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Pediatrics > Kidney and gastroenterology > Flashcards

Kidney and gastroenterology Flashcards

1
Q

Calculation of eGFR

A

= (k * height (cm) ) / creatine (micro mol/L)

k = 31 or 40 (old Jaffe method)

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2
Q

Symptoms of UTI in infant

A

Nonspecific:

  • Fever (usually present), febrile seizures
  • Vomiting
  • Lethargy or irritability
  • Poor feeding/faltering growth
  • Jaundice
  • Septicemia - may develop rapidly
  • Offensive urine
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3
Q

Symptoms of UTI in child

A
  • Dysuria, frequency, and urgency
  • Abdominal pain or loin tenderness
  • Fever with or without rigors
  • Lethargy and anorexia
  • Vomiting, diarrhea
  • Hematuria
  • Offensive/cloudy urine
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4
Q

What can dysuria alone as a symptom indicate?

A
  • Cystitis
  • Vulvitis
  • Balanitis (in uncircumcised boys)
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5
Q

Most common pathogens causing UTI

A
  1. E. coli
  2. Klebsiella
  3. Proteus (more common in boys)
  4. Pseudomonas
  5. Streptococcus faecalis
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6
Q

Causes of vesicoureteric reflux

A
  1. Familial (30-50% chance of occurring in first-degree relatives)
  2. Secondary to bladder pathology (neuropathic bladder, urethral obstruction)
  3. Temporary after a UTI
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7
Q

Causes of daytime enuresis

A
  • Developmental or psychogenic
  • Blader instability or neuropathy
  • UTI
  • Constipation
  • Ectopic ureter
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8
Q

What is orthostatic proteinuria?

A

Proteinuria is only found when the child is upright during the day.

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9
Q

Causes of protienuria

A
  • Orthostatic proteinuria
  • Glomerular abnormalities
  • Minimal change disease
  • Glomerulonephritis
  • Abnormal glomerular basement membrane
  • Increased glomerular filtration pressure
  • Reduced renal mass in chronic kidney disease
  • HTN
  • Tubular proteinuria
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10
Q

Main features of nephrotic syndrome

A
  1. Proteinuria
  2. Edema
  3. Low plasma albumin (<2,5 g/dL)
  4. Hyperlipidemia (loss of enzymes responsible of breakdown of cholesterol and lipids)
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11
Q

Clinical signs of nephrotic syndrome

A
  • Periorbital edema (often the earliest sign)
  • Scrotal or vulval, leg and ankle edema
  • Ascitis
  • Breathlessness - due to pleural effusion and abdominal distension
  • Infection - peritonitis, septic arthritis, sepsis (loss of Ig in urine)
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12
Q

Nephrotic syndrome is often precipitated by …

A

respiratory infections

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13
Q

Features suggesting steroid-sensitive nephrotic syndrome

A
  • Age 1-10 years
  • No macroscopic hematuria
  • Normal BP
  • Normal complement levels
  • Normal renal function
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14
Q

What is the most common nephrotic syndrome?

A

Steroid-sensitive minimal change disease

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15
Q

What is seen on the electron microscopy in steroid-sensitive nephrotic syndrome

A

Electron microscopy - fusion of the specialized epithelial cells that invest the glomerular capillaries (podocytes)
- Light microscopy usually normal

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16
Q

Complications in nephrotic syndrome

A
  • Hypovolemia (during initial phase of edema formation)
  • Thrombosis (urinary loss of antithrombin III, thrombocytosis, increased synthesis of clotting factors, increased blood viscosity)
  • Infection (esp. pneumococcus)
  • Hypercholesterolemia
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17
Q

Prognosis of nephrotic syndrome

A

1/3 - resolve directly
1/3 - infrequent relapses
1/3 - frequent relapses - steroid-dependent

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18
Q

What is often the earliest sign in nephrotic syndrome?

A

Periorbital edema

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19
Q

What is the most common steroid-resistant nephrotic syndrome?

A

Focal segmental glomerulosclerosis

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20
Q

Management of steroid-resistant nephrotic syndrome

A
  • Treat edema - diuretics, salt restriction, ACEI
  • Non-steroidal antiinflammatory drygs
  • Genetic testing
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21
Q

Most common cause of hematuria?

