GI Flashcards
mesenteric adenitis mx
close monitoring and repeated evaluation in hospital Admit!! symptoms should remain static or improve (unlike appendicitis which would worsen)
Gastro oesophageal reflux investigations
usually clinical diagnosis if severe: 24 hour oesophageal pH Study (pH <4 >4h indicative of reflux) Barium swallow to exclude anatomical abnormalities endoscopy w oesophageal biopsies can identify oesophagitis
Meckel diverticulum w persistent rectal bleeding Mx
Laparotomy + surgical resection
idiopathic constipation ix?
abdo exam - assess for faecal impaction inspection of perianal area Lower limb neuro exam- exclude neuro causes of constipation
mesenteric adenitis presentation
mimics appendicitis High fever +/- cervical lymphadenopathy malaise central abdo pain
risk factors for kernicterus?
serum bilirubin level greater than 340 micromol/litre in babies with a gestational age of 37 weeks or more a rapidly rising bilirubin level of >8.5 μmol/litre per hour clinical features of acute bilirubin encephalopathy
neonatal jaundice essential things to ask?
pale stools / dark urine within 24 h of life? how long? breastfeeding?
GORD surgical mx
Nissens fundoplication
GO reflux common when?
horizontal posture, mainly fluid diet
hirschsprungs disease- absence of ganglion cells from?
myenteric and submucosal plexuses FULL thickness rectal biopsy for diagnosis
where does intussusception most commonly occur?
ileocaecal junction
Assess dehydration best measure
weigh child (% weight loss)
Gastroenteritis Ix
Stool culture Assess level of dehydration FBC, WCC, CRP Blood cultures
advice to parents re disimpaction tx?
can initially increase soiling and abdo pain
neonatal jaundice ix?
examine- sclera and skin bilirubin level measurement - total and conj/ unconj plot bilirubin level on threshold graph to see if need for phototx/ transfusion if indicated- FBC, blood group (mother + baby), direct anti globulin test, blood film, blood G6PD level, blood cultures, urine cultures, CSF
GORD conservative mx
mild: parental assurance adding thickening agents to feeds Position baby upright after feeds
assoc w central abdo pain and URTI.
mesenteric adenitis. conservative mx +/- administration of abx
cows milk protein intolerance ix
skin prick test patch test Total igE Specific ig E (RAST) for cows milk protein
Intussusception Mx
Immediate IV fluid resuscitation IV Abx before surgery NG tube to take out contents in stomach and release air that has built up 1st line: reduction by rectal air insufflation by radiologist Done under supervision of paediatric surgeon 25% fail or perforate 2nd line: surgery
Red flag findings that suggest underlying disorder? Not just idiopathic constipation
reported from birth/ first few wks of life meconium delay (>48h) abdo distension w vomiting abnormal appearance/ patency of anus abnormal neuromuscular signs Refer urgently to secondary care amber flag - FTT
Acute abdo pain- always check on examination
testes, hernial orifices, hip joints
Acute appendicitis Ix
None helpful USS investigation of choice - thickened appendix, may show abscess, perforation or appendix mass
E.g. of stimulant laxatives?
Senna sodium picosulfate Bisacodyl
drawing up of legs, redcurrant jelly stools, episodes of severe colicky pain, bile stained vomit, sausage-shaped mass on abdomen
Intussusception
what is the rate of success of rectal air insufflation?
75%
Rovsing sign pain felt in the RLQ when palpating LLQ
Acute appendicitis
Coeliac Mx
Lifelong gluten free diet Refer on to dietician, MDT Provide leaflets and support group contacts
1st line mx for intussusception
rectal air insufflation AFTER fluid resus
Technetium scan (only shows uptake by ectopic gastric mucosa)
Meckel diverticulum
Pyloric stenosis more common in which gender?
Males
what is the metabolic abnormality with pyloric stenosis
hypochloraemic hypokalaemic metabolic alkalosis
E.g. of osmotic laxatives?
Lactulose Macrogol
Coeliac Ix
IgA TTG, anti endomysial antibodies, total serum IgA Diagnosis on biopsy
Blood in stool gastroenteritis sugests?
bacterial gastroenteritis
signs of dehydration
sunken fontanelle, dry mucus membranes, prolonged CRT, pale/ mottled skin, decreased LOC, cold extremities, weak peripheral pulses
what are the VACTERL associations?
vertebral defects, anal atresia, cardiac defects, tracheo-esophageal fistula, renal anomalies, and limb abnormalities.
