ILA- gastro and renal Flashcards
A four month old boy is referred to the outpatient clinic because of concerns about his weight gain. At birth he was on the 25th centile for weight, with his head circumference on the 50th. Since two months of age his weight gain has slowed and his weight is now below the 0.4th centile. His head circumference remains on the 50th centile. The baby is exclusively breast fed. There are no concerns about his ability to feed. The parents don’t initially identify any particular symptoms. However on detailed questioning they say he has been posseting (reflux) more frequently, and been generally more unsettled. However his stools appear normal and he doesn’t have any respiratory symptoms. On examination the child does look thin, but you find no other abnormalities. hat are the possible causes of faltering growth in this baby?
Socioeconomic
No milk- get mum to express and see how much she’s producing
inadequate intake – how much are they feeding, should be waking them up in night to feed, ask about wet and dry nappies
Find out urine output to see if being absorbed but if poor stool eg blood or fatty malabsorption or if too much
Increased energy
GORD
CMPA
UTI
How could you classify the causes of faltering growth?
Inadequate intake – eg socioeconomic, poor breast milk technique, unsuitable food offered, neglect. Pathology – impaired swallowing CP, cleft palate, anorexia secondary to chronic illness eg CF
Inadequate retention – GORD, vomiting
Malabsorption – IBD, CF, CMPA, cholestasis of liver, post-necrotising enterocolitis
Failure to utilise nutrients – chromosome disorders, IUGR, premature, metabolic disorder eg congenital hypothyroidism
Increased requirements – CF, thyrotoxicosis, cronic infection, malignancy, CHD, kidney disease
What investigations for FTT and possetting?
History milk feeding
Withdraw milk from diet and see if theres a change - CMPA
FBC – immunodeficiency and anaemia
U+E, - renal failure and sodium shows nutrition
bone profile,- phosphate shows nutrition
LFTs- transaminase raised or albumin increased
Abg – metabolic problems
Skin prick test
PH testing possible for GORD
Urinalysis and culture – uti can cause FTT as well as possetting
Coeliacs screen
Sweat test - CF
TFTs
Immunoglobulins – immunodeficiency
Stool analysis for occult blood or parasites or reducing substances
Infection eg tb or hiv
Would you advise giving additional formula feeds in FTT?
Depends on history but if worried then yes
You ask for a urine sample to be tested by urinalysis. Large amounts of nitrites and leucocytes are found, suggesting what?
urinary tract infection.
Name two possible causative organisms of UTIs?
E.coli
Klebsiella proteus
Pseudomonas
Staphylococcus saprophyticus.
What antibiotic would you prescribe in the first line for UTI?
PO trimethoprim (if there is low risk of resistance), or nitrofurantoin (if eGFR ≥ 45ml/minute).
Give two second line oral antibiotics which are also used in urinary tract infections.
Second line options include nitrofurantoin (if eGFR ≥ 45ml/minute) if it has not been used as a first-line option, amoxicillin (only if culture results available and susceptible), or cefalexin or cephalosporin
What further investigations could you do for a UTI other than dipstick and what do they do?
U/S - looks for gross structural abnormalities eg hydronephrosis, abscess
MCUG (micturating cystourethrogram) - VUR
DMSA – radioisotope uptake – if work well then will pick up dye well and shine up and be scarred
What factors affect your choice of investigations for UTIs? i.e. whats atypical
Age for ways of collecting urine
Do more extensive investigations if is an atypical presentation: septic, poor urine flow, abdo mass, raised creatinine, fail respond abx in 48 hrs, infection by other organism than e.coli
Give most typical presentation for CMPA
Cows milk protein allergy – arching, don’t want feeds, young, blood and mucus in poo
A 5 year old girl is referred because she has started soiling herself in the day. Until a year ago she had no problems with her bowels and had been out of nappies. However recently she has started passing small amounts of loose, watery stool at school. She says that she is unaware that she is doing this. On examination you find a mass in the left iliac fossa. The remainder of the examination is unremarkable. What is the most likely diagnosis in this case?
Constipation with overflow
What are the possible causes of diarrhoea in children?
Gastroenteritis Hyperthyroidism Ibd Coeliacs Constipation Toddles diarrhoea – post viral gastroenteritis, food lumps made worse by milk
What is overflow incontinence?
Overflow incontinence – hard mass is blocking the way so the only thing that can get around it is liquid so cannot consciously decide when to BO
What would your management plan be for overflow incontinence?
