CCP of Abdomen Flashcards
visceral pain
dull, poorly localized, usually felt in midline
transmitted via unmyelinated fibers
- stimuli resulting in tension, stretching and ischemia
- tissue congestion and inflammation lower threshold for stimuli
- transmitted via unmyelinated fibers
parietal pain
- noxious stimuli to parietal peritoneum, transmitted - via myelinated afferent fibers to specific dorsal root ganglia
- described as sharp, intense, localized
- occurs on same side and same dermatomal level as original pain
- could be due to ischemia, inflammation or stretching.
referred pain
similar to parietal pain, but felt in a remote area.
- due to shared central pathway for afferent neurons from different sites
hx: patient presents with periumbilical, poorly localized pain. Some diarrhea. tiny lymph nodes palpated cervically. Diffuse pain palpated in RLQ, no rebound and no HSM. 101F fever.
- acute appendicitis
- could also be pregnancy, gastroenteritis (Viral GI bug = “stomach flu”), pharyngitis (maybe didn’t fully take Ab for strep throat)
but. with CT see lymph nodes! it is Mesenteric Lymphadenitis
Mesenteric Lymphadenitis
- inflammation of mesenteric lymph nodes - easily missed and often mistaken for appendicitis.
- generally benign
- usually occurs to age <15 years old
- caused by viral/bacterial agents
hx: 4 day old, normal baby, milk came in today, stooling 2-3 x/day, still meconium stools, everything is noted to be normal except for mild jaundice of facial skin.
ddx: indirect (unconjugated) hyperbilirubinemia
physiologic jaundice due to breast-feeding
hyperbilirubinemia
- increased bilirubin load (hemolysis, nonhemolytic causes such as bruising polycythemia, exaggerated enterohepatic circulation)
- decreased bilirubin conjugation
- impaired bilirubin excretion
reasons for hemolysis
Rh incompatibility
ABO incompatibility
Minor antigens (D type…)
RBC cell membrane defects, enzyme defects
mediationcs
hemoglobinopathies (i.e. sickle cell disease)
Sepsis
nonhemolytic causes of increased bilirubin load
- Extravascular sources (Cephlohematoma, CNS hemorrhage, swallowed blood, bruising)
- Polycythemia (fetal-maternal transfusion, delayed cord clamping, twin-twin transfusion)
- exaggerated enterohepatic circulation (exaggerating the process of bilirubin being conjugated in liver, it is being unconjugated and is going back into the liver)
decreased bilirubin conjugation
phys. jaundice Gilbert's Crigler-Najjar Hypothyroidism Breast milk
tests for the baby?
fractionated bilirubin level
CBC
Retic count
Peripheral smear
- If it is less than 24 hours with jaundice presenting, then need a greater amount of tests taken to look out for Sepsis.
Jaundice
usually begins on the face and progresses caudally, more intense color suggests a higher bilirubin
- seen at about 5 mg/dL
regular physiologic jaundice hyperbilirubinemia in a neonate
bilirubin levels of 12 mg/dL by 3 days of life
- indicates physiologic immaturity, peaks at day 4-5, disappears at 2 weeks.
- predominantly unconjugated
two types of physiologic jaundice?
- breastfeeding jaundice: related to fact mom’s milk isn’t coming in right away, causing dehydration - low blood volume, results in higher concentration of bilirubin. This peaks a little bit later than typical physiologic.
- breast milk jaundice: appears by day 3-4,
pathologic jaundice
appearance of jaundice within 24 hours increased bilirubin beyond 5 mg/dL/day high peak levels jaundice beyond 2 weeks elevated conjugated bilirubin
HPI: 11.5 y/o girl, abdominal pain, vomiting, fever, 2 days history of abdominal pain. no blood in vomit. pain is periumbilical and hard to localize and rating 8/10. described as crampy and constant, feels better when lying in fetal position, pain in RLQ
negative obturator, psoas and rovsings
PMH: had strep 1 week prior
ROS: fatigue, appetite was poor, headache, fever, diarrhea since symptoms started, menstrual period 2 weeks ago.