Gastro-oesophageal reflux
V common in infancy due to functional immaturity of Lower oesophageal sphincter will grow out of it (nearly all resolve by 12 months)
most common bacterial gastroenteritis
campylobacter jejuni
if neonatal jaundice <24h of life IX?
direct Antiglobulin Coombs test Blood group (baby + mother) FBC Blood film G6PD level Obs and Septic screen if unwell
Hirschsprungs findings on examination
DRE- get senior to do this may reveal narrowed segment. withdrawal of finger releases liquid stool and flatus Diagnosis- Biopsy - demonstrates absence of ganglion cells
idiopathic constipation mx
1st line: disimpaction regimen (osmotic laxative movicol - ie. polyethylene glycol + electrolytes) using escalating dose regimen e.g. start w 2 sachets on 1st day then 4 daily for 2 days, then 6 daily for 2 days then 8 daily (for children 1- 5 yrs : max 8) for children 5-12 yrs : max 12 2nd line: stimulant laxative e.g. Senna if no improvement after 2 wks continue for 6 months til normal stools. then gradually reduce dose over period of months. + Lifestyle Advice
GORD medical mx
medication to decrease acid production and increase gastric motility H2 receptor antagonists (ranitidine) PPI (omeprazole/ Gaviscon) Metoclopramide/ domperidone
GORD complications
FTT from severe vomiting Oesphagitis - haematemesis, IDA Recurrent pulmonary aspiration - recurrent pneumonia, cough, apnoea Dystonic neck posturing (Sandifer syndrome)
Coeliac Biopsy findings
villous atrophy crypt hyperplasia increased intraepithelial lymphocytes
Pyloric stenosis IX
Test feed - peristalsis observed + palpate pyloric mass USS helpful if diagnosis in doubt
Clinical features of pyloric stenosis
Projectile vomiting hunger after vomiting dehydration weight loss
Cows milk protein allergy
urticaria angioedema Skin prick test- strongly positive to cows milk
During phototherapy?
give eye protection / tinted headboxes short breaks of up to 30 min for breast feeding, cuddles, nappy changing
Pyloric stenosis Mx
Initially: correct fluid and electrolyte imbalances (IV fluids 0.45% saline 5% dextrose and K+ supplements) Surgery (pyloromyotomy) Post op - can be fed within 6h
Buttock wasting
Coeliac disease
What is meckel diverticulum?
ileal remnant which contains ectopic gastric mucosa or pancreatic tissue. Causes GI bleeding, obstruction or inflammation
If intensified phototherapy what happens?
do not interrupt for feeding, administer IV/ enteral feeds
Target sign on USS
Intussusception
gastroenteritis essential hx qns?
travel abroad? food? contact w unwell ppl?
Most common cause of gastroenteritis in children
rotavirus
Dermatitis herpetiformis (chronic blistering skin condition)
Coeliac disease
What is mesenteric adenitis?
inflammation of mesenteric LNs during viral infection e.g. tonsillitis/ otitis media
Malrotation w volvulus IX
urgent upper GI contrast to assess intestinal rotation If vascular compromise of gut present -> urgent laparotomy AXR- dilated stomach and duodenum (double bubble)
What is pyloric stenosis?
hypertrophy of the pyloric muscle causing gastric outlet obstruction
Food allergy IX
Skin prick tests RAST test (measuring specific IgE in blood) Gold Std- exclusion of relevant food under dieticians supervision followed by food challenge
idiopathic constipation lifestyle advice
increased fluid intake and ensure balanced diet (e.g. increased fibre content, fruits and veggies) give written info + refer to dietician if needed
high caecum at midline. features in exomphalos, congenital diaphragmatic hernia, intrinsic duodenal atresia. may be complicated by development of volvulus -infant w bile stained vomiting.
malrotation. diagnosis by upper GI contrast study and USS. Tx by laparotomy. if volvulus present, Ladd’s procedure for detorsion of the bowel.