A

UTI

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22
Q

Nonglomerular causes of hematuria

A
  • Infection
  • Trauma
  • Stones
  • Tumors
  • Sickle cell disease
  • Bleeding disorders
  • Renal vein thrombosis
  • Hypercalciuria
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23
Q

Glomerular causes of hematuria

A
  • Acute glomerulonephritis (usually with proteinuria)
  • Chronic glomerulonephritis (usually with proteinuria)
  • IgA nephropathy
  • Familial nephritis (e.g., Alport syndrome)
  • Thin basement membrane disease
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24
Q

Types of steroid-resistant nephrotic disorders

A
  • Focal segmental glomerulosclerosis
  • Membranoproliferative glomerulonephritis
  • Membranous nephropathy
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25
Q

Main features of acute nephritis

A
  1. Decreased urine output and volume overload
  2. Hypertension - may cause seizures
  3. Edema, initially periorbital
  4. Hematuria and proteinuria
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26
Q

Causes of acute nephritis

A
  • Post-infectious (including streptococcus)
  • Vasculitis (Henoch-Schonlein purpura, SLE, Wegener granulomatosis, microscopic polyarteritis, polyarteritis nodosa)
  • IgA nephropathy and mesangiocapillary glomerulonephritis = membranoproliferative
  • Antiglomerular basement membrane disease (Goodpasture syndrome)
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27
Q

Titres in post-streptococcal nephritis

A
  • Raised Antistreptolysin O/anti-DNAse B titres

- Low complement C3 levels

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28
Q

Common features in Henoch-Schonlein purpura

A
  • Characteristic skin rash on extensor surfaces
  • Arthralgia
  • Periarticular edema
  • Abdominal pain
  • Glomerulonephritis
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29
Q

Characteristics of the rash in Henoch-Schonlein purpura

A
  • Symmetrically distributed
  • Buttock, the extensor surfaces of the arms, legs and ankles
  • Trunk is usually spared
  • Initially urticarial –> maculopapular and purpuric
  • Palpable
  • Rash is first clinical features in about 50%
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30
Q

Clinical features in Henoch-Schonlein purpura

A
  • Fever
  • Rash
  • Joint pain - knees and ankles, 2/3 of patients
  • Colicky abdominal pain (hematemesis, melena)
  • Renal involvement - 80% have micro- or macroscopic hematuria or mild proteinuria
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31
Q

Most common chronic glomerular disease

A

IgA nephropathy (Berger disease)

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32
Q

Most common familial nephritis

A

Alport syndrome

- Usually associated with nerve deafness and ocular defects

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33
Q

Most common vasculitis to involve the kidneys

A

Henoch-Schonlein purpura

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34
Q

Clinical presentations in hypertension

A
  • Vomiting
  • Headaches
  • Facial palsy
  • Hypertensive retinopathy
  • Convulsions
  • Proteinuria
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35
Q

Most common features of hypertension in infants

A
  • Cardiac failure

- Faltering growth

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36
Q

Causes of hypertension

A
  • Renal
  • Renal artery stenosis
  • Renal parenchymal disease
  • Polycystic disease
  • Renal tumors
  • Coarctation of the aorta
  • Catecholamine excess
  • Pheochromocytoma
  • Neuroblastoma
  • Endocrine
  • Congenital adrenal hyperplasia
  • Cushing syndrome or corticosteroid therapy
  • Hyperthyroidism
  • Essential HTN
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37
Q

Causes of unilateral palpable kidney

A
  • Multicystic kidney
  • Compensatory hypertrophy
  • Obstructed hydronephrosis
  • Renal tumor (Wilms tumor)
  • Renal vein thrombosis
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38
Q

Causes of bilateral palpable kidneys

A
  • ARPKD - most common cause
  • ADPKD
  • Tuberous sclerosis
  • Renal vein thrombosis
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39
Q

Fanconi syndrome causes dysfunction of which part of the kidneys?

