Paediatrics Flashcards
Which disease refers to infection of the lung tissue?
Pneumonia
What does pneumonia cause in the lung tissue?
Inflammation of the lung tissue
sputum fills the airways and the alveoli
What are the Risk factors for Pneumonia?
Immunocompromise
IV Drug User
Age Extremities
HIV (w/ P Jurovecci)
What are the three types of Pneumonia
Community
Hospital
Aspirational
What is Aspirational Pneumonia
Food aspirates up into airways instead of down
What can pneumonia be seen as on a CXR?
Consolidation and Air Bronchogram
What are the Bacterial causes of Pneumonia?
- S. Pneumonia
- Group A strep (S.Pyogenes)
- Group B strep
- S.Aureus
- H. Influenza
- Mycoplasma pneumonia
- Chlamydia Pneumonia
What does S Aureus cause in Pneumonia?
Pneumatocoeles- round air filled cavities and consolidations in multiple lobes
What are two common causatives of Pneumonia in unvaccinated children?
Group B Strep
H. Influenzae
What are the causes of Atypical Pneumonia
M. Pneumoniae
C. Pneumoniae
C. Psitacci
Legionella
What is the presentation of Typical pneumonia?
Purelent Cough
Rusty Sputum
High fever (> 38.5ºC)
Dyspnoea
Lethargy
Delirium
What is the presentation of Atypical Pneumonia?
Dry Cough
Low grade Fever
Dyspnoea
Lethargy
Delirium
What are the signs of pneumonia?
Tachypnoea (raised respiratory rate)
Tachycardia (raised heart rate)
Hypoxia (low oxygen)
Hypotension (shock)
Fever
Confusion
What is sepsis 6?
Three Tests:
Blood lactate level
Blood cultures
Urine output
Three Treatments:
Oxygen Sats 94-98% (or 88-92% in COPD)
Empirical broad-spectrum antibiotics
IV fluids
What are the three characteristic chest signs seen in pneumonia?
BRONCHIAL BREATHING
These are harsh breath sounds that are equally loud on inspiration and expiration. These are caused by consolidation of the lung tissue around the airway.
BIBASAL COARSE CRACKLES
Caused by air passing through sputum similar to using a straw to blow into a drink.
DULL PERCUSSION
Due to lung tissue collapse and/or consolidation.
What are the investigations for pneumonia?
1st) Chest X-Ray
Other
- Sputum cultures and throat swabs
- Blood cultures - sepsis
- Capillary blood gas analysis - monitor respiratory or metabolic acidosis and blood lactate levels in unwell patients
What is the management for pneumonia?
02 Sats, Antibiotics and Fluids
1) Amoxicillin
2) Add Macrolide (Clarithromycin)
Severe) IV Clarithromycin
Pen Allergic) Macrolide Monotherapy
B-Lactam Resistant) Clarithromycin
Which tests can be done for recurrent lower respiratory tract infections?
- FBC
- Chest X Ray
- Serum Ig
- Sweat test to check for cystic fibrosis.
- HIV test, especially if mum’s status is unknown or positive.
What is Immunoglobulin Class Switch Recombination Deficiency?
Some patients are unable to convert IgM to IgG, and therefore cannot form long-term immunity to that bug.
In this case you test Ig vs Previous Vaccines
What is croup?
Acute URTI affecting young children - 6months to 2 years
What does croup cause in the larynx?
URTI leads to oedema in the larynx (Laryngeoadema)
What are the causes of Viral croup?
Parainfluenza virus
Influenza virus
Adenovirus
Respiratory Syncytial Virus (RSV)
Diphtheria
What are the signs of Acute Respiratory Distress?
- Retractions
- Tracheal Tug
- Intercostal Reccession
- Accessory Muscle Breathing
- Nasal Flaring
What is the presentation of croup?
Barking Cough
Hoarse Voice
Stridor
Acute Respiratory Distress
- Retractions
- Tracheal Tug
- Intercostal Reccession
- Accessory Muscle Breathing
- Nasal Flaring
What is the management of croup?
MILD
- Self Limiting
MODERATE
- Dexamethasone Single Dose 150mcg
SEVERE
1) Oral dexamethasone
2) Oxygen
3) Nebulised budesonide
4) Nebulised adrenalin
5) Intubation and ventilation
What scoring system is used in Croup?
Westley score
What are the parameters of the Westley Score?
Consciousness / 5
Cyanosis / 5
Stridor / 5
Retractions / 3
Air Entry / 2
How is Croup Diagnosed?
Clinical
X Ray = Steeple Sign
Stridor on Auscultation
DO NOT EXAMINE AIRWAYS
What xray sign is charecteristic of Croup
Steeple Sign - Subglottal Narrowing (Wine Bottle Shape)
What is Bacterial Croup?
A Superinfection affecting the airways (Bacterial Tracheatis)
What investigations can be done for suspected bacterial croup
Clinical
Lateral Neck X Ray
- Steeple Sign
- Tracheal Secretions
Bronchoscopy
Labs and Cultures
What can be seen on Bronchoscopy for Bacterial Croup?
- Inflamed Mucosa
- Thick Purulent S ecretions
- Pseudomembrane
How do you manage bacterial Croup
1) Intubation and Suction
2) IV Flucloxacillin/ Ceftriaxone
3) ICU and Support
What immunoglobulin is raised in Asthma?
IgE
What is an acute exacerbation of asthma characterised by?
Rapid deterioration of symptoms of asthma
Give examples of what an acute exacerbation of asthma may be triggered by?
–> infection
–> exercise
–> cold weather
What is the presentation of an acute asthma exacerbation?
- Progressively worsening shortness of breath
- Respiratory distress
- Fast respiratory rate (tachypnoea)
- Expiratory wheeze and chest tightness on auscultation
What is an ominous sign in asthma exacerbations?
A silent chest is an ominous sign. This is where the airways are so tight it is not possible for the child to move enough air through the airways to create a wheeze. This might be associated with reduced respiratory effort due to fatigue
How can the severity of acute exacerbations be graded?
MODERATE
- Peak flow >50% predicted
- Normal speech
- No other features
SEVERE
- Peak flow <50% predicted
- Saturations <92%
- Unable to complete sentences in one breath
- Resp distress w/ RR >30
- Heart rate >125 in >5 years
LIFE-THREATENING
- Peak flow <33% predicted
- Saturations <92%
- Poor resp effort and Hypotension
- Silent chest
- Cyanosis
- Confusion
What are the Moderate features of an Asthma Exacerbation?
- Peak flow >50% predicted
- Normal speech
- No other features
What are the Severe features of an Asthma Exacerbation?
- Peak flow <50% predicted
- Saturations <92%
- Unable to complete sentences in one breath
- Resp distress w/ RR >30
- Heart rate >125
What are the Life Threatening features of an Asthma Exacerbation?
- Peak flow <33% predicted
- Saturations <92%
- Poor resp effort and Hypotension
- Silent chest
- Cyanosis
- Confusion
Describe the stepwise management of acute asthma attack
O - Oxygen
S - Salbutamol (Nebulised or Inhaled)
H - Hydrocortisone (Oral)
I - Ipratropium bromide (Anti-muscarinic)
I - IV magnesium sulphate
T - Theophyline/ Aminophyline (IV)
M - Morphine
E - Escalate
How can mild cases of acute asthma exacerbations be treated
Managed as an outpatient with regular salbutamol inhalers via a spacer (e.g. 4-6 puffs every 4 hours)
Describe the stepwise management of acute asthma exacerbations for moderate to severe cases
Nebulised SABA (10 Puffs/every 2 hours)
PO Prednisolone
Nebulised Ipratropium w/ Magnesium Sulfate
IV Aminophyline
Intubation and Ventilation
What should be monitored whilst a patient gets high doses of salbutamol and what are other side effects?
Serum potassium
- Salbutamol causes potassium to be absorbed from the blood into the cells
Can also cause Tachycardia and Tremor
Which asthma medication is known to trigger nightmares?
Montelukast
What is asthma?
Chronic inflammatory airway disease leading to reversible airway obstruction in response to a stimulus and causing bronchoconstriction
What is the presentation suggestive of a diagnosis of asthma?
