The oedematous patient

The oedematous patient
Oedema is a collection of fluid in the interstitial tissue. Commonly oedema will
collect in the legs as the fluid sinks to the lowest points in the body.
Other sites fluid will collect are the pleural cavity (pleural effusion), the
peritoneum (ascites) and the sacrum. Though fluid can accumulate anywhere in
the body.
To decide on the cause of the oedema and decide on treatment we must examine
the patient, take a good history and investigate appropriately.
Firstly look at the distribution of the oedema and does it pit
when you push on it?
The common causes of gross oedema of both legs and other sites are:
 Heart failure
 Renal failure
 Nephrotic syndrome
 Liver failure
 Protein malnutrition (not usually gross oedema)
The common cause of single leg oedema which pits:
 Deep vein thrombosis
The common causes of non-pitting single leg oedema:
 Lymphatic filariasis
 Radiotherapy
Second take a full history
This would be to suggest the likely cause.
Has the patient any chest pain? Has the patient been short of breath? Have they
got short of breath whilst walking? Do they wake up short of breath at night or
need to sleep sat up to avoid being short of breath? These symptoms suggest
heart failure.
Is the urine out put ok? Is there any blood in the urine? These symptoms suggest
renal failure.
Do they have a history of drinking excess alcohol? Have they had any jaundice?
These symptoms suggest liver failure.
Deep vein thrombosis presents with a single leg swelling and aching. Often after
or during pregnancy, surgery or spending a prolonged time in the same position
(long bus rides).
Provided by T. Whitfield 2012
Lymphatic filiariasis will occur gradually over time in endemic areas.
Investigations for oedema
Six tests should be done on bilateral oedematous patients:
 Liver function tests
 Abdominal ultrasound
 Cardiac ultrasound
 Urinalysis and dipstick
 Chest x-ray
U+E will highlight any renal failure; liver function tests will demonstrate any
liver damage and low albumin. Low albumin could be a result of liver damage or
chronic disease, albumin may also be lost through the kidney in nephrotic
Abdominal ultrasound will look at the kidneys and liver to demonstrate and
cirrhosis or fattiness of the liver or shrinkage of the kidneys in renal failure.
Cardiac ultrasound will look at the contractility of the heart and assess for heart
Urinalysis will demonstrate any protein lost in nephrotic syndrome (protein ++
on dipstick) and any blood or casts seen in glomerulonephritis. Nephrotic
syndrome is a triad of oedema, low albumin and proteinuria.
Chest x-ray will show any pulmonary oedema which is present in congestive
cardiac failure and severe renal failure and nephrotic syndrome.
Single oedematous legs should undergo ultrasound scanning to rule out any deep
vein thrombosis.
The history examination and investigations can be fit together to reach a
diagnosis and treatment plan
Provided by T. Whitfield 2012