Patient with oedema: What observations to make- Dr. YK Amdekar
M3 India Newsdesk Nov 29, 2021
The power of observation is amazing that doctors can guess which organ is responsible for causing oedema. Observation is the guide to rational practice, next to an analysis of detailed history. In this article, Dr. YK Amdekar throws light on clues for diagnosing the underlying diseases that present with oedema as a symptom.
Practice pearls
- Fluid collects in the subcutaneous tissue because of reduced osmotic pressure as a result of hypoalbuminemia or increased capillary pressure or permeability. It may also collect in serous cavities as in pleural effusion or ascites.
- Besides, the lymphatic or venous obstruction may lead to localised oedema evident in the affected part of the body. Physiologically, one may find mild puffiness around the eyes after prolonged sleep (venous stasis) and also due to severe cough. Mild oedema may be evident around the eyes- periorbital or over the dependent parts of the body- legs.
- Acute onset oedema is first observed around the eyes as happens in acute nephritis or nephrotic syndrome or angioneurotic oedema.
- Chronic oedema often presents on the legs. However once oedema increases in severity, it would be observed all over the body including abdominal distension (ascites) as is often the case in nephrotic syndrome.
Observe these relevant clues
Sick or not sick?: An acutely sick child suggests capillary leak syndrome following dengue viral infection or acute cardiac failure. A chronically sick child with oedema represents chronic diseases such as:
- Chronic liver disease (often without jaundice)
- Chronic nephritis
- Chronic cardiac dysfunction
- Protein malnutrition
The patient is comfortable in the case of nephrotic syndrome and also may be in localised oedema as in the case of lymphatic obstruction due to filariasis or venous obstruction as in inferior vena cava obstruction. Patients with angioneurotic oedema may also be apparently well.
Nutrition and growth: A child with chronic disease (malnutrition, liver, renal or cardiac) has poor nutrition and growth is also affected.
Severity and distribution of oedema: Generalised severe oedema is classic of nephrotic syndrome while acute glomerulonephritis presents with mild periorbital oedema (also seen in hypothyroidism), cardiac failure with oedema on legs, also in protein malnutrition and chronic liver disease besides oedema of legs with abdominal distension due to ascites.
Localised oedema of the leg or hand may be due to lymphatic or venous obstruction. Puffiness of face along with swelling of lips or other areas, around the face, looking inflamed and itchy may suggest angioedema.
Abdominal distension: It may be due to ascites as in nephrotic syndrome or chronic liver disease with portal hypertension or due to organomegaly in compensated chronic liver disease. Gaseous abdominal distension may be present in malnutrition but is waxing and waning.
Breathlessness: It may suggest cardiac disease but may also be due to severe abdominal distension due to ascites that hinders the inspiratory expansion of lungs or due to pleural effusion as in the case of capillary leak syndrome.
Jaundice: In the presence of oedema, it is a sign of liver disease. However, severe haemolytic anaemia with jaundice may present with oedema due to cardiac failure but not common (cardiac function is well compensated in chronic as well as acute haemolytic anaemia with jaundice).
Lethargy: It may be seen in hypothyroidism, protein malnutrition and also in capillary leak syndrome.
Importance of general observation
The following examples would reiterate the importance of general observation when a patient presents with oedema.
Case 1
A four-year-old child presented with acute onset of puffiness of eyelids. Observation revealed a comfortable child, good growth with normal development, periorbital oedema, oedema over both the legs and generalised abdominal distension, and no other findings.
Diagnosis: This child has severe generalised oedema with probable ascites and the diagnosis of nephrotic syndrome is obvious.
Case 2
An eight-year-old child presented with swelling around the eyes which was noticed when the child woke up in the morning. Observation revealed a mildly-sick child with periorbital oedema, no oedema in the legs, no abdominal distension, and no other findings.
Diagnosis: This is likely to be acute glomerulonephritis. It is not angioedema as there is no swelling noticed around the face as may often be the lips nor is there any itching or redness.
Case 3
A ten-year-old child presented with swelling on both legs. Observation revealed a sick, breathless child with oedema in both lower legs and feet, mild upper abdominal distension (probable hepatomegaly) and precordial pulsations.
Diagnosis: This is typically a cardiac disease with volume overload such as mitral regurgitation or ventricular septal defect. A child with acute glomerulonephritis may develop a cardiac failure due to hypertension but will not reveal precordial pulsations.
Case 4
An eight-year-old child presented with swelling in both legs. Observation revealed a chronically-sick child who was undernourished with oedema in both the legs, marked abdominal distension with flank fullness and stretched umbilicus, and jaundice.
Diagnosis: This suggests chronic liver disease with portal hypertension and liver cell failure (evident by ascites).
Case 5
A four-year-old child presented with puffiness of the face noticed by parents over a month. Observation revealed a comfortable child, normal development, mild puffiness of eyelids, subconjunctival haemorrhage, and no oedema anywhere else.
Diagnosis: This is likely to be due to severe cough (sub-conjunctional haemorrhage is a clue) and not due to renal disease. A child with chronic renal disease would look sick and undernourished.
Disclaimer- The views and opinions expressed in this article are those of the author's and do not necessarily reflect the official policy or position of M3 India.
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