- Episodic symptoms with intermittent exacerbations
- Diurnal variability - typically worse at night and early morning
- Dry cough with wheezing and shortness of breath
- Typical triggers
- History of other atopic conditions such as eczema, hayfever and food allergies
- Family history of asthma or atopy
- Bilateral widespread “polyphonic” wheeze
- Symptoms improve with bronchodilators
What presentation is suggestive of a non-asthma diagnosis?
- Wheeze only related to coughs and colds, more suggestive of viral induced wheeze
- Isolated or productive cough
- Normal investigations
- No response to treatment
- Unilateral wheeze suggesting a focal lesion inhaled foreign body or infection
What Hypersensitivity reaction can trigger Asthma Attack?
Type 1 Hypersensitivity
What are the typical triggers of asthma?
Dust (house dust mites)
Animals
Cold air
Exercise
Smoke
Food allergens
How is a diagnosis of asthma made?
- History and presentation
- Peak flow variability is measured by keeping a diary of peak flow (several times a day for 2 to 4 weeks)
- Spirometry with Bronchodilator Reversibility (Children >5 years)
- Direct Bronchial Challenge test with histamine or methacholine
- Fractional exhaled nitric oxide (FeNO)
What is the stepwise management of asthma in under 5’s
1) SAB2A
2) Low ICS Inhaler
3) Moderate ICS Inhaler
4) LTRA (Montelukast)
What is the stepwise management of asthma in 5-16 Years?
1) SAB2A
2) Low dose ICS Inhaler
3) Add Oral LTRA (Montelukast)
4) Titrate up the corticosteroid inhaler to a medium dose.
5) Replace LTRA w/ LABA
5) Increase the dose of the inhaled corticosteroid to a high dose.
6) Initiate MART Therapy w/ SABA
What is MART Therapy?
ICS w/ Long acting Beta 2 Agonist
How do you establish complete control of asthma?
Experience no symptoms during the day/ night
Require no rescue medication
Have no exacerbations
Maintain normal activity levels
Exhibit minimal side effects from treatment Display optimal lung function.
What should you offer to a child who has established complete control of Asthma?
Influenza Vaccine - If after long period of steroid use do to risk of immunocompromisation
What is a viral-induced wheeze?
Wheezy illness caused by a viral infection.
What organisms can cause a viral induced wheeze?
RSV
Rhinovirus
Influenza Virus
What is the pathophysiology of viral-induced wheeze?
Small airways encounter a virus (commonly RSV or rhinovirus) they develop a small amount of inflammation and oedema, swelling the walls of the airways and restricting the space for air to flow
This inflammation also triggers the smooth muscles of the airways to constrict, further narrowing the space in the airway.
Air flowing through these narrow airways causes a wheeze, and the restricted ventilation leads to respiratory distress
How can you differentiate between asthma and a viral-induced wheeze?
- Presenting before 3 years of age
- No atopic history
- Only occurs during viral infections
Asthma has other triggers not just bacterial and Viral
Asthma has reversible obstructive properties
What is bronchiolitis usually caused by?
RSV - respiratory syncytial virus
Parainfluenza
Influenzae
Adenovirus
Rhinovirus
What is the presentation of a viral-induced wheeze?
Evidence of a viral illness (fever, cough and coryzal symptoms) for 1-2 days preceding the onset of:
Shortness of breath and Tight Chest
Signs of respiratory distress
Expiratory wheeze throughout the chest
Why is a viral infection in adults less noticeable than in children?
Adults have larger airways so inflammation and mucus production doesn’t cause a problem whereas children have smaller airways to begin with.
What does a focal wheeze suggest?
Inhaled foreign body or tumour or infection
In what age bracket does bronchiolitis occur in?
3 Months to 1 Year
What is the management of a viral-induced wheeze?
Mild = Self Resolving
Severe
1) SABA (10 Puffs)
2) + ICS (200mg Beclametesone)
3) LTRA (Montelukast)
What is the presentation of bronchiolitis?
Coryzal symptoms
- Running and snotty nose
- Sneezing
- Mucus in the throat
- Watery eyes
Signs of respiratory distress
Dyspnoea/ Tachypnoea
Apnoea
Poor feeding
Mild fever under 39
Wheeze and crackles on auscultation
What are the signs of respiratory distress?
Raised respiratory rate
Accessory Muscle Breathing
Intercostal and subcostal recessions
Nasal flaring
Head bobbing
Tracheal tugging
Cyanosis (due to low oxygen saturation)
Abnormal airway noises
What are some differentials for Wheeze?
Allergies
Asthma
Anaphylaxis
Foreign Body
Viral Infection
Bronchiectasis
Bronchiolitis
Bronchitis
Cystic Fibrosis
Pneumonia
What is a wheeze?
–> Wheezing is a whistling sound caused by narrowed airways, typically heard during expiration
What are some differentials for Stridor?
Laryngomalacia
Laryngospasm
Vocal Paralysis
Croup
Epiglotitis
GORD
Trauma/ Tumour
What is bronchiolitis?
inflammation and infection of the bronchioles (small airways of the lungs)
What is stridor?
–> Stridor is a high pitched inspiratory noise caused by obstruction of the upper airway, for example in croup
What is the typical course of bronchiolitis in children?
1) Bronchiolitis starts with URTI with coryzal symptoms/ half gets better
2) Spontaneously, the other half develops chest symptoms/ Sx last for 7 to 10 days
Children who have had bronchiolitis are more likely to have viral-induced wheeze during childhood.
What happens to the Bronchioles and Alveoli in Bronchiolitis?
Bronchioles
- Mucus Build Up
- Inflammation
Alveoli
- Alveolar Collapse
- Hyperinflation
what are the causes of clubbing in children?
–> Hereditary clubbing
–> Cyanotic heart disease
–> Infective endocarditis
–> Cystic fibrosis
–> Tuberculosis
–> Inflammatory bowel disease
–> Liver cirrhosis
What is the management of bronchiolitis?
Supportive management
- Ensuring adequate intake
- Saline nasal drops and nasal suctioning
- Supplementary oxygen
- Ventilatory support if required (CPAP if Severe)
Immunocompromised = IM Palivizumab
Fever = Acetaminophen
What can cause Bronchiolitis Obliterans?
Transplant
Recurrent Infections
Typically triggered by Adenovirus
How can you investigate Bronchiolitis Oblieterans?
Severe scarring in a Mosaic Pattern on High Res CT
How can you manage Bronchiolitis Oblieterans?
IM Palivizumab
What are the investigations for CF?
Genetic Testing (Amniocentesis/ Chorionic Villous for CFTR)
Newborn Blood Spot/ Heel Prick (Trypsinogen)
Faecal Elastase = Negative
Gold = Sweat Test (NaCl >60mmol/L)
How can you assess ventilation in children e.g severe rep distress?
Capillary blood gases
What are the key colonisers in the airways of CF patients?
- Staph aureus - given prophylactic flucloxacillin to prevent staph
- Pseudomonas - Resistant to many types of abx, ciprofloxacin can be used
What are useful signs of poor ventilation from capillary blood gas?
Rising pCO2
Collapsed airways can’t clear waste carbon dioxide
Falling pH
CO2 is building up and they are not able to buffer the acidosis this creates. This is respiratory acidosis. If they are also hypoxic, this is classed as type 2 respiratory failure.
What is the management of CF?
Chest physiotherapy
- Clear mucus and reduce the risk of infection and colonisation
Exercise
- Improves respiratory function and reserve, and helps clear sputum
A high-calorie diet
- For malabsorption, increased respiratory effort, coughing, infections and physiotherapy
CREON
- Digest fats in patients with pancreatic insufficiency (these replace the missing lipase enzymes)
Prophylactic Flucloxacillin
- Reduce the risk of bacterial infections (particularly staph aureus)
Bronchodilators
- Help treat bronchoconstriction
Nebulised DNase (dornase alfa)
- An enzyme that can break down DNA material in respiratory secretions, making secretions less viscous and easier to clear
Nebulised hypertonic saline
**Vaccinations **
- Pneumococcal, influenza and varicella
What can be given to high-risk babies which target RSV?