Movicol first (osmotic) second line - senna (stimulant)
Need to get hard mass out
Disimpaction
Clean Oreo- when stools are clear 2/3 to shows works so just eat ice lollies, give them the laxative via NGT as have to have a lot of it to work
List different meds for constipation and say what types they are
Movucol – first line and osmotic Lactulose – osmotic Sodium picofulfae – stimulate Busacodyl – stimulant Senna – stimulant Docusate – stool softener
A four year old boy is referred to the paediatric ward because he has developed swelling around the face, scrotum and ankles. About 2 months ago he had a minor coryzal illness but has been otherwise fit and well. On examination he has swelling of the eyes, scrotum and ankles. He is afebrile. His abdomen is slightly distended and there is no rash. Urinalysis is performed and large amounts of protein are found but no blood. His weight is 17kg. What is the most likely diagnosis?
Nephrotic syndrome - steroid sensitive- minimal change most common!!
What are the causes of proteinuria in children?
Nephritic syndrome also causes proteinuria but with haematuria
Nephrotic syndrome due to:
Orthostatic proteinuria – first wee
Glomerular abnormal: minimal change, glomerulonephritis, abnormal glomerular basement membrane
increased GFR pressure
Hypertension
tubular proteinuria
Systemic disease: SLE, heoch-schonlein purpura
Infection
Alpert’s syndrome
Tubular: PKD, acute tubular necrosis, proximal renal tubular acidosis
What are the specific diagnostic criteria for nephrotic syndrome?
4 things for nephrotic: hypoalbumin, oedema, proteinuria and hyperlipidaemia
may present with:periorbital oedema, scrotal/leg/ankle oedema, ascites, SOB due to pleural effusion, infection eg peritonitis, septic arthiritis, sepsis due to loss of protetive immunoglobulins loss in urine
What are the features of Steroid sensitive nephrotic syndrome?
age between 1-10 yrs, no macroscopic haematuria, normal BP, normal complement levels, normal renal function
What initial investigations would you fo for nephrotic syndrome?
FBC Blood pressure Urinalysisis Protein and creatinine ratio ESR U&E Bone profile Chicken pox status Antistrepsolin O or anti-DNAse B titres and throat swab Urine culture Hep B and C screen Complement C3 levels
How would you manage nephrotic sydrome in a child as described before?
Corticosteroids – prednisolone !!!! If don’t respond to steroids then biopsy Immunise Fluid balance Low salt diet Pen V Anti hypertensives VERY rare diuretics used - IV furosemide
What steroids would you prescribe for nephrotic syn?
Prednisolone
What is the prognosis for nephrotic syndrome?
A 1/3rd resolve directly, a 1/3rd have infrequent relapses, a 1/3rd have frequent relapses and needs steroids - so usually on steroids for a long time
<1% mortality – usually for the non minimal change ones
What is the definition of a UTI?
Growth of bacteria in the urinary tract – 10 to the 5 number on organisms on a culture – so UTI can only be confirmed properly by culture
What is acute pyelonephritis vs cystitis?
Acute pyelonephritis - infection of renal parenchyma, presenting with symptoms of systemic infection
Acute cystitis - infection of bladder, presenting with voiding symptoms
How does a UTI present in infants?
fever, vomiting, lethargy, irritable, poor feed, FTT. Abdo pain, jaundice, haematuria (most common to least common)
What are sx of an upper UTI?
–Fever, septicaemic illness (with meningitis in infancy)
–General malaise, vomiting
–Loin/abdominal pain – older child
–Failure to thrive, jaundice
What are the sx of a lower UTI?
–Dysuria –Urinary frequency/urgency –Incontinence –Lower abdominal pain –Haematuria
When should a urine sample be collected?
When they have UTI sx, fever of over 38 degrees, less than 3 months old
How should a urine sample be collected?
MSU, clean catch (best), catheter, collect pad, suprapubic aspirate (SPA)
What should should be analysed in a urine sample?
visual and dipstick (LOOK at nitrites and leucocyte esterase - high nitrites and no leucocytes = abx; high leukocytes and no nitrites = MCS)
what makes a uti atypical?
septic, not e.coli causing, poor urine flow, abdo mass, raised creatinine, no response to abx within 48 hrs
What makes a UTI recurrent?
2 UTIs with systemic symptoms or 3+ without
mx of a UTI?
admit if systemically unwell or less than 3 months. Give PO abx for 3 days if well. Can give fluids and pain relief.
