Abdomen Flashcards
Normal liver span children? (3)
Neonate: 5 cm
Prepubescent boy: 8 cm
Prepubescent girl: 7 cm
Therafter: <15cm
Describe the abdominal examination (14)
- Introduce, orientate, expose, position, consent
- General appearance: acute/chronic, syndromic features, equipment
- vitals
- anthropometry
- limbs: jaccold, koilonychia, leukonychia, palmar erythema
- face: sclera icterus, aniridia, kaiser Fleischer rings, neuroblastoma, corneal arcus, angular stomatitis, glossitis, aphthous ulcers, dental carries, macroglossia, pigmentation/polyps
- inspection: distension, striae, kaput medusae, spider naevi, hernia, drains/tubes/access, scars
- Palpate: light (rigidity, tender, guarding, masses)
- deep palpation: liver edge, gallbladder, spleen, kidney, descending aorta, fluid thrill
- percussion: shifting dullness, liver, suprapubic
- auscultate: normal / tinkling / absent bowel sounds, renal artery and aortic bruits
- genital examination (penile abnormalities, descended testes, scrotal swelling, external Genitalia )
- rectal: perforate, skin tags (Chrons), prolapse, underwear staining)
- summarise and differential
What is and causes picture 10? (4)
Palmar erythema
- chronic liver disease
- polycythaemia (excessive rbc)
- Kawasaki disease (mucocutaneous lymph node syndrome)
- Thyrotoxicosis
Name 5 broad causes of oedema and how differentiate
With proteinuria
- renal disease
Without proteinuria
- increased vascular permeability (capillary leak)
- increased hydrostatic pressure
- decreased oncotic (colloid osmotic) pressure
- iatrogenic
Name 3 causes oedema with proteinuria
- Glomerulonephritis
- nephrotic syndrome
- acute kidney injury
Name 14 causes oedema without proteinuria
Increased vascular permeability (capillary leak)
- sepsis
- allergy: histamine mediated , anaphylaxis
- Premature
- post op, burns
- CCF, cor pulmonale
Increased hydrostatic pressure
- Ht and drugs
- heart failure
Decreased oncotic (colloid osmotic) pressure:
- nutritional: PEM: SAM (decreased intake protein)
- liver: cirrhosis (decreased production)
- git: protein losing enteropathy (increased loss)
- short bowel
- nephrotic syndrome (increased loss)
Iatrogenic
- drugs
- fluid overload: Na cl
What is and causes picture 11
Aniridia (partial/complete absence iris )
- wilms tumour
- WAGR syndrome
Name 5 causes abdominal distension
- Constipation
- Hirchsprung’s disease
- ascites
- organonegaly
- malignancy
Identify and name cause of picture 16
Caput medusae
- portal ht
Identify and name cause of picture 17 a
Spider naevi
Chronic liver disease
Name 2 causes generalised abdominal tenderness
- Mesenteric adenitis
- peritonitis
Describe the usual character of Wilm’s tumour (3)
- renal mass
- sometimes visible
- does not cross midline
Describe the usual character of abdominal neuroblastoma (3)
- Irregular firm
- may cross midline
- child very unwell
Most common site intussusception?
RUQ
Name 8 red flags constipation <1 year
- no meconium > 24 hours
- abdominal distention
- vomiting
- Failure to thrive
- bloody stools
- neurodevelopmental delay
- anal/sacral abnormalities
- any signs of other organic causes
Management difficult or rare ( < 1/3 days formula fed, < 1/7 breastfed) defecation (constipation) for at least 2 weeks in infants (10)
Check for red flags; if present transfer
child exclusively breastfed and 2 or more weeks old
→ assure, family education, probably normal, follow up
Formula feeding with or without solid food, or <2 weeks old.
