail of drugs – including diuretics to get rid of the excess fluid and heart failure medications – through a catheter. He stayed in the hospital for a week. 

“I started losing at least 15 pounds of fluid a week, for the first three weeks,” Holston said. “And I started feeling better.” 

If you don’t know what edema looks like, here’s a visual: Remember the Pillsbury doughboy, and how his tummy would hold a dimple for a few seconds after being poked by a finger? In medicine, that’s called pitting. If a swollen leg – or other body part – pits or stays indented for a few seconds after pressing on it, you likely have edema.    

Edema is most common in the legs, ankles and feet due to gravity, but can show up anywhere, including your face, hands, arms, back or abdomen.  

Though the swelling can signal heart failure, it can also be a symptom of a host of other conditions, some serious, some not.  

There is no one cause of edema. It could be a side effect of medication, a result of standing too long, a sign of inflammation resulting from trauma to the body or a symptom of a systemic illness.  

Though not necessarily a cause for alarm, it should not be ignored, either.  

But how do you know when your swelling is cause to see a doctor? 

If your legs swell after standing or sitting in one position for a long time, you may have dependent edema, which is not usually serious, said Dr. Douglas Wolfe, professor of cardiology.  

On the other hand, Wolfe said, if you’re also short of breath, notice swelling in places other than your legs, or it doesn’t improve with rest and elevation, you should seek medical help.   

“Although a minimal degree of edema can be seen in healthy adults, edema per se needs to be evaluated by a doctor since a variety of systemic conditions can cause it,” said Dr. Gabriel Hernandez, associate professor of medicine in the advanced heart failure and transplant division of Interventional Cardiology, and one of the physicians who treated Holston.  

“As a cardiologist with heart failure expertise, I see patients with edema every day,” said Hernandez. “The edema associated with heart failure is secondary to an [abnormal] response between the kidney and the heart. Water and salt retention by the kidney leads to more blood volume; the heart’s inability to pump the blood to the body leads to fluid accumulating and subsequent edema.”   

Swelling could also signal emergent issues in other areas. 

“A liver specialist might see mainly cirrhosis as the cause of edema,” said Wolfe. “The renal doctors would see kidney failure. Cancer doctors might see anemia and poor nutrition from cancer.  We all see each of these causes, but the preponderance depends on the patient population.” 

These are some red flags your swelling could be a symptom of a more serious issue, said Wolfe and Hernandez: 

• You experience sudden edema that does not go away 

• You first notice the swelling when you wake up in the morning 
• The swelling is accompanied by shortness of breath, decreased urination, foamy urine, puffiness in your eyes or an increase in abdominal size 
• You develop leg pain and swelling after traveling or sitting for a long time 
• You are pregnant; although some swelling is normal, doctors need to rule out preeclampsia 

How doctors treat edema depends on its cause, though a diuretic, as in Holston’s case, is usually part of the treatment plan, along with dietary changes focused on reducing fluid and sodium intake, said Hernandez. Wearing compression socks and elevating legs can also help if you have edema in the lower body.  

For long-term maintenance, the key is managing the underlying effect. And if the underlying cause can be reversed, edema can sometimes be cured, said Wolfe.  

Because of his heart failure diagnosis, Holston’s medical team performed surgery in July to implant a left ventricular assist device in his chest. The battery-operated LVAD helps pump blood from the lower left heart chamber to the rest of his body.  

Holston, who now sees Hernandez every two weeks, no longer has swelling or trouble breathing, and can wear his old shoes again. 

“Other than wearing a battery pack, I feel like my old self,” said Holston. “Those doctors in the heart failure division are unbelievable. They know their stuff. They saved my life. I’d be a dead man if it wasn’t for them.”

To find out how to schedule an appointment with a UMMC cardiologist, call 601-984-5678.

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