Palivizumab - monoclonal antibody
- Monthly injection
- Passive protection for high-risk (ex-premature or congenital heart disease)
What is epiglottitis?
Inflammation and swelling of the epiglottis and can swell to the point where airway is obstructed completely
What is cystic fibrosis?
- Autosomal recessive condition affecting the mucus glands, Mutation of the CFTR gene on chromosome 7
- CFTR codes for chloride cellular channels
What is epiglottitis normally caused by?
Haemophilus influenza type B infection
What are the key presentations of cystic fibrosis
Most Patients
- Chronic Cough
- Finger Clubbing
- Poor Weight Gain
- Salty Sweat
- Thick Secretions
- Increased URTI risk
- Malabsorption (Steatorrhea)
Neonates
- Meconium Ileus (Treat w/ Gastrogaffin)
- Intestinal Obstruction
- Failure to Thrive
Children
- Absent Vas Deferens
- Bronchopulmonary Aspergillosis
- Poor Growth
- Bronchiectasis
Other than HiB Infection, what are some other causes of Epiglotitis
Bacterial
- S Pneumoniae and S Pyogenes
Viral
- Varicella Zoster and Herpes
Trauma
- Inflammation
Irritants
- Smoking and Pollution
What is the presentation of a child that suggests possible epiglottitis?
5 Ds FT
Dysphagia
Dysphonia
Drooling
Dehydration
Distress (Respiratory)
Fever
Tripoding
What are the investigations for epiglottitis?
1) DO NOT EXAMINE AIRWAYS
2) ENT and Anaethesia
3) Lateral neck x-ray = Thumb Sign
What are the signs of CF?
Low weight or height on growth charts
Nasal polyps
Finger clubbing
Crackles and wheezes on auscultation
Abdominal distension
What is the management of epiglottitis?
Important to not distress the patient - can cause prompt closure of the airway
1) Intubation preparation and secure the airway
2) Iv abx (ceftriaxone) and steroids (dexamethasone)
3) Nebulised Adrenaline
Give two preventative measures in Epiglottitis
H Influenza B Vaccine
Rifampicin for Close Contacts
What is an atrial septal defect?
–> hole in the septum between the two atria
What is the pathophysiology of atrial septal defects?
ACYANTOIC (Left to Right)
- Blood shunting from left to right atrium as high pressure in left
- Blood continues to flow into the pulmonary vessels and lungs to get oxygenetated
- Leads to right heart strain/ failure and Pulmonary Hypertension
What is Eisenmenger syndrome?
Pulmonary Hypertension
- Right Sided Overload = Right Ventricular Hypertrophy
- Increased Right sided Pressure = Reversal of Shunt
- Right to Left Shunt = Cyanosis (Eisenmenger)
What are the complications of an atrial septal defect
Stroke (VTE Shunts from right to left)
Arrythmia (Atrial Flutter/Fibrillation)
Pulmonary Hypertension
Heart Fail
What is the presentation of ASD’s?
Mid-systolic, crescendo-decrescendo murmur loudest in the upper left sternal border w S2 Splitting
- Asymptomatic
- Swelling/ Oedema
- Palpitations
- Dyspnoea
- Failure to Thrive
- Poor Weight gain
What is the management of ASD’s
Referral to a paediatric cardiologist
Surgical
- Transverse Catheter Closure
- Open Heart Surgery
Medication
- Anticoagulants are used to reduce the risk of clots and stroke in adults
What is a VSD?
congenital hole in the septum between the two ventricles
What are the underlying genetic conditions associated with VSDs?
Downs syndrome
Turners syndrome
What is the pathophysiology of VSD’s?
Increased pressure in left ventricle
Blood shunt from left to right = Oxygenated
Right Ventricular Hypertrophy = Increased pressure in right side
Shunt reversal = Right to left (Cyanotic)
What is the presentation of VSD?
Small = Asymptomatic
Large = Failure to Thrive/ Pansystolic Murmur
Cyanotic = Right Ventricular Hypertrophy and Eisenmenger
What are the examination findings in patients with VSD’s?
Pan systolic murmur heard at the lower left sternal border may be a systolic thrill on palpation
What are the other differentials for a pan-systolic murmur?
-VSD
Mitral regurgitation
Tricuspid regurgitation
What is the treatment of a VSD?
Small = Spontaneous
Large = Transvenous Catheter Closure/ Heart Surgery
There is an increased risk of infective endocarditis in patients with a VSD. Antibiotic prophylaxis should be considered during surgical procedures to reduce the risk of developing infective endocarditis.
What is a patent ductus arteriosus?
When the Ductus Artriosus does not close <3 days after birth
What is a risk factor for a patent ductus arteriosus?
Prematurity
How can an asymptomatic patent ductus arteriosus be picked up in adult life?
Signs of heart failure
Machine like Murmur
What is the pathophysiology of a patent ductus arteriosus?
–> The pressure in the aorta is higher than that in the pulmonary vessels, so blood flows from the aorta to the pulmonary artery.
–> This creates a left-to-right shunt where blood from the left side of the heart crosses to the circulation from the right side.
–> This increases the pressure in the pulmonary vessels causing pulmonary hypertension, leading to right-sided heart strain as the right ventricle struggles to contract against the increased resistance.
–> Pulmonary hypertension and right-sided heart strain lead to right ventricular hypertrophy.
–> The increased blood flowing through the pulmonary vessels and returning to the left side of the heart leads to left ventricular hypertrophy.
What is the presentation of a patent ductus arteriosus?
A patent ductus arteriosus can be picked up during the newborn examination if a murmur - left upper chest continuous machine-like murmur is heard. It may also present with symptoms of:
Shortness of breath
Difficulty feeding
Poor weight gain
Lower respiratory tract infections
what type of murmur can be heard in a patent ductus arteriosus?
Continuous crescendo-decrescendo “machinery” murmur that may continue during the second heart sound, making the second heart sound difficult to hear.
How is the diagnosis of PDA made?
Echocardiogram - can also assess the hypertrophy effects on the heart
What is the management of PDA?
<1 Year = Echo Monitoring
>1 year of age = Trans-catheter/ surgical closure Symptomatic patients or those with evidence of heart failure as a result of PDA are treated earlier.
Can be Prescribed Ibuprofen/ Indomethacin/ Methacin
What is a feature of Persistant Patent Ductus Arteriosus?
A persistent patent ductus arteriosus (PDA) in a paediatric patient may result in a collapsing pulse due to increased pressure gradients across the defect.
What is the coarctation of the aorta?
Coarctation of the aorta is a congenital condition where there is narrowing of the aortic arch at the Ductus Arteriosus
Which genetic condition is coarctation of the aorta associated with?
Turners syndrome
What is the pathophysiology of coarctation of the aorta
Narrowing of the aorta reduces the pressure of blood flowing to the distal
It increases the pressure in areas proximal to the narrowing, such as the heart and the first three branches of the aorta.
Perfusion is greater in Upper body > Lower Body
What is the presentation of aortic coarctation?
- Weak Femoral Pulse w/ 4 limb Blood Pressure
- Systolic murmur heard below the left clavicle (left infraclavicular area) and below the left scapula.
- Scapular Bruits
INFANTS
Tachypnoea and increased work of breathing
Poor feeding
Grey and floppy baby
OLDER
Left ventricular heave due LVH
Underdeveloped left arm where there is a reduced flow to the left subclavian artery
Underdevelopment of the legs
What is the management of aortic coarctation?
Neonates = Prostaglandin E is used to keep the ductus arteriosus open while waiting for surgery. This allows some blood to flow through the ductus arteriosus into the systemic circulation distal to the coarctation. Surgery is then performed to correct the coarctation and to ligate the ductus arteriosus.
> 1 year olds = Angioplasty and stent insertion
What is the tetralogy of Fallot?
Congenital condition with four coexisting pathologies:
–> VSD
–> Overriding aorta
–> pulmonary valve stenosis
–> right ventricular hypertrophy
What is the pathophysiology of the tetralogy of Fallot?