→ functional constipation. Reassure,educate, verify proper formula preparation
> good response, maintenance therapy and close follow up
> partial or bad response
- reconsider diagnosis
- < 6 months: lactulose
- > 6 months: lactulose or peg
- Consider switching formula to pHf or eHf
- Rectal treatment for acute relief (glycerine suppository)
- If partial/bad response, transfer. If good, maintenance therapy and close follow up
Define troublesome regurgitation (3)
- 4 or more regurgitations per day
- 2 or more weeks
- age of onset 3 weeks - 6 months
Define infantile colic (5)
- 3 months age or less
- fussy, irritable or frequent crying
- 3 or more hours per day
- 3 or more days per week
- at least 1 week
How differentiate vomiting and regurgitation (3)
- Prodromal period with nausea, autonomic symptoms vs none
- Retching and muscle contraction vs none
- forceful expulsion stomach contents vs effortless passive reflex
Name 6 causes vomiting in first week of life
Common
- gastric irritation: ingestion blood, mucus
- under/over feeding
Other
- infections: sepsis, meningitis, NEC, UTI, oral thrush
- raised intracranial pressure: hydrocephalus, ich
- intestinal malformation and obstruction: intestinal atresia, hiatus hernia, malrotation, meconium ileus, volvulus
- Toxic and metabolic disorders
Name 6 causes vomiting in early infancy
Common
- gord
- feeding faults
- infection: URTI, oral thrush, gastroenteritis
Other
- Intestinal malformation and obstruction: hypertrophic pyloric stenosis, malrotation, volvulus
- intracranial pathology: hydrocephalus
- toxic and metabolic: inborn errors metabolism, uremia, drugs
Name 5 causes vomiting in late infancy
Common
- infections: gastro-enteritis, respiratory tract infection, UTI
Less common
- intestinal malformation and obstruction: intussusception, malrotation
- food intolerance: celiac, CMPA
- toxic and metabolic disorders: poisoning, drugs, uremia
- infections: meningitis, hepatitis
Name 7 causes vomiting in childhood
Common
- acute: gastro-enteritis, resp tract infection, food poisoning
- acute dietary indiscretion
Other
- Digestive tract disorders: peptic ulcers, appendicitis
- Raised ICP: ht, tumor, hydrocephalus
- infection: UTI, meningitis, encephalitis, hepatitis
- Toxic and metabolic: drugs, poisons, DM
- psychogenic / other: migraine, bulimia, cyclic vomiting syndrome
Significance of vomit containing undigested food?
Gastric outlet obstruction
Significance of vomit containing bile?
Intestinal obstruction
Significance of vomit containing blood,? (5)
- Esophagitis
- esophageal varices
- Gastritis
- peptic ulcer
- secondary swallowing nasopharyngeal blood
Significance increased bowel sounds? (2)
- Gastro-enteritis
- obstruction
Significance decreased bowel sounds?
Ileus
What derangement is seen on blood gas after vomiting
Hyponatremic hypochloremic metabolic alkalosis
Regurgitation vs gord?
Regurg = effortless, gastric contents via oesophagus to orophanynx
Gord = effortless passing of gastric contents to oesophagus, doesn’t have to present at mouth
Name 5 anatomical anti-reflux mechanisms
Extrinsic
- Crura
- angle of his
Intrinsic
- Lower oesophageal sphincter,
- increased tone 10 - 40 mm
- fluctuations “normal” reflux
Name 3 predispositions for gor
- Cerebral palsy
- Tubes in seriously ill patients
- sliding hiatus hernia
How does milk scan work and what is it indicated for?
Consists of 4 parts:
- oesophageal transit
- reflux
- gastric emptying
- pulmonary aspiration
Tests functioning of oesophagus: motility, emptying, esophagitis, aspiration
Non invasive, low radiation
Mix radio pharmaceutical with milk, then picked up on gamma camera
To diagnose gor
Management gor? (5)
- Feeding and post feeding position: prone, elevate
- change feeding pattern: frequent small feeds, thicken feeds with nestargel/gelatine
Gord:
- H2 receptor antagonists, PpI, antacid
- prokinetics: domperidone or metoclopromide before meals, erythromycin
- surgery: nissen fundoplication
Define functional constipation criteria (6)
Two or more in the last 1-2 months:
- 2 or less defecations in toilet each week
- at least 1 episode faecal incontinence each week
- history retentive posturing or excessive volitional stool retention
- history painful/hard bowel movements
- presence large faecal mass in rectum
- history large diameter stools that may obstruct toilet
Name 10 causes constipation in infants and toddlers
From history
- genetic predisposition
- Nutritional Change eg from breastfeeding to cow’s milk
- cow’s milk protein allergy
- lack fibre in diet
- stool withholding behaviour
- retentive posturing
- coeliac disease
From examination
- anal fissures
- anorectal malformations
- spina bifida
- Hirschprung’s
Name 9 causes constipation for school children and adolescents
From history
- inadequate food intake
- toilet training coerced
- attention deficit disorders
- developmental handicaps
- toilet phobia, school bathroom avoidance
- excessive anal interventions
From examination
- Anorexia nervosa
- depression
- slow transit constipation
Name 6 organic causes of constipation
- Neurogenic constipation: Hirchprung’s, spinal dysraphisms, tumor, cp, chronic intestinal pseudo-obstruction
- anal lesions: fissure, anterior location, stenosis, atresia
- endocrine and metabolic: hypothyroid, renal acidosis, di, hypercalcaemia, Cf
- neuromuscular disorders:muscular dystrophy
- abnormal abdominal musculature: prune belly syndrome, downs, gastroschisis
- drugs: methylphenidate, morphine, codeine, antacids, phenytoin
Definition and management infant dyschezia?