Coeliac signs
FTT abnormal stools buttock wasting abdo distension Skin: dermatitis herpetiformis
Hirschsprungs tx?
Treatment is with rectal washouts initially, thereafter an anorectal pull thorugh procedure
Toddler diarrhoea Mx
Normal, most grow out of the symptoms by 5 yrs old Some symptoms can be relieved by ensuring child eats adequate fat and fibre. Reduce excessive consumption of fresh fruit juice
Intussusception Ix
Abdo Xray - distended small bowel 1st line USS - characteristic target sign
Cows milk protein intolerance
FTT loose stools skin prick will be -ve Mx: elimination of cows milk. mom avoids cows milk. extensive hydrolysed formula milk if formula fed
Abdo pain causes (non GI)?
Lower lobe pneumonia DKA Primary peritonitis UTI, including acute pyelonephritis
Food allergy mx
avoidance of food w help of paediatric dietician to avoid nutritional deficiencies teach parents to manage allergic attack. self managment plans and training drug mx with antihistamines if sever- IM adrenaline
what is intussusception?
invagination of proximal bowel segment into distal segment.
premature infant. abdo distension and passage of bloody stools. Xray showing pneumatosis intestinalis and evidence of free air.
necrotizing enterocolitis. tx with total gut rest and TPN, babies w perforation require laparotomy.
What is hirschsprungs?
absence of ganglionic cells from myenteric and submucosal plexuses of part of the large bowel
Neonatal jaundice tx?
encourage mother to breastfeed frequent;y seek senior advice if conjugate br level high as this may indicate serious liver disease if <24 h w jaundice - urgest medical rv to exclude pathological causes
choking and cyanotic spells following aspiration. assoc w polyhydramnios.
oesophageal atresia/ tracheo-oesophageal fistula VACTERL associations: vertebral defects, anal atresia, cardiac defects, tracheo-esophageal fistula, renal anomalies, and limb abnormalities.
Intussusception complications
necrosis of bowel, bleeding, fluid loss, perforation, peritonitis
Ix for pyloric stenosis
Test feed - peristalsis from left to right. may feel pyloric mass, which is the size of a 2cm olive. (felt in the R hypochondriac by careful palpation) + abdo USS
Tx of pyloric stenosis
if hypoK, hypoCl, alkalosis: treat the dehydration, acid base and electrolyte abnormalities. w IV fluids (0.9% saline w 5% dextrose and added KCl). Feeds should then be stopped, ng tube inserted and stomach emptied. Definitive operation is Ramstedt’s pyloromyotomy.
peak age for pyloric stenosi
6 wks
Ddx blood in stools
GI Infection, anal fissure, intussusception, cows milk protein allergy, meckels’ diverticulum, IBD, polyp, clotting abnormality, sexual abuse.
Mx of intussusception
IV fluid resus + IV abx e.g. penicillin, gentamicin and metronidazole. NG tube inserted and stomach emptied. Reduction by air insufflation by radiologist. may need surgery if perforation.
Crohn’s disease Ix
examine the anus, as skin tags, abscess, fistula present in half of the patients. Clubbing may also be present. Usually IDA - due to blood loss, insufficient dietary intake, inadequate iron absorption. WCC, Pl often raised. and CRP/ ESR elevated. Albumin often low due to malabsorption and protein loss in the stool. ALL pts require an expert ophthalmic examination, which may reveal episcleritis, or uveitis. ***a colonoscopy with colonic and terminal ileal biopsies should be performed. Upper GI endoscopy should also be performed.
Extraintestinal manifestations of crohns
remember to ask! about arthritis. erythema nodosum, pyoderma gangrenous. eye problems?
Ddx of chronic diarrhoea (>14 days)
Infection: bacterial, giardiasis, post-gastroenteritis diarrhoea. Malabsorption: lactose intolerance, cows milk protein intolerance, CF, coeliac. GI disorders: Crohns, UC.
Mx of Crohns
to achieve clinical remission and promote growth w adequate nutrition. Refer to MDT- GI paediatrician, dietician, specialist nurse. Support group. Mild disease- 5-ASA e.g. sulfasalazine, antibiotics such as metronidazole and nutritional therapy. If no response, corticosteroids and immunosuppressive therapy w 6-mercaptopurine or methotrexate can be tried. Surgery is considered where medical tx fails.
