Approach to child with generalized body swelling


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Approach to child with generalized body swelling

  1. 1. Edema is a clinical condition characterizedby an increase in interstitial fluid volume andtissue swelling that can be either localized orgeneralized. Severe generalized edema isknown as anasarca. More localized interstitialfluid collections include ascites and pleuraleffusions.
  2. 2. Generalized edema is typically chronic andprogressive It may result fromcardiac, renal, endocrine, or hepatic disordersas well as from severe burns, malnutrition, orthe effects of certain drugs and treatmentsCommon factors responsible for edema arehypoalbuminemia and excess sodiumingestion or retention, both of whichinfluence plasma osmotic pressure
  3. 3. 1.1.Skin disorders2.Allergic reaction3.Vasculitis4.Septicemia5.Vitamin E deficiency6.Hereditary angioedema1.Increased blood volume1.Fluid overload2.Cardiac failure3.Renal disease
  4. 4. 2. Increased venous pressure2. Constructive pericarditis3. Portal hypertension4. Venous thrombosis5. Tumor3. Increased lymph pressure1. Lymphedema2.1. Renal disease1. Glomerulonephritis2. Nephrotic syndrome3. Renal failure
  5. 5. 1.Acute and chronic liver disease1.Hepatitis2.Cirrhosis3.Portal hypertension2.Gastrointestinal disease1.Protein-losing enteropathy1.Cow milk protein sensitivity2.Cystic fibrosis3.Celiac disease4.Inflammatory bowel disease5.Intestinal lymphangiectasia3.Protein-calorie malnutrition4.Congenital albumin deficiency3.
  6. 6.  Medical history questions documenting swellingin detail may include the followingTime patterno When did you first notice this?o Is it present all the time?o Does it come and go?Qualityo How much swelling is there?o When you poke the area with a finger, does thedent remain?Locationo Is it overall or in a specific area (localized ?o If swelling is in a specific area, what is thatarea?
  7. 7. Otherso What seems to make the swelling better?o What seems to make the swelling worse?o Is the edema worse in the morning or at theend of the day?o Is it affected by position changes?o Is it accompanied by shortness of breath orpain in the arms or legs?o Find out how much weight the patient hasgainedo Has his urine output changed in quantity orquality?o What other symptoms are also present?
  8. 8.  Next, ask about previous burns orcardiac, renal, hepatic, endocrine, or GIdisorders. Ask the patient to describe hisdiet so you can determine whether hesuffers from protein malnutrition. Explorehis drug history, and note recent I.V.therapy.
  9. 9. Begin the physical examination bycomparing the patient’s arms and legs forsymmetrical edema. Also, noteecchymosis, rash and cyanosis. Assess theback, sacrum, and hips of the bedriddenpatient for dependent edema. Assess theabdomen for ascites and scrotum. Palpateperipheral pulses, noting whether hands andfeet feel cold, and measure the bloodpressure. Finally, perform a completecardiac, respiratory and abdominal
  10. 10.  Skin Disorders• Cellulitis, exfoliative dermatitis, andburns can cause increase in capillarypermeability and edema.• History and physical exam arediagnostic.
  11. 11.  Allergic Reaction• Release of histamine and other vasoactivemediators can produce localized or generalizededema.• Drugs, chemical exposure by inhalation, foods)especially milk, eggs, chocolate, nuts(, and beestings are common causes of allergic reactions.• Lips, eyelids, and face are frequentlyinvolved, and urticaria also may occur.• Wheezing, laryngospasm, and hypotensionmay be seen with anaphylactic reactions.• History and physical exam are usuallydiagnostic.
  12. 12.  VasculitisCommon causes of vasculitis causingedema include Kawasaki disease andcollagen vascular disease. SepticemiaSevere bacterial or rickettsial infectionscan cause increase in capillary permeabilityand edema.
  13. 13.  Vitamin E Deficiency• Uncommon since addition of vitamin Eto infant formulas.• Preterm infants 4–6 weeks of agewithout normal intake of vitamin E maydevelop generalized edema, hemolyticanemia, and thrombocytosis.• Serum concentration of vitamin E is low.
  14. 14.  AngioedemaRecurrent attacks ofacute, painless, nonpitting edema involvingthe skin and mucous membranes — especiallythose of the respiratorytract, face, neck, lips, larynx, hands, feet, genitalia, or viscera — may be the result of a foodor drug allergy or emotional stress; they mayalso be hereditary. Abdominalpain, nausea, vomiting, and diarrheaaccompany visceral edema; dyspnea andstridor accompany life-threatening laryngealedema. .• Diagnosis is confirmed by measurement of
  15. 15. Increased Hydrostatic Pressure Increased BloodVolume• Administration of excessive amounts ofsodium or fluid can produce volumeoverload and edema.• In cardiac failure, diminished renal bloodflow leads to decrease in glomerularfiltration rate (GFR) and edema.• Renal disease e.g., (glomerulonephritis)or any cause of renal failure also may leadto decrease in GFR and edema.