- Young healthy infants with 10 minutes straining and crying before successful defecation,
- complex defecation process is a learned practice: immature, failure to coordinate abdominal muscle contraction with pelvic floor relaxation
- reassure
Definition and management non retentive fecal incontinence
- Repeated socially inappropriate stool passage in absence of fecal retention or predisposing medical condition
- > 4 years old
- no evidence constipation
- educate family, vigorous toilet training, caution against intensive use stool softeners
Name 8 red flags of constipation in children by history
- Onset <12 months
- delayed passage meconium
- not stool with holding
- no soiling
- intermittent diarrhoea and explosive stools
- No response to conventional treatment
- bladder disease
- extra intestinal symptoms
Name 7 red flags of constipation in children by examination
- Failure to thrive
- empty rectal ampulla
- tight anal sphincter
- gushing of stool with rectal exam
- abnormal neurological exam
- pigmentary abnormalities
- heme positive stools
Constipation disimpaction and maintenance therapy? (5)
Disimpaction
- Oral: mineral oil 15 - 30 ml /year of age until 240ml or peg 1,5 g/kg/day
- phosphate enema
- glycerine suppository
Maintenance, At least 6 months
- Osmotic laxatives: lactose or polyethylene glycol 3350
- mineral oil: lubricant and hydroxy fatty acids
- stimulant laxatives
- behavioural modification: gastrocolic reflex,
- dietary measures: high fibre, good floods
Which supplement can prevent diarrhoea
Vitamin A
Which supplement can treat diarrhoea
Zinc
Name 2 common viral causes diarrhoea in children
- Rotavirus
- adenovirus
Name the 8 management principles for diarrhoea
- Hydration assessment
- fluid management
- metabolic and electrolyte disturbances
- feeding,
- anti emetic
- anti diarrhoeal
- antibiotics
- probiotics
Moderate vs severe dehydration? (3)
Moderate
- sunken eyes
- slow skin pinch <2 seconds
- drinks eagerly
- irritable/restless
Severe
- sunken eyes
- very slow skin pinch >2 seconds
- drinking poorly
Fluid management for moderate dehydration? (4)
ORS trial
- homemade: 1/2 teaspoon salt, 8 sugar, dissolved in 1 L
- 20ml / kg every hour for 4 hours or 5 ml / kg every 15 minutes
- give child more if want more.
- If vomit, wait 10 minutes and continue slowly
- insert NGT if baby refuse to drink/ use regular ORS,
- weigh patient at start without clothes and nappy
- weigh after 4 -6 hours and assess general condition, capillary refill, conciousness,, skin turgor, sunken eyes, passing urine, number and quality stools
worsen: decreased weight or more dehydrated → admit, iv fluids
Fluid management for failed ORS trial or severe dehydration?
(3)
1/2 Darrows dextrose iv at 5 ml /kg/h for 4 hours then reassess
Plus
ORS 20 ml/kg/hour using frequent sips as before
Plus
Oral feeds
Compensated vs decompensated shock? (3)
Compensated
- delayed capillary refill > 3 sec
- rapid weak pulses
- cool peripheries
Decompensated
- decreased loc
- decreased pulse volume
- decreased blood pressure
Poor urine output
Blood tests for acute hepatitis?
Elevated alt and AST
Blood tests for biliary atresia?
Elevated GGT and alp
Blood tests for liver failure?
