Edema

Edema: Excerpt from The 5-Minute Pediatric Consult

Lawrence Copelovitch, MDMitchell Schwartz, MD (4th edition)

Edema - BASICS

Edema - description

Presence of abnormal amount of fluid in the extracellular spaces of the body; usually secondary to low albumin, obstruction of venous or lymphatic channels, or trauma

Edema - etiology

• Excessive losses:
  • Renal loss of protein
  • GI
• Inadequate production:
  • Liver disease
  • Malnutrition
• Local trauma
• Increased hydrostatic pressure:
  • CHF
  • Pericardial effusion
  • Post cardiac surgery
  • Venous obstruction
    • Superior vena caval syndrome
    • Deep vein thrombosis
  • Lymphatic obstruction

Edema - DIAGNOSIS

Edema - signs & symptoms

Approach to the patient: General goals:

• Determine the cause of swelling:
  • Is it localized?
  • Are there any losses of protein?
  • Is there underproduction of protein?
• Determine the serum protein/albumin; consider increased losses or decreased production.
• Phase 1: Is the swelling localized as seen in trauma, lymphatic, or venous obstruction?
• Phase 2: Are there urinary or GI losses?
  • Associated with decreased serum albumin
  • Most likely source of loss is renal disease, less frequently gastrointestinal losses.
• Phase 3: Search for other causes of edema, such as insect bites, pericardial effusion, metabolic disease.

Edema - history

• Is the edema localized or generalized? (See “Differential Diagnosis.”)
• Determine treatment urgency: Patient is asymptomatic or in some distress specifically because of the edema.
• Major causes of edema: Evidence of cardiac, renal, or gastrointestinal disease
• Evidence of edema in body: Waist size has become larger, difficulty putting shoes on.
• In some patients, excess salt intake in diet contributes to edema.
• If there is shortness of breath, there may be ascites, which compresses the diaphragm or causes pleural effusions.
• Chronic diarrhea is seen in protein-losing enteropathy or lymphatic obstruction.
• Any urinalyses that has been performed in the past may help date the onset of the problem.
• Allergies commonly cause swelling around the eyes or face.

Edema - physical exam

• Dependent edema: Lumbosacral area pretibial pressure to detect edema scrotum/labia
• Percussion of chest: Pleural effusion
• Shifting dullness: Early sign of ascites
• Soft ear cartilage: Common finding in nephrotic syndrome
• Pitting edema: Seen in cases of protein loss and obstruction of venous/lymphatic flow, whereas nonpitting edema is seen in salt poisoning

Edema - tests

Edema - lab

• Dipstick urinalysis: If there is generalized edema with heavy proteinuria and hypoalbuminemia, the presumptive diagnosis is always nephrotic syndrome until proven otherwise.
• Serum albumin:
  • If there is generalized edema with no proteinuria but hypoalbuminemia, consider cardiac, GI, or hepatobiliary disease and direct additional studies to evaluate these three organ systems specifically.
  • If there is either localized edema or generalized edema but a normal urinalysis and a normal serum albumin, consider other unusual causes for edema, such as mechanical or lymphatic obstruction, certain endocrine disorders, or the effects of drugs or toxins.
• Stool albumin: Seen in protein-losing enteropathy

Edema - differencial diagnosis

• Localized:
  • Trauma—pressure or sun damage
  • Infection
  • Allergy
  • Lymphatic obstruction (less common):
    • Filariasis
  • Bee stings or insect bites
• Generalized:
  • Congenital: Lymphatic obstruction of legs or thoracic duct
  • Infection: Hepatitis and liver failure; pericarditis
  • Toxic, environmental, drugs:
    • Sodium poisoning
    • Toxic effect on liver and/or heart (chemotherapy)
    • Cirrhosis
    • Drug reaction
  • Tumor:
    • Obstruction of venous return from enlarged abdominal lymph nodes or tumor
  • Genetic/metabolic: Sickle cell renal failure
  • Allergic/inflammatory: Protein-losing enteropathy
  • Renal:
    • Nephrotic syndrome
    • Renal failure
  • Cardiac:
    • CHF
    • Pericarditis
  • GI
    • Intestinal protein loss
    • Postpericardiotomy or congenital heart surgery
    • Hepatobiliary diseases
  • Endocrine—sodium retention, hypothyroidism

Edema - TREATMENT

Edema - initial stabilization

Any child or adolescent with an edema-forming state that compromises either cardiorespiratory function or the vascular integrity of a peripheral organ or limb should be referred immediately to an appropriate specialist for emergency care.

Edema - general measures

• Moisturize skin
• Avoid pressure sores
• Decrease sodium intake
• Active or passive leg exercise to avoid venous thromboses
• If edema is massive, the patient may awaken with swollen eyelids. Place blocks under the head of the bed to keep the patient’s head elevated.
• If there is scrotal edema, jockey shorts will help support the scrotum and protect the skin from breaking down.

Edema - FOLLOW UP

Edema - disposition

Edema - issues for referral

• Nephrotic edema with impaired glomerular function—pediatric nephrologist
• Protein-losing enteropathy or hepatobiliary disease—pediatric gastroenterologist
• CHF secondary to occult cardiac disease—pediatric cardiologist
• Endocrine-mediated edema—pediatric endocrinologist
• Lymphatic or other mechanical obstructions— vascular surgeon or pediatric surgeon, if readily available

Edema - bibliography

1. Dudin A, Othman A. Acute periorbital swelling: Evaluation of management protocol. Pediatr Emerg Care. 1996;12:16–20.
2. Holliday MA, Segar WE. Reducing errors in fluid therapy management. Pediatrics. 2003;111:424–425.
3. Jacobs ML, Rychik J, Byrum CJ, et al. Protein-losing enteropathy after Fontan operation: Resolution after baffle fenestration. Ann Thorac Surg. 1996;61:206–208.
4. Kelsch RC, Sedman AB. Nephrotic syndrome. Pediatr Rev. 1993;14:30–38.
5. Molina JF, Brown RF, Gedalia A, et al. Protein losing enteropathy as the initial manifestation of childhood systemic lupus erythematosus. J Rheumatol. 1996;23:1269–1271.
6. Moritz ML, Ayus JC. Prevention of hospital acquired hyponatremia: A case for using isotonic saline. Pediatrics. 2003;111:227–230.
7. Rosen FS. Urticaria, angioedema, anaphylaxis. Pediatr Rev. 1992;13:387–390.
8. Vande Walle JG, Donckerwolcke RA. Pathogenesis of edema formation in the nephrotic syndrome. Pediatr Nephrol. 2001;16:283–293.

Edema - CODES

Edema - icd9

782.3 Edema, edematous

Edema - FAQ

• Q: At what level of serum albumin does edema occur?
• A: Edema is generally associated with serum albumin <2.5 g/dL.
• Q: Why does pericardial effusion cause edema?
• A: Pericardial effusion is associated with decreased lymphatic flow and increased venous pressure.
• Q: Is there a certain group of allergens that cause edema?
• A: No special allergens are associated with edema. The usual causes include foods such as peanuts and drugs such as penicillin.

Book Source Details

• Book Title: The 5-Minute Pediatric Consult
• Author(s): M. William Schwartz MD; et al.
• Year of Publication: 2008
• Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Lippincott Williams & Wilkins.

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More About This Book: Title: The 5-Minute Pediatric Consult Authors: M. William Schwartz MD; et al. Publisher: Lippincott Williams & Wilkins Copyright: 2008 ISBN: 0-7817-7577-9

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