When should a U/S be done for a UTI and why?
good for seeing size and obstruction. Do if less than 6 months. Look for vesicoureteric reflux—>
A congenital abnormality with a posterior urethra that causes retrograde flow of urine from bladder into ureter/ pelvicalyceal system/intrarenal –> looks dilated and torturous
When should a DMSA scan be done for a UTI and why?
radionucleotide imaging, shows renal scarring and function. Do if <3 months, recurrent UTI or atypical UTI
how may oedema present?
can cause pitting oedema, ascites, pleural effusions, pulmonary oedema , PERIORBITAL
What causes oedema?
An increase in interstitial fluid –
Oedema can be caused by lymphoedema eg due to Turners, venous obstruction eg VTE,
low oncotic pressure due to low albumin eg from malnutrition or liver problems or increased loss from kidney,
salt and water retention eg heart failure, kidney low GFR
What are the key sx of nephrotic syndrome?
proteinuria –> hypoalbuminaemia —> oedema (plus hyperlipidaemia)
How may the urine look in proteinuria?
frothy
What are the different types of nephrotic syndrome?
congenital (<1 yrs), steroid sensitive, steroid resistant
how does steroid sensitivity nephrotic syndrome present?
–Normal BP –No macroscopic haematuria –Normal renal function –No features to suggest nephritis –Respond to steroids
how does steroid resistant nephrotic syndrome present?
• Elevated BP • Haematuria • May be impaired renal function • Features may suggest nephritis • Failure to respond to steroids
What is the usual histology on a steroid sensitive nephrotic syndrome in a child? What is the next most common?
most common: minimal change (no change seen under microscope) then Focal segmental glomerulosclerosis (scarring kidney)
Ix for nephrotic syndrome?
initially:
Proteinuria – first morning urine sample, with the protein: creatinine ratio raised
blds: Albumin, FBC, clotting, ESR, U&Es, cholesterol and blood glucose
consider further ix if doesnt resolve eg kidney biopsy or US
Mx for nephrotic syndrome?
Prednisolone for steroid sensitive
Consider diuretics, salt and sodium moderation, ACE-i, Pen V + vaccines to prevent infections
Remember AKIs and inreased risk of thromboembolism
What are the key sx for glomerulonephritis?
Haematuria – normally macroscopic Proteinuria Oedema (this and htn due to salt and water retention) Htn reduced UO
What ix should be done glomeulonephritis and what does it show?
–FBC – mild normochromic, normocytic anaemia
–U&Es – increased urea and creatinine, (impaired GFR)(hyperkalaemia, acidosis)
–Immunology – raised ASOT/antiDNAse B titre, low C3, C4
–Throat /other swabs
Urinalysis:
–Haematuria – usually macroscopic
–Proteinuria – dipstick, protein:creatinine
–Microscopy – RBC cast
Most common cause of glomeulonephritis?
Post-strep nephritis from grp A Nasopharyngeal/ skin infection roughly 10 days post-infection
Mx of glomeulonephritis?
Fluid balance – measure input and output, moderate fluids, give diuretics and restrict salts
Mx htn: diuretics etc
Correct any other imbalances eg potassium or acidosis
Dialysis if severe
Penicillin for strep infection
What is henoch schonlein purpura (HSP)?
Vasculitis with a palpable rash of skin, joints, gut and kidneys
Caused by IgA deposition
What is the pneumonic for remmbering HSP sx?
REMEMBER RAAR from most common symptoms to least: rash, arthirits, abdo pain and renal involvement (can present with nephrotic and nephritic syndrome)
mx for HSP?
diagnosis is clinical
need immunosuppression, though steroid resistant
ix for a child with faltering growth?
FBC - anaemia, immune deficiency U+Es- renal or metabolic problems LFT- liver disease, malabsorption TFT- hypothyroidism CRP + ESR- inflammation ferritin- iron defiency anaemia urine dipstick- UTI stool microscopy and culture- infection or parasites karyotype- turners sweat test- CF Total IgA, Anti-endomysial IgA, tissue transglutaminase IgA- coeliacs
What are causes of FTT? (Think inadequate intake, inadequate retention, malabsorption, increased requirements)
inadequate intake: environmental issues; psychosocial factos; neglect; impaired suck/ swallow eg cleft palate or CP or SOB; anorexia from chronic illness
inadequate retention: GORD
Malabsorption: coeliacs, CF, CMPA, cholestatic liver disease, necrotising enterocolitis
Incresed requirements: thyrotoxicosis, CF, malignancy, congenital heart disease, CKD, endocrine
What causes GORD?
Due to sphincter immaturity- acid damaged oesophagus
