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Approach to oedematous child

Edema
• Defined as the presence of excess fluid in the interstitial space of the
body
• Divided into 2 types: localized edema and generalized edema
• Severe generalized edema is known as anasarca
• Localised interstitial fluid collections include ascites and pleural
effusion
Causes of Edema

Impaired venous flow


Increase hydrostatic pressure
• Major organ failure (cardiac, renal, liver)
• Acute nephritic syndrome

Decrease oncotic pressure


• Nephrotic syndrome
• Chronic liver failure
• protein losing enteropathy
• 1) Increased hydrostatic pressure
• acute nephritic syndrome, acute tubular necrosis, cardiac failure
• 2) Decreased plasma oncotic pressure (hypoproteinaemic states) •
nephrotic syndrome, chronic liver failure, protein losing enteropathy,
protein • caloric malnutrition
• 3) Increased capillary leakage • insect bite, trauma, allergy, sepsis,
angio-oedema
• 4) Impaired lymphatic flow • lymphatic obstruction (tumour),
congenital lymphoedema
• 5) Impaired venous flow • hepatic venous outflow obstruction,
superior/inferior vena cava obstruction
Clinical approach to an edematous child
1. Confirm edema.

2. Assess distribution of edema: Localised versus generalised. In


generalised edema, look for dependent areas such as pretibial, sacral,
scrotal, vulval edema other than peri-orbital edema and ascites.

3. Detailed history and physical examination to assess severity,


associated complications and underlying cause of the edema
(algorithm 1).
Inspection:
• The overlying skin may be smooth, shiny, taut and even hairless.
• There may be loss of normal small skin wrinkles, obliteration of dorsal
finger joint creases, obscurity of metacarpal head definition and of
the dorsal finger extensor tendons.
• There may be loss of normally distinct appearing edges of medial
malleoli.
• Observe for puffiness of eyelids and face and also the scrotal edema.
• Observe for signs of inflammation if any.
Palpation:
• Press with your right thumb over the following bony backgrounds
for 5-10 seconds (different on different books!):
• Medial malleolus
• 5 cm above medial malleolus
• Shin of tibia
• Sacrum (in case of non-ambulatory patients) – ask patient to sit fo
• Rib or sternum
• Forehead (In case of anasacra)
Pitting edema
* palpate the pretibial area and medial malleolus for at least 10 secs
- indentation of the skin which slowly refills

Generalized Localized
- CVS (only in the lower half of the body) - venous obstruction (e.g., DVT)
- right heart failure or CHF - immobile or bedridden patient
- constrictive pericarditis - e.g., paralysis
- pericardial effusion - inflammation (e.g., cellulitis)
- IVC obstruction
- Renal (generalized more on face)
- nephrotic syndrome (↓ albumin)
- renal failure
- GIT/hypoproteinemia
- liver cirrhosis (↓ albumin synthesis)
- malnutrition
- malabsorption (e.g., Coeliac disease)
- protein-losing enteropathy
Non-Pitting edema
Applying pressure to non-pitting edema doesn’t cause any lasting indentation

Lymphatic Others
- filariasis or elephanthiasis - hypothyroidism (i.e., myxedema)
- Milroy’s disease - allergy (e.g., angioedema)
- unexplained lymphedema which
- appears at puberty & is more common
- in females
- surgical removal or irradiation of nodes
- e.g., post radical mastectomy
• How much body fluid may collect in tissue before pitting
occurs ?
Ans: Atleast 10 lb (4.5 kg)

• Why edema is pitting?


Ans: In general, this type of edema contains protein-poor
transudate and the lymphatic drainage is not obstructed.
Types of Edema fluid

Transudate Exudate Lymph


Protein-poor (< 3 g/dl) Protein-rich (>3 g/dl) Protein-rich
Cell-poor Cell-rich

Pitting edema Non-pitting edema Non-pitting edema


Percussion (For Ascites):
• Puddle sign: 120-250 ml (Mild ascites)
• Fullness of flanks: > 500 ml fluid
• Shifting dullness: > 1000-1500 ml fluid (Moderate ascites)
• Fluid thrill: >2000 ml fluid (Tense ascites)
Quantitative Assessment of Edema
1. Circumferential or girth measurement – use same tape, same bony
reference point, same measurement technique and if possible the
same time of the day.
2. Volumetric water displacement – use same time of the day and
same temperature of water; volume of the extremity can be
determined by the volume of water displaced from the volumeter
when the extremity is submerged.
3. Functional performance limited by edema
Grading of Edema