Ventricular Septal Defect
Allows blood to flow between the ventricles
Overriding Aorta
Aorta entrace displaced further right above ASD. This means that when the right ventricle contracts and sends blood upwards, the aorta is in the direction of travel of that blood, therefore a greater proportion of deoxygenated blood enters the aorta from the right side of the heart.
Pulmonary Valve Stenosis
Greater resistance against the flow of blood from the right ventricle. This encourages blood to flow through the VSD and into the aorta rather than taking the normal route into the pulmonary vessels.
Right Ventricular Hypertrophy
Attempts to pump blood against the resistance of the left ventricle and pulmonary stenosis, causes right ventricular hypertrophy, with thickening of the heart muscle.
–> These cardiac abnormalities cause a right to left cardiac shunt. This means blood bypasses the child’s lungs. Blood bypassing the lungs does not become oxygenated. Deoxygenated blood entering the systemic circulation causes cyanosis. The degree to which this happens is related mostly to the severity of the patients pulmonary stenosis.
Which feature of Tetrology of Fallot is the greatest indicator for Severity?
Pulmonary Valve Stenosis
- the greatest determinant of the magnitude of the shunt, and accordingly, the degree of cyanosis
What are the risk factors of tetralogy of Fallot?
Rubella infection
Increased age of the mother (over 40 years)
Alcohol consumption in pregnancy
Diabetic mother
What are the investigations for the tetralogy of Fallot?
Chest X-Ray = Boot Shaped Heart
Gold = ECHO w/ Doppler Studies
What is the presentation of the tetralogy of Fallot?
Ejection systolic murmur caused by pulmonary stenosis may be heard on the newborn baby check.
Cyanosis @ Tips and Lips
Clubbing @ Tips and Toes
Failure to Thrive
Tet Spells
Tet Squat (Patient may do this to relieve symptoms)
Heart Fail
What are tet spells in tetralogy of Fallot?
Intermittent symptomatic periods where the right to left shunt becomes temporarily worsened, precipitating a cyanotic episode
Decreased Systemic Vascular resistance = Blood will be pumped into aorta instead of Pulmonary Vessels
These episodes may be precipitated by waking, physical exertion or crying. The child will become irritable, cyanotic and short of breath. Severe spells can lead to reduced consciousness, seizures and potentially death.
What are the treatment options for tet spells in tetralogy of Fallot?
Tet Squat
Squatting increases systemic vascular resistance. This encourages blood to enter the pulmonary vessels.
Critical?
Hypoxic? Supplementary O2
Beta blockers = Relax the right ventricle and improve flow to the pulmonary vessels.
IV fluids = Increase pre-load, increasing the volume of blood flowing to the pulmonary vessels.
Morphine can decrease respiratory drive, resulting in more effective breathing.
Sodium bicarbonate = Buffer any metabolic acidosis that occurs.
Phenylephrine infusion = Increase systemic vascular resistance.
What is the management of the Tetralogy of Fallot?
Neonates
Prostaglandin infusion can be used to maintain the ductus arteriosus. This allows blood to flow from the aorta back to the pulmonary arteries.
Total surgical repair by open heart surgery is the definitive treatment, however, mortality from surgery is around 5%.
What is transposition of the great arteries?
Attachments of the aorta and Pulmonary vessel are swapped
This means the right ventricle pumps blood into the aorta
Left ventricle pumps blood into the pulmonary vessels
In this scenario are two separate circulations that don’t mix: one travelling through the systemic system and right side of the heart and the other travelling through the pulmonary system and left side of the heart.
Which conditions is transposition of the great arteries associated with?
Ventricular septal defect
Coarctation of the aorta
Pulmonary stenosis
What is the pathophysiology of the transposition of the great arteries?
During pregnancy, there is normal development of the fetus. The gas and nutrient exchange happens in the placenta, therefore it is not necessary for blood to flow to the lungs.
After birth, the condition is immediately life-threatening as there is no connection between the systemic circulation and the pulmonary circulation. The baby will be cyanosed.
Immediate survival depends on a shunt between systemic circulation and pulmonary circulation that allows blood flowing through the body an opportunity to get oxygenated in the lungs. This shunt can occur across a patent ductus arteriosus, atrial septal defect or ventricular septal defect.
What is the presentation of the transposition of the great arteries?
The defect is often diagnosed during pregnancy with antenatal ultrasound scans.
Close monitoring is necessary during the pregnancy and arrangements should be made so that the woman gives birth in a hospital capable of managing the condition after birth.
- Cyanosis
- Respiratory Distress
- Tachycardia
- Poor Feeding
- Failure to Thrive
- Sweating
What is the management of the transposition of the great arteries?
Where there is a ventricular septal defect, this will allow some mixing of blood between the two systems and provide some time for definitive treatment.
A prostaglandin infusion can be used to maintain the ductus arteriosus. This allow blood from the aorta to flow to the pulmonary arteries for oxygenation.
Balloon septostomy involves inserting a catheter into the foramen ovale via the umbilicus, and inflating a balloon to create a large atrial septal defect. This allows blood returning from the lungs (on the left side) to flow to the right side of the heart and out through the aorta to the body.
Open heart surgery is the definitive management. A cardiopulmonary bypass machine is used to perform an “arterial switch” procedure within a few days of birth. If present, a VSD or ASD can be corrected at the same time.
What are the differential diagnosis of cyanotic lesions (right –> left shunt)
Differential diagnoses of cyanotic lesions using the 6 ‘T’s are:
Tetralogy of Fallot
Transposition of great arteries
Truncus arteriosus
Total anomalous pulmonary venous connection
Tricuspid valve abnormalities
Ton of others – hypoplastic left heart, double outlet right ventricle, pulmonary atresia
What is rheumatic fever?
Rheumatic fever is a systemic inflammatory disorder. It arises as a complication following infection with group A Streptococcus, but unlike the initial infection, rheumatic fever is not contagious.
In whom does rheumatic fever normally occur?
between 5-15 years old
more girls affected then boys
What is the pathophysiology of rheumatic fever?
1) Group A Strep ( S Pyogenes) causing Tonsilitis
2) The antibodies produced fight the infection as well as the myocardial muscle cells
3) This causes a Type 2 Hypersensitivity reaction
What is the presentation of rheumatic fever?
The typical presentation of rheumatic fever occurs 2 – 4 weeks following a streptococcal infection, such as tonsillitis. Symptoms affect multiple systems, causing:
–> Fever
–> Joint pain
–> Rash
–> Shortness of breath
–> Chorea
–> Nodules
JOINTS –> migratory arthritis in large joint, hot swollen and painful joints
HEART –> Carditis, or inflammation throughout the heart, with pericarditis, myocarditis and endocarditis, leads to –> Tachycardia or bradycardia/Murmurs from valvular heart disease, typically mitral valve disease/ Pericardial rub on auscultation/Heart failure
SKIN–> subcutaneous nodules and erythema marginatum rash
NERVOUS SYSTEM –> Chorea - key nervous system symptoms - irregular uncontrolled and rapid movements of limbs
what are the investigations for rheumatic fever?
Investigations that can help support the diagnosis include:
–> Throat swab for bacterial culture
–> ASO (antistreptococcal antibodies) antibody titres
–> Echocardiogram, ECG and chest x-ray can assess the heart involvement
–> A diagnosis of rheumatic fever is made using the Jones criteria.
What criteria is used to diagnose rheumatic fever?
Jones criteria
What is the Jones criteria?
A diagnosis of rheumatic fever can be made when there is evidence of recent streptococcal infection, plus:
Two major criteria OR
One major criteria plus two minor criteria
The mnemonic for the Jones criteria is JONES – FEAR.
Major Criteria:
J – Joint arthritis
O – Organ inflammation, such as carditis
N – Nodules
E – Erythema marginatum rash
S – Sydenham Chorea
Minor Criteria:
F - fever
E - ECG Changes (prolonged PR interval) without carditis
A - Arthralgia without arthritis
R - Raised inflammatory markers (CRP and ESR)
What is the management of rheumatic fever?
1) Immediate Referral
Infection? Phenoxymethylpenicillin for 10 days
Joint Pain? NSAID’s
Carditis? Aspirin and Steroid
2) Prophylactic Penicillin
What are the complications of rheumatic fever?