  16. 16. Severe, generalized pitting edema — occasionallyanasarca — may follow leg edema late in a patientwith heart failure. The edema may improve withexercise or elevation of the limbs and tends to beworse at the end of the day. Other classic latefindings include hemoptysis, cyanosis, markedhepatomegaly, clubbing, crackles, and a ventriculargallop. Typically, the patient also experiencestachypnea, palpitations, hypotension, weight gaindespite anorexia, nausea, slowed mentalresponse, diaphoresis, and pallor.Dyspnea, orthopnea, tachycardia, and fatiguesignal left-sided heart failure; jugular veindistention, enlarged liver, and peripheral edema
  17. 17.  IncreasedVenous Pressure• Increased venous pressure from deepvenous thrombosis, constrictivepericarditis, portal hypertension, orimpaired venous drainage from tumor mayproduce edema.• Deep venous thrombosis in thigh or calfproduces pain and swelling of leg distal tothrombus. U/S is usually diagnostic.
  18. 18. , generalizedpitting edema may be most prominent inthe arms and legs. It may be accompaniedby chestpain, dyspnea, orthopnea, nonproductivecough, pericardial friction rub, jugular veindistention, dysphagia, and fever
  19. 19.  Increased Lymph Pressure• Lymphedema is excessive accumulationof lymph in interstitial space and isprincipal cause of increased lymphpressure.• Can be congenital or acquired, sporadicor familial, and may appear at birth or inchildhood or adolescence.• Abnormal development or dysfunctionof lymphatic vessels, lymph nodeobstruction, and venous stasis arecommon mechanisms producinglymphedema.
  20. 20. • Common presentation isunilateral, painless edema of leg;however, pain may occur with massiveedema or cellulitis.• U/S and MRI are useful in detection oflymphatic malformations and obstructivelesions. Disorders with Proteinuria• Any renal disorder causing severeproteinuria may produce edema.Nephrotic syndrome and acuteglomerulonephritis are common examples.
  21. 21. is characterized bygeneralized pitting edema, the edema isinitially localized around the eyes. Withsevere cases, anasarca develops, increasingbody weight by up to 50%. Other commonsigns and symptoms areascites, anorexia, fatigue, malaise, depression, and pallor. UG confirms presence of proteinuria.
  22. 22. Generalized pitting edema occurs as a latesign of acute renal failure. With chronic renalfailure, edema is less likely to becomegeneralized; its severity depends on thedegree of fluid overload. Both forms of renalfailure cause oliguria, anorexia, nausea andvomiting, drowsiness, confusion, hypertension, dyspnea, crackles, dizziness, and pallor.
  23. 23.  Disorders without Proteinuria Acute and Chronic Liver Disease• Decrease in synthesis of albumin in liverproduces hypoalbuminemia.• Serum albumin of <2.5 g/dL causesdecrease in plasma oncotic pressure andedema.edema is a late sign ofcirrhosis, a chronic disease. Accompanyingsigns and symptoms include abdominalpain, anorexia, nausea andvomiting, hepatomegaly, ascites, jaundice, pruritus, bleeding tendencies, mustybreath, lethargy, mental changes, andasterixis.
  24. 24.  Gastrointestinal Disease• Loss of serum albumin in GI tract leads todecreased plasma oncotic pressure andedema.• Screening test for protein loss in stool ismeasurement of alpha1-antitrypsin in spotstool sample.
  25. 25.  Protein-Calorie Malnutrition• Severe protein-calorie malnutrition canproduce edema because of decrease inserum albumin.• Growth failure, decreased musclemass, diarrhea, hepatomegaly, anemia, pigment changes of hair andskin, fatigue, and apathy are otherfindings.• Edema resolves with adequate calorieand protein intake.
  26. 26.  Congenital Albumin Deficiency• Severe edema occurs with congenitalalbumin deficiency, which is rare.• Very low or undetectable serum albuminconcentration in absence of other causesof hypoalbuminemia confirms diagnosis. Hydrops Fetalis: Immune and NonimmuneHydrops fetalis is term used to describesevere generalized edema in fetus ornewborn, Because of use of anti-Dimmune globulin for Rh isoimmunization;most cases of Hydrops are nonimmunetype
  27. 27. • UG screens for proteinuria and renal disease.• In absence of significant proteinuria orcardiac failure, serum albumin should bemeasured. Fluid overload and allergic reactionsare common causes of edema with normalserum albumin. Decreased serum albuminwithout proteinuria suggests liverdisease, protein-losing enteropathy, or protein-caloric malnutrition.• Electrolytes, B.urea and S.creatinine• CXR, ECG, ECHO and others
  28. 28. • Jaundice, hepatomegaly, and abnormalliver function tests are manifestations of liverdisease.• Elevated fecal alpha1-antitrypsin levelindicates increased protein loss in stool andis seen with various causes of protein-losingenteropathy.• Protein-calorie malnutrition can beassessed by plotting weight and height ongrowth charts
  29. 29.  Treatments for edema are focused onreversing the underlying cause, if there is onepresent treat accordingly. Bed rest, dietary and lifestylemodifications, such as limiting sodiumchloride (salt) intakes, are recommended. many physicians implement diuretictherapies. Diuretics are used to decrease theamount of water in the body by increasingthe flow of urine.
  30. 30.  Avoid I.V. saline solution infusions and enteralfeedings may cause sodium and fluidoverload, resulting in generalizededema, especially in patients with cardiac orrenal disease Monitor intake and output and daily weight.Also monitor serum electrolyte levels —especially sodium and albumin. Renal failure in children commonly causesgeneralized edema. Monitor fluid balanceclosely. Remember that fever and diaphoresiscan lead to fluid loss, so promote fluid intake.