A

Proximal tubules

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40
Q

Features of Fanconi syndrome

A
  • Excessive loss of:
  • Amino acids
  • Glucose
  • Phosphate
  • Bicarbonate
  • Sodium
  • Calcium
  • Potassium
  • Magnesium
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41
Q

Clinical presentation of Fanconi syndrome

A
  • Polydipsia and polyuria
  • Salt depletion and dehydration
  • Hyperchloremic metabolic acidosis
  • Rickets
  • Faltering or poor growth
42
Q

Definition of oliguria

A

<0,5 ml/kg per hour

43
Q

Most common cause of acute kidney injury

A

Prerenal - hypovolemi

  • Gastroenteritis
  • Burns
  • Sepsis
  • Hemorrhage
  • Nephrotic syndrome
44
Q

Features of acute-on-chronic renal failure

A
  • Growth failure
  • Anemia
  • Disordered bone mineralization (renal osteodystrophy)
45
Q

2 most common renal causes of acute renal failure

A
  1. Haemolytic uraemic syndrome

2. Acute tubular necrosis

46
Q

Triad of hemolytic uremic syndrome (HUS)

A
  1. Acute renal failure
  2. Microangiopathic hemolytic anemia
  3. Thrombocytopenia
47
Q

Cause of HUS

A

GI infection with verocytotoxin-producing E. coli O157:H7

48
Q

Definition of stage 5 chronic kidney disease

A

End stage renal failure

GRF <15 ml/min per 1,73 m2

49
Q

Bile-stained vomit can be caused by

A

Intestinal obstruction

50
Q

Hematemesis can be caused by

A
  • Esophagitis
  • Peptic ulceration
  • Oral/nasal bleeding
  • Esophageal variceal bleeding
51
Q

Projectile vomiting, in first weeks of life can indicate

A

Pyloric stenosis

52
Q

Vomiting at the end of paroxysmal coughing can indicted

A

Whooping cough (pertussis)

53
Q

Abdominal distention can indicate

A

Intestinal obstruction including strangulated inguinal hernia

54
Q

Blood in stool can indicate

A
  • Intussusception

- Bacterial gastroenteritis

55
Q

Clinical features of gastro-esophageal reflux

A
  • Recurrent regurgitation or vomiting

- Infant is putting one weight normally and are otherwise well

56
Q

Gastro-esophageal reflux disease is more common in which children?

A
  • Children with CP or other neurodevelopmental disorders
  • Preterm infants, especially in those with BPD
  • Following surgery for esophageal atresia or diaphragmatic hernia
57
Q

Complications of G-E reflux = G-E disease

A
  • Faltering growth from severe vomiting
  • Esophagitis:
  • Hematemesis
  • Discomfort on feeding or heartburn
  • Iron-deficiency anemia
  • Recurrent pulmonary aspiration
  • Recurrent pneumonia
  • Cough or wheeze
  • Apnea in preterm infants
  • Dystonic neck posturing (Sandifer syndrome)
  • Apparent life-threatening events
58
Q

Investigations of G-E reflux

A
  1. 24-houre esophageal pH
  2. 24-houre impedance monitoring
  3. Endoscopy with esophageal biopsies
59
Q

What is normal lower esophageal pH?

A

Above 4 for most of the time

60
Q

Management of G-E reflux

A
  • Thickening agents to feed
  • Smaller, more frequent feeds
  • Acid suppressants:
  • H1-receptor antagonists (e.g. Ranitidine)
  • PPIs (e.g. Omeprazole
  • Surgical management - only in children with complications unresponsive to treatment
  • Nissan fundoplication
61
Q

Pathophys of pyloric stenosis

A
  • Hypertrophy of the pyloric muscle - gastric outlet obstruction
62
Q

When does the clinical features of pyloric stenosis present?

A

At 2-8 weeks of age.

More common in boys (4:1)

63
Q

Clinical features of pyloric stensosis

A
  • Vomiting, increases in frequency and forcefulness over time - becoming projectile
  • Hunger after vomiting
  • Dehydration
  • Weight loss
64
Q

Blood gass i pyloric stenosis show

A

Hypochloremic metabolic alkalosis with a low plasma sodium and potassium

65
Q

Findings on physical examination of pyloric stenosis

A
  • Gastric peristalsis may be seen as a wave moving from left to right across the abdomen
  • Palpation of the pyloric mass - olive shaped in right upper quadrant
66
Q

Management of pyloric stenosis

A
  • Fluid and electrolyte treatment

- Pyloromyotomy - division of the hypertrophied muscle down to, not including, the mucosa.