–> Recurrence of rheumatic fever
–> Valvular heart disease, most notably mitral stenosis
–> Chronic heart failure
What is infective endocarditis?
Infective endocarditis refers to infection of the endothelium (the inner surface) of the heart. Most commonly, it affects the heart valves. It can be acute, subacute or chronic, depending on how rapidly and acutely the symptoms present and the causative organism.
What are the risk factors for endocarditis?
The risk factors for infective endocarditis are:
–> Intravenous drug use
–> Structural heart pathology (see below)
–> Chronic kidney disease (particularly on dialysis)
–> Immunocompromised (e.g., cancer, HIV or immunosuppressive medications)
–> History of infective endocarditis
Structural pathology can increase the risk of endocarditis:
–> Valvular heart disease
–> Congenital heart disease
–> Hypertrophic cardiomyopathy
–> Prosthetic heart valves
–> Implantable cardiac devices (e.g., pacemakers)
What are the causes of infective endocarditis?
S Aurues (IVDU, Surgery and Diabetics) - High Virulence = Acute Onset
S Viridians (Poor dental hygiene) - Low Virulence = Sub Acute
S Bovis (Colon cancer patients) -Rule out w/ colonoscopy
-Alpha Haemolytic Strep w/ Partial Haemolysis
What is the presentation of infective endocarditis?
The presenting symptoms are non-specific for an infection:
Fever
Fatigue
Night sweats
Muscle aches
Anorexia (loss of appetite)
The key examination findings are:
New or “changing” heart murmur
Splinter haemorrhages (thin red-brown lines along the fingernails)
Petechiae (small non-blanching red/brown spots) on the trunk, limbs, oral mucosa or conjunctiva
Janeway lesions (painless red flat macules on the palms of the hands and soles of the feet)
Osler’s nodes (tender red/purple nodules on the pads of the fingers and toes)
Roth spots (haemorrhages on the retina seen during fundoscopy)
Splenomegaly (in longstanding disease)
Finger clubbing (in longstanding disease)
What are the investigations for infective endocarditis?
1st) ECG (Long PR? Aortic Root Abscess)
2nd) Raised ESR/CRP and Neutrophilia
3rd) Blood Cultures from 3 sites in 24 hrs
Gold) Trans Oesophageal ECHO
- Preffered for visuals but more invasive than TTE
18F-FDG PET/CT - SPECT-CT for Prosthetic heart valves
Modified Dukes criteria
Which criteria can be used to diagnose infective endocarditis?
Modified Dukes criteria
What is the modified Dukes criteria?
The Modified Duke criteria can be used to diagnose infective endocarditis. A diagnosis requires either:
One major plus three minor criteria
Five minor criteria
Major criteria are:
Persistently positive blood cultures (typical bacteria on multiple cultures)
Specific imaging findings (e.g., a vegetation seen on the echocardiogram)
Minor criteria are:
Predisposition (e.g., IV drug use or heart valve pathology)
Fever above 38°C
Vascular phenomena (e.g., splenic infarction, intracranial haemorrhage and Janeway lesions)
Immunological phenomena (e.g., Osler’s nodes, Roth spots and glomerulonephritis)
Microbiological phenomena (e.g., positive cultures not qualifying as a major criterion)
What is the management of infective endocarditis?
S AUREUS
* 1) Flucloxacillin (+ Genatmycin)
* 2) IV Vancomycin w/ Rifampicin
Prosthetic
* 1) IV Flucloaxacillin, Rifampicin and Gentamycin
S VIRIDIANS- Benzylpenicillin w/ Gentamycin
GRAM NEGATIVE - Teicoplanin
MRSA - Vancomycin (+ Gentamycin)
HACEK - Ceftriaxone
GOLD) Valve replacement w/ prosthetics
When is Valve Replacement indicated in Infective Endocarditis?
Heart failure relating to valve pathology
Large vegetation or abscesses
Infections not responding to antibiotics
What are the complications of infective endocarditis?
Heart Fail 2nd to Regurgitation
Aortic Root Abscess (Prolonged PR)
Septic Emboli/ Sepsis
-Suspect Acute Mesenteric Ischaemia
If an ECG shows PR Prolongation in Infective Endocarditis, What is the cause and managent?
Aortic Root Abscess - Need urgent Cardiothoracic Assessment/ Surgery
In patients who are at high risk of infective endocarditis, what is the advice?
Good oral health to reduce the risk of IE, streptococcus viridans
What is GORD?
Gastro-oesophageal reflux is where contents from the stomach reflux through the lower oesophageal sphincter into the oesophagus, throat and mouth
Why are babies more susceptible to GORD?
In babies there is immaturity of the lower oesophageal sphincter, allowing stomach contents to easily reflux into the oesophagus. It is normal for a baby to reflux feeds, and provided there is normal growth and the baby is otherwise well this is not a problem, however, it can be upsetting for parents.
What is the presentation of GORD in babies?
Normal due to premature Lower Oesophageal Sphincter
Problematic If…
- Chronic cough
- Hoarse cry
- Distress, crying or unsettled after feeding
- Reluctance to feed
- Pneumonia
- Poor weight gain
Older Children
- Heartburn
- Acid regurgitation
- Retrosternal or epigastric pain
- Bloating
- Nocturnal cough
- Hallitosis
What is the Presentation of GORD in Children (Not Babies)?
- Heartburn
- Acid regurgitation
- Retrosternal or epigastric pain
- Bloating
- Nocturnal cough
- Hallitosis
What are some possible causes of vomiting in children?
Vomiting is very non-specific and is often not indicative of underlying pathology. Some of the possible causes of vomiting include:
–> Overfeeding
–> Gastro-oesophageal reflux
–> Pyloric stenosis (projective vomiting)
–> Gastritis or gastroenteritis
–> Appendicitis
–> Infections such as UTI, tonsillitis or meningitis
–> Intestinal obstruction
–> Bulimia
What are the red flags for vomiting in children?
Not Keeping down food/ Projectile?
- Pyloric Stenosis/ intestinal Obstruction
Bile-stained vomit
- Intestinal obstruction
Haematemesis or melaena
- Peptic ulcer, Oesophagitis or Varices
Abdominal distention
- Intestinal obstruction
Reduced consciousness/ bulging fontanelle
- Meningitis or Raised intracranial pressure
Respiratory symptoms
- Aspiration and infection
Blood in the stools
- Gastroenteritis or Cows milk protein allergy
Infection
- Pneumonia, UTI, tonsillitis, otitis or meningitis
Rash/ Angioedema
- Cows milk protein allergy
Apnoeas? Urgent Assessment Needed
What is the management of GORD in babies?
MILD = Conservative
Small, frequent meals
Burping regularly to help milk settle
Not over-feeding
Keep the baby upright after feeding (i.e. not lying flat)
MODERATE = Medication
Gaviscon w/ Feeds
Thickened Milk or Anti Reflux Formula
PPI (Omeprazole)
SEVERE = INVESTIGATION
Barium meal w/ endoscopy
Surgical fundoplication
What are some risk factors for Pyloric Stenosis?
Prematurity
Age 6-8 weeks
Male
Caucasian
What is the pathophysiology of pyloric stenosis?
Hypertrophy of the Pyloric sphincter causes narrowing of the canal between the stomach and duodenum. This prevents food from travelling from the stomach to the duodenum as normal.
After Feeding
Increasingly powerful peristalsis in the stomach as it tries to push food into the duodenum
Stomach ejects the food into the oesophagus, out of the mouth and across the room. This is called “projectile vomiting”.
What are the features of pyloric stenosis?
First few weeks of life
- Hungry, Thin, Pale baby
- Failure to Thrive
- Projectile Vomiting
After Feeding
A firm, round mass can be felt in the upper abdomen that “feels like a large olive”. This is caused by the hypertrophic muscle of the pylorus.
Blood gas analysis
Hypochloric/ Hypokalaemic metabolic alkalosis as the baby is vomiting the hydrochloric acid from the stomach
How can pyloric stenosis be diagnosed?
Abdominal ultrasound to visualise the thickened pylorus
May feel a “large olive” after feeding in the abdomen
What is the mainstay treatment of pyloric stenosis?