1st line mx of crohns
sulfasalazine, antibiotics such as metronidazole and nutritional therapy.
2nd line mx of Crohns if not responsive to first line?
corticosteroids and immunosuppressive therapy e.g. methotrexate, 6-mercaptopurine.
If medical tx fails, what mx in Crohns?
Surgery. Indications include intractable disease w growth failure, obstruction due to strictures or adhesions, abscess drainage, fistula, intractable haemorrhage and perforation.
What are the key investigations for Crohns disease?
Colonoscopy and Upper GI endoscopy.
What are the key examinations for Crohns?
examining the perianal area.
how would you calculate fluid replacements for a child w viral gastroenteritis?
Fluid requirement = maintenance + correction of deficit + replacement of ongoing losses
if child is clinically dehydrated w viral gastroenteritis? (mild to moderate e.g. 5-10%)
rehydration usually possibly with enteral rehydration (oral or NG). with appropriate oral rehydration solution. - 50 ml/kg ORS solution for rehydration + Maintenance over a 4 hour period. Continue to breastfeed on top of the ORS solution. If child is unable to drink or vomits persistently-> trial of NG tube. If neither oral/ nasogastric volume replacement is tolerated, then give IV.
Dehydration with viral gastroenteritis. why is enteral preferred over IV?
IV rehydration associated w slower recovery and longer hospital stay. But it is necessary if child needs acute replacement for shock or cant tolerate enteral fluids.
Diagnosing gastroenteritis?
suspect gastroenteritis if there is a sudden change to loose or watery stools or onset of vomiting. Recent contact w someone w acute d+v? recent travel?
Advice for parent of child w gastroenteritis?
safety net on red flag symtpoms (e.g. if clincally dehydrated/ shocked), how to get immediate help and arrange follow up if necessary. most can be managed safely at home, diarrhoea usually lasts for 5-7 days and stops within 2 wks, and vomiting ususally lasts for 1-2 days and stops within 3 days.
Advice for a child w gastroenteritis but not clinically dehydrated
continue usual feeds. encourage child to drink plenty of fluids, discourage carbonated/ fruit juices.
Advice for child w gastroenteritis not clinically dehydrated yet, but at risk of dehydration.
supplement usual feeds and fluids with ORS.
Advice for parent of child w gastroenteritis w clinical dehydration
rehydration possible w ORS. encourage ORS in small amounts, frequently. seek advice if child refuses to drink of vomits persistently. Continue breastfeeding alongside the ORS. dont give other oral fluids unless advised. also dont give any solid foods.
Advice for parent of child w gastroenteritis. To prevent the spread.
wash hands with soap and careful drying. wash hands after going to the toilet, changing the nappies, before preparing, serving or eating food. Towels used by infected children should not be shared. Children should stay home from school til 48 h after last episode of diarrhoea and vomiting. Children should not swim in swimming pools for 2 wks after the last episode of diarrhoea.
Ix of child w suspected viral gastroenteritis
measure plasma Na, K, Urea, Cr and glucose concentrations. Measure venous blood acid-base status and Cl- concentration if shock is suspected or confirmed.
Examining a child w suspected viral gastroenteritis
assess for symptoms and signs of dehydration. e.g sunken eyes, fontanelle, dry mucous membranes, reduced skin turgor. Tachypnoea, tachycardia. If clinically shocked: pale mottled skin, cold extremities, weak peripheral pulses, prolonged cap refill time, hypotension. Suspect hyperNa dehydration if jittery movements, increased muscle tone, hyperreflexia, convulsions, drowsiness or coma.
what is the most common cause of gastroenteritis in infants and young children?
rotavirus.
How do you assess % dehydration?
if possible, use expected weight and current weight. if not, estimate % dehydration on clinical signs e.g. skin turgor, fontanelle etc.
If child w gastroenteritis w clinical shock, mx?
Give rapid IV bolus of 20ml/kg 0.9% NaCl.
If child w viral gastroenteritis has hypernatraemic dehydration?
obtain urgent advice on fluid management. use isotonic solution (0.9% NaCl or 5% glucose) for fluid deficit replacement and maintenance. Replace fluid deficit slowly (typically over 48h) to prevent cerebral oedema and seizures.