DDX: appendicitis, pregnancy, pneumonia, gastroenteritis, pharyngitis
Labs:
CBC- elevated neutrophils
enlarged lymph nodes seen in the CT: mesenteric lymphadenitis
What could cause hemolysis?
increased indirect bilirubin due to hemolysis
Rh incompatibility ABO incompatibility Minor antigens (D type…) RBC cell membrane defects RBC enzyme defects Medications Hemoglobinopathies Sepsis
What are nonhemolytic causes of increased indirect bilirubin?
Extravascular sources: Cephlohematoma CNS hemorrhage Swallowed blood Bruising
Polycythemia:
Fetal-maternal transfusion
Delayed cord clamping
Twin-twin transfusion
Exaggerated enterohepatic circulation:
CF, ileal atresia, pyloric stenosis, breast milk jaundice, Hirschsprung’s
What can caused decreased bilirubin conjugation?
Physiologic jaundice Breast feeding Breast milk Gilbert’s Criglar-Najar Hypothyroidism
what is newborns bil production? why higher?
6-8 mg/day
- due to the shortened life span of RBC’s
- declining hematocrit
- immature liver uptake and conjugation of bilirubin
- increased enterohepatic circulation (increased intestinal reabsorption of bilirubin intestinal bacteria can deconjugate bilirubin allowing for reabsorption of bilirubin into the circulation)
What is heme degredation pathway?
- An RBC dies, a macrophage engulfs it and the heme is released
- Heme is reduced by hemeoxidase into the components iron and biliverdin
- Biliverdin is reduced by biliverdin reductase into free bilirubin
- Free (unconjugated) bilirubin is bound to albumin ( in plasma) and passes into he hepatocytes where it is released from the albumin and conjugated
- (UDPGT) conjugates bilirubin into an excretable form.
What can caused decreased bilirubin conjugation?
Physiologic jaundice Breast feeding Breast milk Gilbert’s Criglar-Najar Hypothyroidism
What does high reticulocyte count indicate?
increased hemolysis
What is heme degredation pathway?
- An RBC dies, a macrophage engulfs it and the heme is released
- Heme is reduced by hemeoxidase into the components iron and biliverdin
- Biliverdin is reduced by biliverdin reductase into free bilirubin
- Free (unconjugated) bilirubin is bound to albumin ( in plasma) and passes into he hepatocytes where it is released from the albumin and conjugated
- (UDPGT) conjugates bilirubin into an excretable form.
What is progression of jaundice?
- spreads from head to toe
- goes away from toe to head
What does high reticulocyte count indicate?
increased hemolysis
Physiologic jaundice? what is the timing like?
- due to physiologic immaturity
- appears between 24-72 hours of age
- peaks by 4-5 days in tern and 7th in preterm
- disappears by 10-14 days of life
- predominantly unconjugated levels usually not exceeding 12 mg/dl
Breastfeeding jaundice? timing?
- jaundice due to late breast milk coming in: results in mild infant dehydration and decrease in blood volume
- usually appears between 24-72 hours of age
- peaks by 5-15 days of life and disappears by third week of life
Breast milk jaundice? timing?
- caused by enzyme in breast milk inhibiting the UDPGT enzyme.
- appears by day 3-4: peaks by day 6-14.
- predominantly unconjugated bilirubin - will usually subside on its own.
- seen later and peaks later than breastfeeding jaundice
What is timing of pathologic jaundice?
- appears within 24 hours
- increase in serum bilirubin beyond 5 mg/dl/day
- presence of clinical jaundice beyond 2 weeks
- elevated conjugated bilirubin
What are signs of kernicterus?
- early signs: lethargy, poor feeding, hypotonia 3-4 days after birth
- late signs: irritability, seizures, apnea, hypertonia, fever a week after birth
- kernicterus results in chronic encephalopathy, cerebral palsy, hearing loss, mild MR
