• Excessive losses
  • Renal loss of protein
  • Gastrointestinal
• Inadequate production
  • Liver disease
  • Malnutrition
• Local trauma
• Increased hydrostatic pressure
  • Congestive heart failure
  • Pericardial effusion
  • Venous obstruction
  • Lymphatic obstruction

• Trauma—pressure or sun damage
• Infection
• Allergy
• Lymphatic obstruction (less common)
• Bee stings or insect bites

• Lymphatic obstruction of legs or thoracic duct

• Hepatitis and liver failure
• Pericarditits

• Sodium poisoning
• Toxic effect on liver and/or heart (chemotherapy)
• Cirrhosis

• Obstruction of venous return from enlarged abdominal lymph nodes

• Sickle cell renal failure

• Protein losing enteropathy

• Nephrotic syndrome
• Renal failure
• Congestive heart failure
• Pericarditis
• Gastrointestinal protein loss
• Post-pericardiotomy or congenital heart surgery
• Endocrine—sodium retention, hypothyroidism
• Hepatobiliary diseases

Question: Is the edema localized or generalized?
Significance: See Differential Diagnosis section.

Question: Is the patient asymptomatic or in some distress specifically due to the edema?
Significance: Determines treatment urgency

Question: Is there evidence of cardiac, renal, or gastrointestinal disease?
Significance: These are the major causes of edema.

Question: Has waist size become larger? Are shoes difficult to put on?
Significance: Evidence of edema in body.

Question: What is the salt intake in diet?
Significance: In some patients, excess salt contributes to edema.

Question: Is there shortness of breath?
Significance: There may be ascites, which compresses the diaphragm or causes pleural effusions.

Question: Is there chronic diarrhea?
Significance: Seen in protein losing enteropathy or lymphatic obstruction.

Question: Have any urinalyses been performed in the past?
Significance: May help date the onset of the problem.

Question: History of allergies?
Significance: Allergies will commonly cause swelling around the eyes or face.

Finding: Dependent edema
Significance: Lumbosacral area pretibial pressure to detect edema scrotum/labia

Finding: Percussion of chest
Significance: Pleural effusion

Finding: Shifting dullness
Significance: Early signs of ascites

Finding: Soft ear cartilage
Significance: Common finding in nephrotic syndrome

Finding: Pitting edema
Significance: Pitting edema is seen in cases of protein loss and obstruction of venous/lymphatic flow while non-pitting edema is seen in salt poisoning.

Test: Dipstick urinalysis
Significance: If there is generalized edema with heavy proteinuria and hypoalbuminemia, the presumptive diagnosis is always nephrotic syndrome until proven otherwise.

Test: Serum albumin
Significance: If there is generalized edema with no proteinuria but hypoalbuminemia, consider cardiac, gastrointestinal, or hepatobiliary disease and direct additional studies to evaluate these three organ systems specifically. If there is either localized edema or generalized edema but a normal urinalysis and a normal serum albumin, consider other unusual causes for edema such as mechanical or lymphatic obstruction, certain endocrine disorders, or the effects of drugs or toxins.

Test: Stool albumin
Significance: Seen in protein losing enteropathy.

• Nephrotic edema with impaired glomerular function—pediatric nephrologist
• Protein-losing enteropathy or hepatobiliary disease—pediatric gastroenterologist
• Congestive heart failure secondary to occult cardiac disease—pediatric cardiologist
• Endocrine-mediated edema—pediatric endocrinologist
• Lymphatic or other mechanical obstructions—vascular surgeon or pediatric surgeon, if readily available

• If edema is massive, the patient may awaken with swollen eyelids. Place blocks under the head of the bed to keep head elevated.
• If there is scrotal edema, jockey shorts will help support scrotum and protect the skin from breaking down.

Q: At what level of serum albumin, will edema occur?
A: Edema is generally associated with serum albumin below 2.5 Gm/dL.

Q: Why does pericardial effusion cause edema?
A: The pericardial effusion is associated with decreased lymphatic flow and increased venous pressure.

Q: Is there a certain group of allergens that will cause edema?
A: No special allergens are associated with edema. The usual causes include such foods as peanuts and drugs such as penicilin.