Elevated INR, ammonia
Blood tests for hypersplenism?
Decreased hb and platelet count
What causes the most UTIs in young children?
E coli
Child with sudden onset severe headache should be investigated for?
Hypertension
Cause of macroscopic haematuria?
Bilharzia
Cause of microscopic haematuria?
Glomerulonephritis
Cause of proteinueria
Nephrotic syndrome
Approach to hepatomegaly with hyperbilirubinemia? (13)
High indirect/mixed bilirubin
- haemolytic anaemia
- CCF
- Toxins
- drugs
Higher direct bilirubin
- with splenomegaly
→ viral infections (torches)
→ Bacterial infections
→ Metabolic disease
- no splenomegaly: do abdominal sonar (consider also biliary scan, liver biopsy)
→ neonatal hepatitis
→ biliary atresia
→ choledochal cyst
→ drugs/toxins
→ TPN
→ tumour
Approach to hepatomegaly without hyperbilirubinemia? (10)
With splenomegaly: do abdominal sonar, consider Doppler
- vascular malformation /obstruction
- liver tumour
- Portal ht
- lipid/ other sd
- malaria/bilharzia
- metabolic disorder
No splenomegaly: abdominal sonar
- Tumour
- Malnutrition
- maternal dm
- Glycogen sd
Name 4 broad mechanisms hepatomegaly
- Increase number/size cells
- increase vascular space
- increase biliary space
- other: trauma, idiopathic benign
Name 9 causes hepatomegaly due to increase number/size of cells
Storage/accumulation disorders
- fat: malnutrition, obesity, dm, TPN, hepatotoxic drugs, pregnancy, metabolic disorders (reye syndrome, FAOD, galactosaemia)
- Lipids: gaucher, Niemann -pick
- glycogen: glycogen storage disease, TPN, infant of dm, beckwith - wiedemann
- misc: alpha 1 trypsin deficiency, Wilson’s disease, haemosiderosis/-chromatosis, vitamin A toxicity
Inflammation
- hepatocytes: hepatitis (infections, Tb treatment, anticonvulsants, analgesia, antibiotics, burns/radiation, hypothermia )
- kupffer cells: RES hyperplasia (septicaema, granulomatous disease, metastases)
- auto-immune: chronic active hepatitis, sclerosing cholangitis, sarcoidosis, SLE
Infiltration.
- Primary tumours: hepatoblastoma, hepatocellular carcinoma, haemangioma
- secondary: leukemia, lymphoma, nephroblastoma, neuroblastoma, histiocytosis
Erythroblastosis
- Rh incompatibility, extra-medullary haemopoiesis
Name 5 causes hepatomegaly due to increase vascular space
Intrahepatic obstruction
- veno-occlusive disease
Suprahepatic
- Ccf
- pericardial tamponade
- Pericarditis
- budd-chiari
Name 6 causes hepatomegaly due to increase vascular space
Intrahepatic obstruction
- biliary atresia/paucity
- Cirrhosis
- fibrosis
- abscess
- tumour
Extra hepatic
- biliary atresia
- space occupying lesions: pancreas head ca, choledochal cyst
How test synthetic liver function (3)
- Albumin
- pt
- ammonia
Define acute liver failure (4)
- severe impairment liver function with or without encephalopathy
- usually < 8 weeks
- no underlying chronic liver disease, hepatic based coagulopathy with
→ INR 1,5 or more with encephalopathy or
→ INR 2 or more without encephalopathy
Define chronic liver failure (4)
- Continuous inflammatory disease liver at least 3 months
- Progresses to cirrhosis, fibrosis, regenerative nodular formation
- distorted architecture with compression hepatic vasculature and biliary structure
- leads to PHT
Name 4 symptoms glomerulonephritis
- Edema
- haematuria
- polyuria
- nocturia
Name 4 characteristics nephrotic syndrome
- proteinuria: urine dipstick 3+ or more; spot protein: creatinine ratio > 0,2 g/mmol
- hypo albuminaemia < 25 g/l
- oedema
- hypercholesterolaemia
Name 7 indications for kidney biopsy in nephrotic syndrome
- Steroid resistant: not in remission after 8 weeks steroid therapy
- mixed nephritic nephrotic presentation
- persistent low serum complement C3
- family history kidney disease
- renal impairment and persistent ht
- secondary nephrotic syndrome
- < 2 years or > 6 years
Treatment primary, non-congenital nephrotic syndrome?