Ramstedt’s Operation (Laparoscopic Pyloromyotomy)
An incision is made in the smooth muscle of the pylorus to widen the canal allowing that food to pass from the stomach to the duodenum as normal.
How do you initially manage a child with pyloric stenosis without surgical intervention?
Nil By Mouth
Dehydrated? IV Fluids
Severe Dehydration? Acute Fluid Resus w/ Electrolyte correction
If there is no significant underlying cause for constipation what can it be described as?
Idiopathic/ Functional constipation
Give examples of secondary causes of constipation
Hirschsprung’s disease
CF (meconium ileus)
Hypothyroidism
Spinal cord lesions
Sexual abuse
Intestinal obstruction
Anal stenosis
Cows milk intolerance
What is the presentation of constipation?
E<3 Stools a week
Hard stools/ Rabbit Dropping
Tenesmus/ Straining
Abdominal pain
Retentive posturing
Rectal bleeding associated with hard stools
Encopresis and Soiling
Loss of the sensation of the need to open the bowels
Whats encopresis?
Faecal Incontinence secondary to Constipation
- Not pathological until 4 years of age
- Sign of chronic constipation where the rectum becomes stretched and loses sensation
- Large hard stools remain in the rectum and only loose stools are able to bypass the blockage and leak out, causing soiling.
What are some lifestyle factors that can contribute to the development of constipation?
Habitually not opening the bowels
Low fibre diet
Poor fluid intake and dehydration
Sedentary lifestyle
Psychosocial problems such as a difficult home or school environment (always keep safeguarding in mind)
Why can rectum desensitisation occur in constipation?
Often patients develop a habit of not opening their bowels when they need to and ignoring the sensation of a full rectum.
Over time they loose the sensation of needing to open their bowels, and they open their bowels even less frequently.
They start to retain faeces in their rectum. This leads to faecal impaction, which is where a large, hard stool blocks the rectum. Over time the rectum stretches as it fills with more and more faeces. This leads to further desensitisation of the rectum.
The longer this goes on, the more difficult it is to treat the constipation and reverse the problem.
What are the red flags of constipation?
Not passing meconium - within 48 hours of birth (cystic fibrosis or Hirschprungs disease)
Neurological signs or symptoms - particularly in the lower limbs (cerebral palsy or spinal cord lesion)
Vomiting - intestinal obstruction or Hirschprungs disease)
Ribbon stool (anal stenosis)
Abnormal anus (anal stenosis/ IBD or sexual abuse)
Abnormal lower back or buttocks (spina, bifida, spinal cord lesion or sacral agenesis)
Failure to thrive (coeliac disease, hypothyroidism or safeguarding)
Acute severe abdominal pain and bloating (obstruction or intussusception)
What are the complications of constipation?
Pain
Reduced sensation
Anal fissures
Haemorrhoids
Overflow and soiling
Psychosocial morbidity
What is the management of constipation?
1) Correct any reversible contributing factors,
2) Recommend high-fibre diet and good hydration
3) Start laxatives (movicol is first line)
Faecal impaction? Disimpaction regimen with high doses of laxatives at first
Encourage and praise visiting the toilet. This could involve scheduling visits, a bowel diary and star charts
Laxatives should be continued long term and slowly weaned off as the child develops a normal, regular bowel habit
What is the pathophysiology of appendicitis?
–> Inflammation of the appendix
–> due to obstruction at the point where the appendix meets the bowel from caecum
–> can quickly progress into gangrene and rupture
–> can release faecal contents and infective material into the abdomen which leads to peritonitis - inflammation of the peritoneal contents
–> peak incidence of appendicitis is between 10 and 20
What is the cause of Appendicitis?
Obstruction at the point where the appendix meets the bowel from caecum
What are the signs and symptoms of appendicitis?
Central abdominal pain that moves down to the right iliac fossa
McBurney’s point is Tender - One-third of the distance from the ASIS to the umbilicus
Loss of appetite
Nausea and vomiting
Rosvings sign - palpation of the left iliac fossa causes pain in the RIF
Guarding on abdominal palpation
Rebound tenderness - increased pain when quickly
releasing pressure on the right iliac fossa
Percussion tenderness is pain and tenderness when percussing the abdomen
REBOUND TENDERNESS AND PERCUSSION TENDERNESS SUGGESTS PERITONITIS, CAUSED BY A RUPTURED APPENDIX
How is the diagnosis of appendicitis made?
1st) Clinical w/ Raised Inflammatory Markers
Female? Rule out Ectopic Pregnancy
Imaging ) CT Abdomen and Pelvis
Ultrasound preferred in mild cases
Negative Investigations w/ Positive Clinical
Diagnostic laparoscopy to visualise appendix and perform appendicectomy if required
What are some key differential diagnosis of appendicitis?
Ectopic Pregnancy (Do a Pregnancy Test)
Ovarian Cysts
Ovarian cysts can cause pelvic and iliac fossa pain, particularly with rupture or torsion.
Meckel’s Diverticulum
Malformation of the distal ileum that occurs in around 2% of the population. It is usually asymptomatic, however it can bleed, become inflamed, rupture or cause a volvulus or intussusception.
Mesenteric Adenitis
Inflamed abdominal lymph nodes. This presents with abdominal pain, tonsilitis and URTI in children.
Appendiccal Mass
Omentum surrounds and sticks to the inflamed appendix, forming a mass in the right iliac fossa.
How do you manage Appendicitis w/o signs of Peritonitis?
IV Fluids and IV ABx w/ Elective Appendiectomy
What is the management of acute appendicitis?
Appendiectomy w/ IV ABx 24hrs or Laparotomy
What are the complications of appendiectomies?
Bleeding, infection, pain and scars
Small Bowel Obstruction
Removal of a normal appendix
Anaesthetic risks
Venous thromboembolism (deep vein thrombosis or pulmonary embolism)
What is a Periappendicular Abscess?
Abcess formed in the presence of appendicitis charecetrised by Swinging Fever
How do you manage an appendicular mass?
Drainage as antibiotics cannot target bacteria in abscess
What is inflammatory bowel disease an umbrella term for?
Inflammation of the walls in the GI tract W/ periods of remission and exacerbations
- Ulcerative colitis
- Chrons disease
What are the features of Crohn’s disease?
Crohn’s (crows NESTS)
N – No blood or mucus (these are less common in Crohn’s.)
E – Entire GI tract
S – “Skip lesions” on endoscopy
T – Terminal ileum most affected and Transmural (full thickness) inflammation
S – Smoking is a risk factor (don’t set the nest on fire)
Crohn’s is also associated with weight loss, strictures and fistulas.
What are the features of UC?
C – Continuous inflammation
L – Limited to colon and rectum
O – Only superficial mucosa affected
S – Smoking is protective
E – Excrete blood and mucus
U – Use aminosalicylates
P – Primary sclerosing cholangitis
What is the presentation of inflammatory bowel disease in Children?
Perfuse diarrhoea
Abdominal pain
Bleeding/ Anaemia
Weight loss
Systemically unwell during flares, with fevers, malaise and dehydration
What are the extra-intestinal manifestations of inflammatory bowel disease?
Apthous Mouth Ulcers (Crohn’s)
Finger clubbing
Erythema nodosum
Pyoderma gangrenosum
Episcleritis and iritis
Inflammatory arthritis
Primary sclerosing cholangitis (ulcerative colitis)
How can you test for inflammatory bowel disease?
pANCA
Type of autoantibody that target the protein myeloperoxidase (MPO) in neutrophils, a type of white blood cell.
Blood tests
Anaemia, Infection, TFT, RFT and LFT
Raised CRP indicates active inflammation.
Faecal Calprotectin
Released by the intestines when inflamed. It is a useful screening test and is more than 90% sensitive and specific for IBD in adults.
Endoscopy (OGD and colonoscopy) with biopsy
Gold standard investigation for diagnosis of IBD.
Imaging with ultrasound, CT and MRI
Complications such as fistulas, abscesses and strictures
What causes Crohn’s Disease?
