GI Cases Flashcards
Describe visceral pain
Stimuli resulting in tension, stretching and ischemia
Tissue congestion and inflammation lower threshold for stimuli
Bilateral pain fibers
Unmyelinated fibers
Enter spinal cord at multiple levels
Described as dull, poorly localized and usually felt midline
Describe parietal pain
Noxious stimuli to parietal peritoneum
Ischemia, inflammation, or stretching
Transmitted via myelinated afferent fibers to specific doral root ganglia
Occurs on same side and same dermatomal level as original pain
Described as:
Sharp, intense, localized
Coughing or moving can aggravate it
Describe referred pain
Characteristics similar to parietal pain but felt in remote area
b/c supplied by same dermatome as affected organ
Shared central pathway for afferent neurons from different sites
Describe mesenteric lymphadenitis
Inflammation of mesenteric lymph nodes Clinical presentation often difficult to differentiate from acute appendicitis Generally benign Male equal to female Occurs more in children <15 y/o
What are causative agents of mesenteric lymphadenitis?
Beta hemolytic streptococcus Staphlococcus species E. coli Streptococcal viridans Yersinia species (most cases currently) Mycobacterium tuberculosis Viruses Coxsackievirus A & B Rubeola virus EBV Adenovirus serotypes 1,2,3,5 & 7
Treatment of mesenteric lymphadenitis?
General supportive care
Hydration
Pain medication
No antibiotics in mild uncomplicated cases
Surgery if signs of peritonitis, indication of abscess/suppuration or acute appendicitis unclear
Describe a cephalohematoma
neonatal subperiosteal hemorrhage that is confined by the suture lines
Describe the two types of hyperbilirubinemia
Direct (conjugated) hyperbilirubinemia
Relatively uncommon
Primarily biliary obstruction and metabolic disorders
Indirect (unconjugated) hyperbilirubinemia
More common
Describe increased bilirubin load as the cause of hyperbilirubinemia
Increased Bilirubin load Nonhemolytic causes Extravascular sources Polycythemia Exaggerated enterohepatic circulation Increased Bilirubin load Hemolysis
What are some hemolytic causes of increased bilirubin load?
Hemolysis due to: Rh incompatibility ABO incompatibility Minor antigens (D type…) RBC cell membrane defects RBC enzyme defects Medications Hemoglobinopathies Sepsis
What are some non hemolytic causes of increased 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
Describe decreased bilirubin conjugation causes
Physiologic jaundice Breast feeding Breast milk Gilbert’s Criglar-Najar Hypothyroidism
Describe impaired bilirubin excretion
Biliary obstruction Infection Metabolic disorders Chromosomal abnormalities Drugs
How is newborn bilirubin production different from adult?
Newborns produce 2x the adult rate which declines to normal adult by 10-14 days
Why is hyperbilirubinemia more common in neonates?
Shortened life span of their red blood cells
Declining hematocrit
Immature liver uptake & conjugation of bilirubin
Increased enterohepatic circulation
Increased intestinal reabsorption of bilirubin
Intestinal bacteria can deconjugate bilirubin allowing for reabsorption of bilirubin into the circulation.
Describe heme degration 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
Uridinediphosphateglucuronyltransferase (UDPGT) conjugates bilirubin into an excretable form.
Where does jaundice usually appear and how does it progress?
Usually begins on the face and progresses caudally
Generally, the farther the jaundice progresses down the body, the higher the total serum bilirubin
The more intense the color (which can approach a yellow-orange) also suggests a higher total serum bilirubin
Jaundice may be clinically detected with a total serum bilirubin of 5 mg per dL.
Clinical findings suggestive of physiologic hyperbili in neonate?
Bilirubin levels of 12 mg/dl by 3 days of life
Describe physiologic jaundice
Physiological immaturity
Appears between 24-72 hours of age
Peaks by 4-5 days in term and 7th day in preterm neonates
Disappears by 10-14 days of life
It is predominantly unconjugated and levels usually do not exceed 12 mg/dl in those without multiple risk factors (in those may rise as high as 17 mg/dL)
Describe difference btw breast feeding and breastmilk jaundice
Breastfeeding Jaundice
in breast-fed babies usually appears between 24-72 hours of age, peaks by 5-15 days of life and disappears by the third week of life.
Breast milk jaundice
Appears by day 3-4; Peaks by day 6-14
Approximately 2-4% of exclusively breast-fed term babies them have bilirubin in excess of 10 mg/dl in the third week of life (not seen clinically)
A diagnosis of breast milk jaundice should be considered if the serum bilirubin is predominantly unconjugated, other causes of prolonged jaundice have been excluded and the infant is in good health, vigorous and feeding well and gaining weight adequately.
Bilirubin levels usually subside over a period of time. Interruption of breast-feeding is not recommended unless levels exceed 20 mg/dl.
Describe pathologic jaundice
Appearance of jaundice within 24 hours
Increase in serum bilirubin beyond 5 mg/dl/day
Peak levels above the expected normal range
Presence of clinical jaundice beyond 2 weeks
Elevated conjugated bilirubin
Describe bili toxicity
Deposition of unconjugated bilirubin in brain tissue
Unconjugated form exceeds binding capacity of albumin
Unbound lipid soluble bilirubin crosses the blood-brain barrier
If blood-brain barrier damaged albumin-bound bilirubin may cross
Toxicity levels vary among ethnic groups, maturity level of neonate and presence of hemolytic disease
>25 mg/dL in healthy term neonate
Describe kernicterus
Effects are often irreversible Early signs Subtle 3-4 days after birth Lethargy, poor feeding, hypotonia Late signs Occur after first week of life Irritability, seizures, apnea, hypertonia, fever, etc. Chronic signs If neonate survives, chronic encephalopathy is seen Evident by 3 years of age Cerebral palsy, high frequency hearing loss, mild MR
How do you treat unconjugated hyperbilirubinemia?
Continued monitoring
Increase feeding
Repeat levels frequently
Phototherapy
Usually 1-2 days
Exchange Transfusion
Rapidly reduce bilirubin in
blood