Prednisone
Name 8 clinical and pathophysiological differences between acute nephritis and nephrotic syndrome (urine, associated symptoms, bloods, cause, relapse)
- Haematuria vs nephrotic range proteinuria
- hypertension vs none
- Oligoanuria vs normal
- normal albumin vs low
- normal cholesterol vs high
- both edema
- 90% post infectious vs 90% idiopathic
- usually one attack vs relapses common
Name 2 differences in investigation between acute nephritis and nephrotic syndrome
- blood urea and creatinine high vs normal
- urine: RBC cast, haematuria, proteinuria vs hyaline cast, proteinuria
Approach to vomiting? (3)
Non-bilious vomiting
- Intestinal obstruction
- non-obstructive
Bilious vomiting
- intestinal obstruction
Name 3 causes non-bilious vomiting caused by intestinal obstruction
Obstruction above ampulla of vater
- pyloric stenosis
- upper duodenal stenosis
- annular pancreas
Name 7 causes non-obstructive non-bilious vomiting
- Physiological: overfeeding!, incorrectly placed ng tube
- infection: systemic! (Septicaemia, UTI, meningitis); local (gastroenteritis, NEC )
- CNS: raised intracranial pressure, intracranial bleed
- endocrine: congenital adrenal hyperplasia
- Drugs: neonatal abstinence syndrome! , aminophylline, caffeine
- Inborn errors of metabolism
- cow’s milk protein allergy
Name 5 causes bilious vomiting
Intestinal obstruction distal to ampulla of vater.
Anatomical obstruction
- small bowel stenosis or atresia: duodenal, jejenal, ileal
- large bowel stenosis or atresia
- imperforate anus
Functional obstruction
- Hirschprung’s disease
- Meconium ileus
Approach to proteinuria? (9)
Urine dipstick shows trace: repeat.
- negative/trace → repeat in 6 months - 1 year
- 1 + or more → see below
Urine dipstick 1 + or more: obtain first morning urine for protein: creatinine and urinalysis with microscopy
- protein: creatinine < 0,02 g/mmol and no microscopic haematuria
→ false positive
→ transient proteinuria eg fever, heavy exercise
→ postural/orthostatic proteinuria (benign)
- protein: creatinine > 0,2 g/mmol with or with out microscopic haematuria
→ nephrotic syndrome (proteinuria > 0,2 g/mmol )
→ ht
→ renal dysfunction eg glomerulonephritis
- Non-nephrotic range proteinuria 0,02 - 0,2 g/mmol, normal renal function, no ht
→ tubular proteinuria
→ tubular interstitial diseases
How investigate for glomerulorephritis and nephrotic syndrome when significant proteinuria > 0,2 g/mmol with or without microscopic haematuria? (6)
- History and physical including bp
- bloods: UCE, total cholesterol (nephrotic syndrome hyper), albumin (nephrotic syndrome <25 g/l), complements C3 C4 , IgA
- Ana, anti-ds DNA, ASOT, anti DNase B
- Viruses (secondary cause)
- Tb work up (secondary cause)
- Renal ultrasound
Management nephrotic syndrome and glomerulonephritis? (6)
- monitor balance, urine output strictly
- Assess hydration
- restrict salt intake
- treat underlying causes eg infections, systemic, SLE, HUS, drugs (ace inhibitors, NSAID), toxins (mercury)
- diuretics
- Pneumococcal booster
Investigations for tubular proteinuria and tubulointerstitial diseases? (4)
- Beta 2 microglobulin (marker for tubular proteinuria )
- toxins
- drug levels
- renal biopsy
Approach and causes macroscopic haematuria with positive dipstick? (11)
positive: blood, hb
- red blood cells
→ first exclude Acute nephritic syndrome. Then do urine protein:creatinine
→ nephrologic/glomerularRBC = dysmorphic RBC = Coke colour
> proteinuria and / or casts
: glomerulonephritis
: apsgn
: HSP /iga gn
: HUS
> inherited
: Alport syndrome (audiology)
: thin basement membrane disease
→ non nephrologic/non-glomerular/ urologic RBC = isomorphic RBC, no casts, no proteinuria = bright red/pink
> UTI /bilharzia (ELISA)
: hypercalciuria (Ca:creatinine ratio)
: urolithiasis (u/s; 24h urine ca, uric acid, oxalate, cysteine; AXR)
: UGT abnormalities
: tumours (CT abdo)
- No RBC
Cause macroscopic pseudo haematuria (negative dipstick) (3)
- colorants
- myoglobin
- medicines eg rifampicin,
Approach and causes microscopic haematuria > 5 RBCs / HPF? (8)
Examine and test for:
- proteinuria
- nephritic urinary sediment
- Ht
- abnormal renal function
- family history CKD
- family / personal history deafness
If any of above positive, consider
- glomerulonephritis
- AlpOrt syndrome
- tubulointerstitial nephritis
- Acute nephritic syndrome nb to rule out.