IX of acute appendicitis
Obs. FBC, WCC, CRP, U+Es, LFTs. Urine dip - may show sterile pyuria (leucocytes +ve may be caused by inflamed appendix irritating the ureter of bladder). should have low grade fever, high WCC, neutrophilia. USS abdomen. - can confirm the diagnosis but can also miss it, particularly if subject is obese or appendix is retrocaecal. CT scan- better sensitivity and specificity but involves a high radiation dose. *still a clinical diagnosis in practice as there is no perfect test for appendicitis.
Diagnosis of appendicitis?
*still a clinical diagnosis in practice as there is no perfect test for appendicitis.
DDx of sudden onset lower quadrant pain
appendicitis, mesenteric adenitis, UTI, gastroenteritis, crohns disease, mittelschmerz, ovarian cyst/ torsion, ectopic pregnancy, PID.
Mx of appendicitis
NBM, admitted to hospital for surgical opinion. if diagnosis is clear clinically, delaying surgery to allow imaging can result in perforation of the appendix and subsequent sepsis.
Ddx of chronic abdo pain
psychosomatic, UTIs, constipation, gastrooesophageal reflux, coeliac disease, IBD, cows milk intolerance, abdominal migraine, peptic ulcer, sexual or other abuse.
Psychosomatic recurrent abdo pain Explanation
focuses on explanation and reassurance. Reassure both child and family that there is no sinister cause. *crucial as the symptoms are very real and there is understandable anxiety. Helpful to liken the condition to tension headaches in adults- common and unpleasant but not serious. Symptoms are not fabricated. children rarely fabricate symptoms and if they do, abuse should be considered.
Recurrent abdo pain presentation
other well and healthy child. with no FTT. classic time for RAP is in the morning before school. the child may be recognised as a ‘worrier’. Absence of other symptoms such as diarrhoea or any association with eating.
Mx of recurrent abdo pain- psychosomatisation
explanation and reassurance. referral to a psychologist or psychiatrist is sometimes necessary.
examination in suspected constipation?
Abdo exam- may feel hard faecal mass in the abdomen. Examine perianal area - for any abnormality, skin tags, fissures. Rectal exam. *anal fissures are common w severe constipation, and is the likely cause of fresh red bleeding.
Causes of constipation
dietary, dehydration, anal fissure/ stenosis, Hirschsprung’s disease, intestinal obstruction, spinal cord lesion, CF, drugs, hypothyroidism, sexual abuse.
Ix in simple functional constipation?
no investigations necessary. usually clinical assessment suffices to make the diagnosis. if child refuses the rectal exam, or if any doubt about the diagnosis, can do abdo xray to assess degree of faecal loading.
Mx of simple constipation
dietary advice, encourage a good fluid intake, a daily high fibre cereal and fruit and vegetables. Star charts may help. Initial disimpaction should involve movicol- an osmotic laxative or (lactulose). if ineffective, then add a stimulant laxative such as Senna. if there is pain secondary to anal tissue, can give local lidocaine ointment.
if oral disimpaction treatment fails, what can you use?
glycerine suppositories or phosphate enemas to help disimpact hard stool in the rectum. in very severe cases, a bowel cleansing solution like Klean-Prep may be needed. in extreme cases- manual evacuation may need to be performed in theatre.
Definition of failure to thrive?
often defined as a weight, or rate of weight gain, that is significantly below what is normal for a child of that age and sex. some define it as weight that has fallen two centile lines on the standard growth charts.
Causes of FTT?
inadequate intake of food: poor feeding, mechanical problem such as cleft palate or bulbar palsy. Malabsorption: Coeliac, Cystic fibrosis. Excessive loss of nutrients: vomiting due to GORD, protein losing enteropathy e.g. cows milk protein intolerance. Increased nutrient requirement: congestive cardiac failure, chronic infection e.g. HIV. Dysmorphic syndromes, inborn errors of metabolism. psychosocial: child abuse and neglect, emotional and social deprivation.
Definitive diagnosis of coeliac
endoscopy w jejunal biopsy.