NOD-2 Mutation resulting in the release of TNF Alpha, IL1 and IL6
What do you see in the investigations for Crohn’s?
pANCA = Negative
Calprotectin = Raised
Endoscopy
- Skip Lesions
- Cobblestone Mucosa
- String Sign Strictures
Biopsy
- Transmural Inflammation
- Non Caseating Granulomas
What can you see on Endoscopy and Biopsy in Crohn’s?
Cobblestone Mucosa w/ Skip Lesions
String Sign Strictures
Transmural inflammation
Non Caseasting Granulomas
Describe the presentation of Crohn’s
General
Right Lower Quadrant Pain
Malabsorption
Anaemia/ Deficiency
Gall stones/ Kidney Stones
Watery Diarrhoea
Extra-Intestinal
Apthous Mouth Ulcers
Uveitis/ Episcleritis/ Spondyloarthropathies
Erythema Nodosum
Pyoderma Gangrenosum
What is the management of Crohn’s disease?
Flare Up
1) Sulfasalazine w/ Prednisolone
Severe) IV Hydrocortisone
Induce Remission
1) Azithioprine/ Mercaptopurine
2) Methotrexate
3) Infliximab/ Ustekenumab
Surgery
Bowel Resection
- Can cause Short Bowel Syndrome
What are some complications of Crohn’s?
Peri-anal Abscess
- Anal gland infection
Anal Fistula
- Abnormal tracks from Anus
Anal Strictures
Small Bowel Obstruction
What is Ulcerative Collitis?
Autoimmune Inflammation of the colon Only
What is the Presentation of Ulcerative Collitis
General
Left Lower Quadrant Pain
Tenesmus
Fever
Extra-Intestinal
Spondyloarthropathies
Uveitis/ Episcleritis
Pyoderma Gangrenosum
Erythema Nodosum
Primary Sclerosing Cholangitis
What do you see in the Investigations for Ulcerative Collitis?
pANCA = Positive
Calprotectin = Raised
Colonoscopy
- Continuous Inflammation
- Lead Pipe Sign
Biopsy
- Dry Mucosal Inflammation
- Crypt Hyperplasia
- Goblet Cell Depletion
What do you see on colonoscopy and biopsy of Ulcerative collitis?
Continuous Inflammation w/ Lead Pipe Sign
Mucosal Inflammation
Crypt Hyperplasia
Goblet (Mucin) Cell Depletion
What Criteria is used in Ulcerative collitis
True Love and Witts
What is the management of Ulcerative colitis?
Flare Up
1) Sulfasalazine w/ Prednisolone
Severe) IV Hydrocortisone
Induce Remission
1) Sulfasalazine/ Mesalazine
2) Azithioprine/ Mercaptopurine
3) Methotrexate
Rescue Therapy
IV Ciclopsporin/ Infliximab
Surgery
Colectomy w/ Stoma bag
What is Toxic Megacolon?
Dilated colon 2nd to Ulcerative Collitis where the patient does not respond to IV Steroids for 3+ days
Diagnose w/ Abdominal X Ray
What is the pathophysiology of coeliac disease?
Autoimmune Type 4 Hypersensitivity reaction vs Alpha Gliadin (Gluten)
Alpha Gliadin binds to IgA and interacts w/ TTG
Increases the amount of…
- IgA
- IgA Anti TTG
- IgG Anti TTG
- Endomyseal Antibodies (EMA)
What is the presentation of coeliac disease?
Failure to thrive/ Weight Loss
Diarrhoea/ Steatorrhea
Fatigue
Anaemia secondary to Malabsorption
Dermatitis herpetiformis
Mouth Ulcers
Rarely coeliac disease can present with neurological symptoms:
–> Peripheral neuropathy
–> Cerebellar ataxia
–> Epilepsy
Patients diagnosed with type 1 Diabetes should also be tested for what and why?
Coeliac disease as they are often linked
What are the genetic associations of Coeliac disease?
HLA-DQ2 gene (90%)
HLA-DQ8 gene
what are the investigations for Coeliac disease?
1) Keep the patient on Gluten for the tests
2) IgA Deficient? 1st = IgG EMA
3) Screening Serology
- Raised anti-TTG antibodies and Total IgA (first choice)
- Raised anti-endomysial antibodies - anti EMA
4) Endoscopy and Duodenal biopsy show:
- Crypt hypertrophy w/ Villous atrophy (SPRUE Biopsy)
- Epithelial Lymphocyte Infiltrate
Which conditions are associated with coeliac disease?
Type 1 diabetes
Thyroid disease
Autoimmune hepatitis
Primary biliary cirrhosis
Primary sclerosing cholangitis
Down’s syndrome
What are the complications of untreated coeliac disease?
Vitamin deficiency
Anaemia
Osteoporosis
Ulcerative Jejunitis
Enteropathy-associated T-cell lymphoma (EATL) of the intestine
Non-Hodgkin lymphoma (NHL)
Small bowel adenocarcinoma (rare)
What is the treatment of coeliac disease?
1) Stop Gluten
2) Replace Mineral/ Vitamin Deficiency
3) Monitor Osteoporosis w/ DEXA (Older Patient)
What other disease can a SPRUE Biopsy Indicate other than Coeliac?
Tropical Sprue
- Enteropathy w/ Tropical travel
- Managed w/ Tetracycline
What is Hirshsprung’s disease?
Congenital nerve cell absence of the myenteric plexus in the distant bowel and rectum
–> Myenteric plexus (Auerbach’s plexus) forms the enteric nervous system which is responsible for peristalsis
What is the myenteric plexus?
Part of the enteric nervous system and is responsible fo peristalsis of the large bowel
What is the pathophysiology of Hirshprungs disease?
Absence of the parasympathetic ganglion cells
Parasympathetic ganglion cells in the myenteric plexus do not migrate all the way down during fetal development therefore cannot initiate persistalsis
Total Colonal Anganglionis
The aganglionic section of the colon does not relax and causes contraction and obstruction due to absence of ganglion cells in the entire colon
What are the risk factors of Hirschprung’s disease?
Family history
Downs syndrome
Which diseases is Hirshprung’s disease associated with?
- Downs syndrome
- Neurofibromatosis
- Waardenburg syndrome (a genetic condition causing pale blue eyes, hearing loss and patches of white skin and hair)
- Multiple endocrine neoplasia type II
What is Waardenburg Syndrome?
Genetic condition causing pale blue eyes, hearing loss and patches of white skin and hair associated w/ Hirschprung’s
What is the presentation of Hirsphrung’s disease?
Acute Intestinal Obstruction
Delay in passing meconium (more than 24 hours)
Chronic constipation since birth
Abdominal pain and distention
Vomiting
Poor weight gain and failure to thrive
What is Hirshprung - Associated Enterocolitis?
Inflammation and obstruction of the intestine occurring in neonates with Hirschsprung’s disease
Presentations
- Fever
- Abdominal distention
- Diarrhoea (+/- Blood)
- Sepsis
Life Threatening
Toxic megacolon and Bowel perforation
- Requires urgent antibiotics, fluid resuscitation and decompression of the obstructed bowel
What investigations can be done for Hirschprung’s?
Abdominal X Ray - Intestinal Obstruction
Rectal Biopsy w/ Histology = Gold
What is the management of Hirsphrung’s disease?
Hirschprung’s Associated Enterocolitis
- Initial fluid resus and management of intestinal obstruction
- IV abx are required with HAEC
Definite management
- Surgical removal of the aganglionic section of the bowel
What is intussusception and pathophysiology
Bowel invaginates into itself thickening the bowel and narrowing the lumen at the folded area
- Leads to a palpable mass in the abdomen and obstruction to the passage of faeces through the bowel
In whom is intussusception most common in?
- 6 months to 2 years
- Males
Which conditions are associated with intussusception
Concurrent viral illness
Henoch-Schonlein purpura
Cystic fibrosis
Intestinal polyps
Meckel diverticulum
What is the presentation of intussusception?
Knees to chest (After eating)
Severe, colicky abdominal pain
Pale, lethargic and unwell child
“Redcurrant jelly” stool
Vomiting/ Intestinal obstruction
Right upper quadrant palpable mass (Sausage Shaped)
How is the diagnosis of intussusception made?