If negative, check parents and siblings for haematuria
- Positive and normal renal function : benign familial haematuria
- negative: do urine ca/creat ratio, renal ultrasound
→ elevated and renal stones: hypercalciuria
→ normal but abnormal ultrasound:
> investigate urologic haematuria
> structural renal disease
Name 5 indications renal biopsy if haematuria
- Persisent/recurrent
- abnormal renal function
- significant proteinuria
- decreased complement, positive Ana or anti-ds DNA
- family history kidney disease
Name 4 symptoms and 3 signs apsgn (acute post streptococcal glomerulonephritis)
Symptoms
- Acute onset macroscopic haematuria
- recent throat / skin infection (impetigo)
- decrease urine output
- headache/ convulsions
Signs
- Periorbital edema
- ht
- volume over load
Special investigations for apsgn (acute post streptococcal glomerulonephritis) (3)
Positive strep serology
- anti DNase B titre
- ASOS
- decreased serum complement C3
How choose appropriate cuff for bp measurement (2)
- bladder width at least 40% of arm circumference at point midway between olecranon and acromion
- length cover 80 - 100% of circumference of the arm
Define stage 1 ht for children aged 1-13
Whichever is lower
- 130 / 80 to 139/89
- more than or on 95th to 95th percentile + 12 mm Hg
Define stage 2 ht for children aged 1-13
Whichever lower
- on or more than 95th percentile + 12 mm Hg
- 140/90 or more
Define normal blood pressure for child aged 1-13
50th to 90th percentile
Define elevated blood pressure for children aged 1-13 (2)
Whichever lower
- on 90th percentile or more to < 95th or
- 120 / 80 mmHg to < 95th percentile
Define normal blood pressure for children aged 13 or more
<120 / < 80
Define elevated blood pressure for children aged 13 or more
120/<80 - 129/80
Define stage 1 ht for children aged 13 or more
130/80 - 139/89
Define stage 2 ht for children aged 13 or more
140/90 or more
Name 5 characteristics primary / essential ht
- At least 6 years
- Positive family history
- obese/overweight
- normal urinalysis
- isolated systolic ht
- diastolic ht may indicate secondary cause!
Name 4 causes secondary ht in newborns/ infants
- Parenchymal infarct: umbilical a catheter
- prematurity with chronic lung disease
- renal artery/vein thrombosis (rat/RVT)
- coarctation aorta
Name 4 causes ht in children aged 1-6 years
- Parenchyma scarring from UTI
- coarctation aorta
- renal artery stenosis
- Glomerular disease (ns, gn )
Name 4 causes ht in children aged 6-12 years
- Glomerular disease (acute glomerulonephritis = macroscopic haematuria, edema; chronic = poor growth, oedema, anaemia )
- Parenchymal scarring from UTI
- renal artery stenosis
- primary ht
- chronic renal failure
Name z causes ht in children aged 12 years and more
- Primary ht
- Glomerular diseases (chronic pyelonephritis = recurrent UTIs, enuresis )
- Chronic renal failure
Name 5 signs haemolytic uraemic syndrome
- Preceding bloody mucous diarrhoea!
- edema
- oliguria
- pallor
- ht
Name 5 causes renovascular ht
- Fibromuscular dysplasia
- syndromic: neurofibromatosis type 1, tuberous sclerosis, William’s syndrome
- vasculitic: takayasu (absent pulses, abdominal bruit), Polyarteritis nodosa
- extrinsic compression: neuroblastoma, Wilm tumour
- other: umbilical vein catheter
Symptoms UTI infants <3 months? (5)
- Fever!