Ix of prolonged jaundice
Total serum bilirubin, conjugated br, unconjugate bilirubin. FBC- Hb, reticulocytes, WCC, Pl. Blood group. TFTs. Urine dip - presence of bilirubin but absence of urobilinogen
When does neonatal jaundice require investigation?
early onset (<24h-36h after birth), severe jaundice, prolonged >14 days.
Why do you get pale stools and dark urine with excess conjugated br?
pale stool because bile pigments not excreted into the gut. dark urine because accumulation of water-soluble conjugated br in the urine. -> indicates bile duct obstruction.
Biliary atresia
progressive destruction of extra hepatic bile ducts occurs, with obstruction of bile flow and subsequently, rapid progression of damage within the liver and cirrhosis.
Ix of biliary atresia
Abdo USS and then liver biopsy to confirm.
Mx of biliary atresia
Kasai procedure (portoenterostomy) ideally before 60 days of age. Needs to be discussed immediately w local specialist centre.
Ddx of abdo pain and jauncie
pre-hepatic: abdo pain is uncommon. possible causes: malaria, sickle cell crisis. Hepatic: often pale stools and dark urine. acute hepatitis due to drugs, viruses and toxins. Posthepatic: pale stools and dark urine. Bile duct stones, cholecystitis, cholangitis.
In an older pt with jaundice, what questions to ask?
differentiate between pre hepatic, hepatic and post hepatic causes. Pale urine dark stools? itching? Abdo pain? drugs? infections? fever? any blood problems? (e.g. G6PD) Full travel hx, immunisations and drug history.
Presentation of pre hepatic vs post hepatic jaundice
if there is increased unconjugated bilirubin production from increased RBC destruction e.g. haemolysis, then there will be jaundice with normally pigmented stool and urine. If there is obstruction to bile excretion (e.g. common bile duct stone), conjugated bilirubin accumulates (causing itching), overflows into urine (dark) and does not reach the gut (pale stools.) Hepatic causes produce a combination of these patterns.
Ix of jaundice in older children
Urine dipstick to confirm bilirubinuria. LFTs. Serum amylase. Serum bilirubin- unconjugated and conjugated fractions. Serology for viral fractions e.g. Hep A IgM. Clotting profile. Abdo USS.
Mx of hepatitis A
flu like prodromal phase, w nausea and anorexia, followed by icteric phase where there may be tender hepatomegaly. Usually children make complete recovery. Hep A can be prevented by immunisation and good hygiene practices, as it is transmitted by the faeco-oral route.
Red flags of vomiting
bile stained: intestinal obstruction. haematemesis. projectile vomiting. abdo pain/ tenderness. abdo distension. blood in stool. severe dehydration/ shock. FTT.
which groups of children are most at risk of inguinal hernia?
preterm infant- esp those w v low birth weight, boys, infants with chronic lung disease (coughing), children w conditions assoc w increased abdo pressure, children w developmental urogenital anomalies, infants w disorders of sexual differentiation e.g. female phenotypically with inguinal hernias.
Tx of inguinal hernia
Surgical. early repair reduces the risk of sac becoming irreducible (incarceration) or hernia becoming strangulated (ischaemic/ gangrenous) w consequent testicular atrophy.
commonest cause of swelling in groin?
lymph node - small and mobile and lie more inferior and lateral than an inguinal hernia. An USS can help.
Cause of inguinal hernia in infant?
patent processus vaginalis. This accompanies the testis as it exits the abdomen and descends into the scrotum and is obliterated by, or soon after, birth. Failure of obliteration can occur anywhere along its length, explaining the range of presentations.
hydrocoele?
swelling of testis.
a hydrocoele is fluid within the tunica vaginalis.
hydrocoeles transilluminate.
they usually resolve spontaneously by the age of 12 months and if not, should be referred to a surgeon.
Ix of acute pyelonephritis >3 yrs
Urine Dip- Leucocytes, nitrites, blood. and send for MCS
FBC- WCC, CRP
Blood cultures
U+Es
creatinine
symtoms of UTI in an infant?
fever, vomiting, lethargy, irritability, poor feeding
symptoms of UTI in older child
fever
frequency, dysuria,
abdo/ loin pain
rigors
what to ask about an infant w UTI?
previous UTI? recurrent fevers of uncertain origin? a previously diagnosed renal abnormality? a FHx of vesicoureteric reflux or constipation?
any previous atypical, severe, recurrent UTI?
when do you have to do USS during an acute infection?
