An approach to a child with oedema

Pushpa Raj Sharma

Professor of Child Health

Institute of Medicine

Oedema: accumulation excess interstitial fluid Increased hydrostatic pressure

Acute nephritic syndromeCongestive cardiac failure

Decreased plasma oncotic pressureProtein calorie malnutrition, Nephrotic syndrome; protein loosing enteropathy

Increased capillary leakageAllergy, sepsis, angiooedema.

Impaired venous flowVanacaval obstruction, hepatic vein obstruction

Impaired lymphatic flowCongenital lymphedema, Wuchereria bancrofti infection

Entry questions and threading questions Sensitivity Specificity Understandable Open ended Leading Short Acceptable

Entry questions: Enters into the organ/

system Threading question

Enters into the specific aetiology.

Examples for formulation of questions Localized oedema

Insect bite; trauma; skin infections Kwashiorkar (bilateral pedal) Superior vanacaval obstruction Lymphatic obstruction Orthostatic

Generalized oedema Renal: periorbital; hematuria; hypertension;

symptoms of collagen disease (rash, joint pain); frothy urine; symptoms of uraemia (vomiting, nausea, pallor), convulsion, low urine output.

Examples for formulation of questions

Cardiac: orthopnoea, joint pain; palpitation; giddiness; fainting episodes; bluish episodes;

Protein energy malnutrition: low calorie and protein in the diet for long; precipitating factors (persistent diarrhea, chronic illnesses)

Hepatic: Jaundice; ascites; prominent abdominal veins; neonatal umbilical sepsis; spleenomegaly; purpura

Collagen diseases: fever, rash, joint pain, pallor

First case 4 year old girl, who

recently recovered from a sore throat, was brought to the OPD with symptoms of swelling of both feet.  Physical examination reveals edema around the eyes and the ankle.  A routine urinalysis reveals the following results.

The most likely diagnosis is

Urine examination

Chemical/Physical Analysis Color:Yellow’ Blood:Moderate;Clarity:Hazy;pH:6.5

Glucose:Negative;Protein:300mg/dL;Ketones:Negative Specific Gravity:1.015 ;Nitrite:Negative Microscopic Analysis

20-50 RBC/hpf 10-20 WBC/hpf 2-5 RBC casts/hpf 2-5 Granular casts/hpf

What is the most likely diagnosis?

Second case 5 year male child Swelling first noticed

around eyes. No history of shortness

of breath; fever; cough; jaundice; umbilical infection; no dark colored urine.

Height: 110cms; Wt: 18kg; liver not enlarged; Ascites present

The most likely diagnosis is

Third case

!2 year male from Pokhara; arrived after traveling by bus for 12 hours.

History of fever Upper abdominal pain Dark colored urine No past history of sore

throat, rash, joint pain diarrhea, trauma.

Comfortably lying flat in bed

Oral temp: 102.0 Respiratory rate: 28.min Bilateral pedal edema, non

tender Absence of Jaundice Weight: 38 Kg. Chest: normal Abdomen: Tender R hypo.

No free fluid

Third case: Normal blood count Urine: routine normal Liver function: normal X-ray chest: normal

What causes we have excluded?

Increased hydrostatic pressure?

Decreased plasma oncotic pressure?

Increased capillary leakage?

Impaired venous flow?

Impaired lymphatic flow?

Third case: further investigation Bilateral edema and

tender R hypochondrium.

Ultrasound of the abdomen: Thickened Gall Bladder

wall Mucocoele

Third case :Final diagnosis and pathophysiology Edema: increased hydrostatic pressure due

to gravitational effect from prolonged leg hanging.

R. Hypochondrium pain and fever: cholecystitis and mucocele of gall bladder (ultrasound supported)

Edema subsided on the next day after admission.

Fourth case

5 year male child Swelling started from limb :

one month No history of cough,

shortness of breath, cyanosis, jaundice, dark colored urine, umbilical infection.

Persistent diarrhea +. Irritable; wt: 6 kg; Ht:

100cms. Serum protein: 1.5G/dL; Urine normal

What is the diagnosis?What is the diagnosis?

Fourth case 6 year female child Swelling both feet for

10 days. History: shortness of

breath off and on for1 year, joint pain; palpitation; low urine output; fever with rigor

Tachypnoea; pyrexial, propped-up; raised JVP, enlarged liver and spleen; urine shows RBC.

The most likely diagnosis is