- poor feeding!
- lethargy
- jaundice
- offensive urine
Symptoms UTI children 3 months -3 years? (5)
- Fever!
- vomiting!
- abdominal pain
- loin tenderness
- poor feeding
Symptoms UTI children > 3 years? (5)
- Frequency!
- fever!
- urgency
- dysuria
- dysfunctional voiding
Diagnosis UTI in children?
Dipstix:
- leucocytes and
- Nitrites
Urine MCs
- culture single uropathogen or
- Any culture from suprapubic or
- 50000 col/ml or more from catheter sample
Empirical antibiotics for UTI? (3)
- Ampicillin and amikacin or
- augmentin or
- cefepime
Don’t use! 3rd generation cephalosporin (can induce esbl K pneumonia ), amoxyl ( E. coli resistance) , bactrim ( E. coli resistance)
Name 4 indications kidney sonar in children with UTI
- All with febrile UTI
- atypical UTI
- Infants < 6 months
- older with recurrent UTI
Lab tests for AKI? (8)
- Osmolality
- UcE
- CMP
- LFT
- FBC
- clotting profile
- urinalysis, urine electrolytes, microscopy
- feNA
Name 10 broad causes AKI
Prerenal
- volume depletion
- decreased effective blood volume
- nephrotoxic drugs
Intrinsic
- vascular damage
- glomerular damage
- Atn
- acute interstitial nephritis
Postrenal
- bladder outlet obstruction
- ureteral obstruction
- pelvis /tubular
Name 10 prerenal causes AKI
Volume depletion
- Haemorrhage
- gi damage losses
- renal losses (drug induced, osmotic diuresis, diabetes insipidus)
- skin losses (burns)
- third space losses (hypoalbuminaemia)
Decreased effective blood volume
- pulmonary ht
- decreased cardiac output
- Sepsis
- liver failure
Nephrotoxic drugs
- NSAIDs
- ace I
- ARBs
Name 4 broad causes and 2 examples each intrinsic causes AKI
Vascular damage
- renal artery/ vein thrombosis
- vasculitis
- ht
- HUS
- Ttp
Glomerular damage
- nephrotic / nephritic syndrome
- glomerulonephritis
- autoimmune
ATN (acute tubular necrosis)
- ischaemic: hypotension, sepsis
- endogenous toxins: Eric acid, myoglobin
- exogenous toxins: nephrotoxic drugs, contrast
Acute interstitial nephritis
- drugs: NSAIDs, antibiotics
- infections
Name 7 postrenal causes AKI
Bladder outlet obstruction
- Posterior urethral valve
- urethral strictures
Ureteral obstruction
- nephrolithiasis
- Bilateral ureteric stenosis
Pelvis /tubular
- renal PUJO
- nephrolithiasis
- hydronephrosis
- VUR
Management AKI? (9)
- ABC
- catheter
- fluids balance
- weigh 6 hourly
- inotropes
- Antibiotics if septic
Assess hydration status:
- hypovolaemia → fluid resuscitation (nacl bolus 20 ml/kg up to 3x) , rehydrationand maintenance fluids, inotropes
- normovolemia (anuric) → fluid challenge bolus 20 mg / kg NaCl once, Lasix 2 mg/kg stat
- hyper volemia (anuric) → fluid restriction, sodabiC and lasix infusion, dialysis after 24 hours if still anuric
Differential and investigations hypertension with hypotension in lower limbs?
Coarctation aorta.
Do echo, Ct angio.
Differential and investigations hypertension with abnormal urinalysis?
Kidney / urinary tract disease (cakut / parenchyma)
Do UCE, aldosterone, renin, abdominal ultrasound
Differential and investigations hypertension with neurocutaneous lesions, seizures, abdominal mass? (2)
- Tuberous sclerosis
- neurofibromatosis
Do abdominal sonar, MRI brain/chest/ abdomen
Differential and investigations hypertension with abdominal bruit, poorly palpable pulses? (2)
- Takayasu disease
- renal artery stenosis
Do sonar Doppler, Ct AngiO
Differential and investigations hypertension with sweating, palpitations? (2)
- Hyperthyroid
- phaechromocytoma
Do TFT, urine VMA, urine catecholamines