67
Q

Extra-abdominal causes of acute abdominal pain

A
  • URT infection
  • Lower lobe pneumonia
  • Torsion of the testis
  • Hip and spine
68
Q

Surgical causes of acute abdominal pain

A
  • Acute appendicitis
  • Intestinal obstruction including intussusception
  • Inguinal hernia
  • Peritonitis
  • Inflamed mocked diverticulum
  • Pancreatitis
  • Trauma
69
Q

Clinical features and signs of acute uncomplicated appendicitis

A 
Symptoms:
- Anorexia
- Vomiting
- Abdominal pain (initially central and colicky, then localized to the right iliac fossa)
Signs:
- Fever
- Abdominal pain aggravated by movement
- Persisten tenderness with guarding
70
Q

Where does intussusception most often appear?

A

Ileum passing into the caecum through the ileocaecal valve

- proximal bowel into a distal segment

71
Q

Complications of intussusception

A

Stretching and constriction of the mesentery –> venous obstruction –> engorgement and bleeding from the bowel mucosa –> fluid loss –> bowel perforation, peritonitis, gut necrosis

72
Q

Clinical features of intussusception

A
  • Paroxysmal, severe colicky pain with pallor
  • May refuse feeds, may vomit
  • A sausage-shaped mass, palpable in the abdomen
  • Characteristic redcurrant jelly stool
  • Abdominal distension and shock
73
Q

What can you see on a abdominal x-ray and USG in intussusception?

A 
X-ray:
* Distended small bowel 
* Absence of gas in the distal colon or rectum
USG:
* Target/doughnut sign
74
Q

What does Meckel diverticulum consist of?

A

Is an ileal remnant of the vitelli-intetsinal duct.

- Contains ectopic gastric mucosa or pancreatic tissue

75
Q

Pathphys of IBS

A
  • Altered GI motility
  • Abnormal sensation of intra-abdominal events
  • Symptoms may be precipitated by a GI infection
  • Abnormally forceful contractions in small intestine
76
Q

Clinical features of IBS

A
  • Non-specific abdominal pain, may be worse before or relieved by defecation
  • Explosive, loose or mucous stools
  • Bloating
  • Feeling of incomplete defecation
  • Constipation
77
Q

Treatment of peptic ulcer

A
  • PPI (e.g. Omeprazole)

- If H. pylori - Amoxicillin and Metronidazole or Clarithromycin

78
Q

What is eosinophilic esophagitis?

A
  • Inflammation of esophagus, caused by activation of eosinophils within the mucosa and submucosa
  • Unknown pathophys. but probably connected with allergy (more common in atopic children)
  • Dx: endoscopy
  • Tx: oral corticosteroids
79
Q

Most common virus causing gastroenteritis in develop countries

A

Rotavirus
60% of cases in children under 2 years of age
- Other viruses: adenovirus, norovirus, calicivirus, coronavirus, astrovirus

80
Q

Most common bacteria causing gastroenteritis in developed countries

A
  • C. jejuni
81
Q

Features for Shigella and Salmonella

A
  • Dysenteric type of infection
  • Blood and pus in the stool
  • Pain
  • Tenesmus
82
Q

Children at increased risk of dehydration from gastroenteritis

A
  • Infants, <6 months of age, those born with low birthweight
  • Passed six or more diarrheal stools in previous 24h
  • Vomited three or more times in previous 24h
  • Unable to tolerate extra fluids
  • Malnutrition
83
Q

Degrees of dehydration

A
  1. Not clinically detectable (<5% loss of body weight)
  2. Clinical dehydration (5-10% loss of body weight)
  3. Shock (>10% loss of body weight)
84
Q