UTI
Atypical UTI in all ages
atypical UTI includes seriously ill, poor urine flow, abdo/bladder mass, raised cr, septicaemia, failure to repsond to abx within 48h, infection w non ecoli organisms.
Recurrent UTI in <6 months
recurrent UTIs: 2 or more upper UTI, 3 or more lower, 1 upper and 1 or more lower
UTI: when do you have to arrange an USS within 6 wks
UTI in <6 mths even if responded well to abx
Recurrent UTIs in those >6 months
2 or more upper, 3 or more lower, 1 upper and 1 or more lower
UTI: when to arrange a DMSA scan 4-6 months following the acute infection?
DMSA scan used to detect renal parenchymal defects.
Atypical UTI in those < 3yrs
atypical = seriously ill, poor urine flow, abdo/ bladder mass, raised creatinine, septicaemia, failure to respond to abx within 48h, infection w non ecoli organisms
Recurrent UTIs in all ages
3 or more lower, 2 or more upper, 1 upper and 1 or more lower
UTI: when to arrange a MCUG?
MCUG: micturating urethrogram.
to demonstrate vesicoureteric reflux.
Atypical UTI < 3 months
atypical: fails to respond to tx within 48h, septicaemia, raised creatinine, abdo/ bladder mass, infection w non ecoli organisms, seriously ill, poor urine flow
recurrent UTI <3 months
2 or more upper, 3 or more lower, 1 upper and 1 or more lower.
Why do you need to do a USS urinary tract during acute infection in atypical UTI?
to identify structural abnormalities such as obstruction, to ensure prompt management.
Why do a DMSA scan and when?
Used to detect renal parenchymal defects.
done in recurrent UTIs in all ages, or atypical UTIs < 3 yrs.
A DMSA scan is used to assess the structure and location of the kidneys and to check how well the kidneys are working. It is also used to show any scarred areas in the kidneys that may not be working as well as they should.
Why do you want to arrange a MCUG in some patients with UTI?
Micturating urethrogram demonstrates vesicoureteric reflux.
perform in infants < 3 months old w atypical or recurrent UTI.
advice for preventing recurrence of UTI?
drink adequate amount
ready access to clean toilets and dont delay voiding.
dysfunctional elimination syndromes and constipation should be addressed.
abx prophylaxis (trimethoprim) for infants w recurrent UTI.
If Infant under 6 months gets UTI
what Imaging to do after?
if atypical / recurrent: USS during the acute infection. + DMSA 4-6 months following + MCUG
even if simple UTI: USS follow up within 6 weeks
if infant is above 6 months of age? what imaging to do with UTI
If atypical UTI, do USS during the acute infection. + if < 3 yrs, also do DMSA 4-6 months after.
If recurrent, do USS follow up within 6 weeks and DMSA 4-6 months after.
Ix for Post strep GN
Urine dip.
Urine for microscopy - red blood cells, casts.
throat swab.
anti streptolysin O titre (ASOT) - raised
C3, C4 - C3 low in post strep GN
ESR and ANA - will be abnormal in vasculitides e.g. SLE.
Abdo Xray, renal USS - will demonstrate normality of kidneys and to exclude calculi
causes of haematuria
UTI
nephritis e.g.
post strep, HSP, IgA nephropathy, nephrotic syndrome
calculi
trauma
haematological- clotting disorders, HUS
anatomical causes- polycystic kidneys
Tumours e.g. Wilms
drugs e.g. cyclophosphamide, aspirin
factitious illness
recurrent benign haematuria.
Mx of post streptococcal glomerulonephritis
primarily symptomatic.
10 day course of oral penicillin
fluids should be restricted to 1L/day and diet should have no added salt.
In cases of HTN-> frusemide. (can help oedema and increase urine output)
If HTN persists, CCB such as amlodipine may be helpful.
Seek renal opinion if renal function deteriorates/ heavy proteinuria.
Dialysis if lifethreatening hyperK and uraemia.
Outpatient follow up to monitor BP, urea, electrolytes, creatinine, urine dip.
what is lactulose?
a man made sugar solution -> stool softener
works as a osmotic laxative by increasing amt of water in bowels
