An approach to a child

with oedema
Pushpa Raj Sharma
Professor of Child Health
Institute of Medicine

Oedema:

accumulation excess
interstitial
fluid pressure
Increased
hydrostatic
Acute nephritic syndrome
Congestive cardiac failure

Decreased plasma oncotic pressure

Protein calorie malnutrition, Nephrotic syndrome; protein
loosing enteropathy

Increased capillary leakage

Allergy, sepsis, angiooedema.

Impaired venous flow

Vanacaval obstruction, hepatic vein obstruction

Impaired lymphatic flow

Congenital 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

Bilateral edema and
investigation
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?

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