Clinical features of shock from dehydration in an infant

A
  • Prolonged capillary refill time
  • Tachycardia. Weak peripheral pulses
  • Reduces tissue turgor
  • Sudden weight loss
  • Reduced urine output
  • Cold extremities
  • Tachypnea
  • Eyes sunken and tearless
  • Dry mucous membranes
  • Sunken fontanelle
  • Decreased level of consciousness
  • Pale or mottled skin
  • Hypotension
85
Q

Clinical features of coeliac disease

A
  • Faltering growth
  • Abdominal distension
  • Buttock wasting
  • Abnormal stools
  • General irritability
86
Q

Serological tests fro coeliac disease

A
  • Anti-tTG (immunoglobulin A tissue transglutaminase antibodies)
  • EMA (endomysial antibodies)
87
Q

Diagnosis of coeliac disease

A
  • Endoscopy biopsy, mucosal changes
  • Increased intraepithelial lymphocytes
  • Variable degree of villous atrophy and crypt hypertrophy
88
Q

Most common inflammatory bowel disease

A

Crohn’s disease is more common than UC

89
Q

Clinical features of Crohn’s disease

A
  • General ill health (fever, lethargy, weight loss) - often presenting symptoms
  • Growth failure, puberty delayed
  • Abdominal pain, diarrhea
  • Extra-intestinal: oral lesions or perianal skin tags, uveitis, arthralgia, erythema nodosum
  • Labs: raised inflammatory markers (platelet, ESR, CRP), iron-deficiency anemia, low serum albumin)
90
Q

Pathophys of Crohn’s disease

A
  • Can affect whole GI tract, most commonly distal ileum and proximal colon
  • Transmural, focal, subacute or chronic inflammation
  • Initially - areas of acutely inflamed, thickened bowel
  • Fistula may develop
91
Q

Histological hallmark of Crohn’s disease

A

Non-caseating epithelioid cell granulomata

92
Q

Management for Crohn’s disease

A
  • Nutritional therapy - normal diet replaced by whole protein modular feeds for 6-8 weeks - effective in 75%
  • Systemic steroids if diet ineffective
  • When relapses - immunosuppressants:
  • Azathioprine
  • Mercaptopurine
  • Methotrexate
    (Anti-tumour necrosis factor agents when conventional treatments have failed)
93
Q

Complications of Crohn’s

A
  • Obstruction
  • Fistula
  • Abscess
94
Q

Clinical features of Ulcerative colitis

A
  • Rectal bleeding
  • Diarrhea
  • Colicky pain
  • Weight loss and growth failure may occur (less frequent than in Crohn’s)
  • Extra-intestinal: Erythema nodosum, arthritis
95
Q

Pathophys of UC

A
  • Affects the colon

- Confluent colitis - extend from rectum proximally. 90% of children have pancolitis (all colon)

96
Q

Histology of UC

A
  • Mucosal inflammation
  • Cryp damage (cryptitis, architectural distortion, abscesses and crypt loss)
  • Ulceration
97
Q

Management of UC

A
  • Mild disease: Aminosalicylates (e.g., Mesalazine) (induction and maintenance therapy)
  • Confined to rectum and sigmoid - topical steroids
  • Aggressive or extensive: systemic steroids, immunomodulatory therapy
98
Q

Primary underlying causes of constipation

A
  • Hirschsprung disease
  • Lower spinal cord problems
  • Anorectal abnormalities
  • Hypothyroidism
  • Coeliac disease
  • Hypercalcemia
99
Q

Pathophys of Hirschsprung disease

A

Absence of ganglion cells from the myenteric and submucosal plexuses of part of the large bowel
75% of cases the lesion is confined to the rectosigmoid

100
Q

Clinical features of Hirschsprung disease

A
  • In neonatal period:
  • Intestinal obstruction - failure to pass meconium within the first 24h.
  • Abdominal distention
  • Later bile-stained vomiting
  • Later in life:
  • Profound chronic constipation
  • Abdominal distention
  • Growth failure
101
Q

Diagnosis of Hirschsprung disease

A
  • Suction rectal biopsy:
  • Absence of ganglion cells
  • Presence of large, acetylcholinesterase-positive nerve trunks

Pediatrics (9 decks)

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