Pediatric emergency medicine trisk 0563 0563
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hepatomegaly should be evaluated for cardiac disease (see Chapter 86 Cardiac
Emergencies ).
In an edematous patient with a normal cardiac examination and no proteinuria,
further evaluation should include a search for hepatic and other gastrointestinal
diseases, as well as other forms of vasculitis. Patients with protein-losing
enteropathy, from milk protein allergy, celiac disease, giardiasis, primary
intestinal lymphangiectasia (Waldmann disease) or inflammatory bowel disease,
can present with generalized edema with few other physical examination
findings. These patients may have significant protein loss through the GI tract and
will often present with hypoalbuminemia. An initial laboratory evaluation,
including liver function tests, electrolytes, erythrocyte sedimentation rate, creactive protein and measurement of total protein and albumin, may reveal
abnormalities. However, further evaluation, including more specific blood, urine,
and stool testing, is often required to definitively diagnose the etiology of edema
in this subset of patients.
As noted throughout this chapter, generalized edema may be a sign of a serious
underlying disease. However, less serious conditions may be causative as well.
Certain medications (oral contraceptive pills, corticosteroids, lithium,
nonsteroidal anti-inflammatory agents, calcium channel blockers, and others) may
cause some patients to become edematous. This swelling usually resolves when
the drug is discontinued. Cyclical edema related to menstruation occurs
frequently in young women. The etiology of this edema is likely hormonally
mediated, although the exact mechanisms are unclear. Pregnancy may result in
edema as well.
In conclusion, it is important to remember that a complete history and physical
examination of the patient with either localized or generalized edema may be
enough to arrive at a likely diagnosis. It is of particular importance to focus on the
renal, cardiovascular, and gastrointestinal systems when searching for an etiology
for generalized edema. Commonly, patients presenting with symptoms of
localized edema will have an allergic, traumatic, or infectious etiology and, with
appropriate management, will have resolution of their symptoms without serious
sequelae.
Suggested Readings and Key References
Braamskamp MJ, Dolman KM, Tabbers MM. Clinical practice. Protein-losing
enteropathy in children. Eur J Pediatr 2010;169:1179–1185.
Downie ML, Gallibois C, Parekh RS, et al. Nephrotic syndrome in infants and
children: pathophysiology and management. Paediatr Int Child Health