Gold = USS
- Target Sign/ Concentric (hypo) echogenic bands
-
Contrast Enema
How is Intussusception managed?
Therapeutic enemas
- Contrast/ water/ air are pumped into the colon to force the folded bowel out of the bowel and into the normal position.
- 1st = Air Enema (Rectal Air Insufflation)
- 2nd = Contrast/ Water (Hydrostatic)
Surgical reduction - Enema Failed
Surgical Resection - Gangrenous/ Perforated
What are the Complications of Intussusception?
Obstruction
Gangrenous bowel
Perforation
Death
What is Bililary Atresia?
Congenital condition in which a section of the bile duct is either narrowed or absent.
What are the two types of Billiary Atresia?
- Perinatal (Acquired) - Symptoms <3 weeks post birth
- Fetal (Embryonic) - Undeveloped Bile ducts = Earlier Symptoms
What is the patho of biliary atresia?
- Absent or narrowed bile duct results in cholestasis
- Bile cannot be transported from the liver to the bowel
- Conjugated bilirubin is excreted in the bile so prevents excretion
What is the presentation of biliary atresia?
Significant Jaundice after birth (High Conjugated bilirubin)
Persistent jaundice > 2 weeks
Dark Urine (Increased Bilirubin)
Pale Stools (Decreased Bile)
Hepatomegaly (Increased Bile)
Splenomegaly (Portal Hypertension)
Failure to Thrive (Malabsorption)
What are the investigations for biliary atresia?
1) Clinical Observations and Abnormal LFT’s
- Raised AST/ALT and Conjugated Bilirubin
Ultrasound = 1st Line Imaging
Percutaneous Liver Biopsy = Diagnostic
Cholangiography = Gold if Uncertain
Other
- New-born blood spot test (Rule out Cystic Fibrosis)
- HIDA Scan ( Lack of bile flow from liver to instetines)
Give an example of another Benign cause of jaundice
Breast Milk Jaundice
What is the management of biliary atresia?
Kasai Portoenterostomy
- Removing damaged bile ducts and replacing them with a loop of intestine to allow bile to follow into the bowel
Liver Transplant
- If portoenterostomy fails
Antibiotic prophylaxis
- To prevent cholangitis
What are the complications of biliary atresia?
- Ascending Cholangitis
- Portal Hypertension
- Cirrhosis which can lead to HCC
What is Acute Gastritis?
Inflammation of the stomach
What does Acute Gastritis present with?
- Nausea and vomiting
- Indigestion
What does enteritis mean?
Inflammation of the Intestines
What does enteritis present with
Diarrhoea
What is gastroenteritis?
Inflammation from the stomach to the intestines
- Presents with nausea, vomiting and diarrhoea
Whats the most common cause of gastroenteritis?
Viral cause (Rotavirus/norovirus)
Whats the main concern with paediatric gastroenteritis?
Establishing if they can keep themselves hydrated
What are the differential dignoses of gastroenteritis?
Infection (Gastroenteritis)
Inflammatory bowel disease
Lactose intolerance
Coeliac disease
Cystic fibrosis
Toddler’s diarrhoea
Irritable bowel syndrome
Medications (e.g. antibiotics)
What are the causative agents for viral gastroenteritis
- Rotavirus
- Norovirus
- Adenovirus
Name other causative agents of gastroenteritis
- E.Coli
- Campylobacter jejuni
- Shigella
- Salmonella
- Bacillus Cereus
- Yersinia enterocoliticia
- Staphylococcus Aereus toxin
- Giardiasis
Why should antibiotics be avoided if E.coli gastroenteritis is suspected?
Increases the risk of the haemolytic uraemic syndrome
What are the symptoms of E.coli gastroenteritis?
E.coli produces the shiga toxin
Causes abdominal cramps, bloody diarrhoea and vomiting.
Which bacteria normally causes travellers diarrhoea?
Campylobacter jejuni
How is campylobacter jejuni spread (traveller’s diarrhoea)
- Raw or improperly cooked meats/ BBQ
- Untreated water
- Unpasteurised milk
What are the symptoms of Campylobacter jejuni gastroenteritis?
Abdominal cramps
Diarrhoea often with blood
Vomiting
Fever
Which antibiotics can be considered for campylobacter jejuni gastroenteritis?
Azithromycin
Ciprofloxacin
How is salmonella spread?
Eating raw eggs/ poultry/ food contaminated with the infected faeces of small animals
What are the symptoms of gastroenteritis caused by salmonella?
Watery diarrhoea with mucus or blood, abdominal pain and vomiting
Which toxin does staphylococcus Aureus produce which causes gastroenteritis symptoms?
Enterotoxins - causes small intestine inflammation and causes diarrhoea, perfuse vomiting and abdominal cramps and fever
What is the pathophysiology of Giardiasis?
Microscopic parasite
- Lives in the small intestine of mammals
- Release cysts in the stool of infected animals
- Faecal-oral transmission
- Can cause chronic diarrhoea
What can giardiasis be treated with?
Metronidazole
What are the principles of gastroenteritis management?
1) Isolate patient and Infection Control
2) Stool MSU
3) Maintain hydration w/ Fluid challenge orally or IV fluids
High Risk? Antibiotics after determining cause
Antidiarrhoeal medication is not recommended
Name some post-gastroenteritis complications
Lactose intolerance
Irritable bowel syndrome
Reactive arthritis
Guillain–Barré syndrome
what does failure to thrive refer to?
–> poor physical growth and development in a child
How do the NICE guidelines define faltering growth in children?
- One or more centile spaces if their birthweight was below the 9th centile
- Two or more centile spaces if their birthweight was between the 9th and 91st centile
- Three or more centile spaces if their birthweight was above the 91st centile
What are the causes of failure to thrive?
- Inadequate nutritional intake
- Difficulty feeding
- Malabsorption
- Increased energy requirements
- Inability to process nutrition
What are the causes of inadequate nutritional intake (failure to thrive)
Maternal malabsorption (Breastmilk)
Iron deficiency anaemia
Family or parental problems
Neglect
Availability of food (i.e. poverty)
What are the causes of difficulty feeding (failure to thrive)
Poor suck, for example, due to cerebral palsy
Cleft lip or palate / Genetic Malformation
Pyloric stenosis
What are the causes of malabsorption (failure to thrive)
Cystic fibrosis
Coeliac disease
Cows milk intolerance
Chronic diarrhoea
Inflammatory bowel disease
What are the causes of increased energy requirements (failure to thrive)
Hyperthyroidism
Chronic disease (congenital heart disease and cystic fibrosis)
Malignancy
Chronic infections (HIV or immunodeficiency)
IWhat causes the Inability to process nutrients properly (failure to thrive)
Inborn errors of metabolism
Type 1 diabetes
How do you carry out an assessment in failure to thrive patients?
- Pregnancy, birth, developmental and social history
- Feeding or eating history w/ Observation
- Mum’s physical and mental health and interaction w/ child
2 years +
- Height, weight and BMI on a growth chart
- Calculate the mid-parental height centile
Inadequate Nutrition/ Growth if…
- Height more than 2 centile spaces below the mid-parental height centile
- BMI below the 2nd centile
What are the investigations in children who fail to thrive?
Urine dipstick (UTI)
Coeliac screen (anti-TTG or anti-EMA antibodies)
History suggestive of underlying cause
What is the management for faltering growth?
MDT Approach
All children with faltering growth should have regular reviews to monitor weight gain
Breastfeeding
Support from midwives, health visitors, peers groups and “lactation consultants”
Rx = Supplementational Milk w/ Breastfeeding
Dietetics
Regular Meals and Snacks
Reduce milk consumption (Increase appetite)
Review by a dietician
Additional energy-dense foods to boost calories
Nutritional supplements drinks
Severe Concerns
Enteral tube feeding. This needs to have clear goals and a defined endpoint.
What is the pathology of meckles diverticulum
Abnormal pouch on the antimesenteric side of the ileum due to failed obliteration of the Vitellin/ Omphalomesenteric duct
+/- Ectopic Epithelia
What are the rule of 2 features in Meckle’s Diverticulum?
2:1 Male to Female ratio
2 cm in length
2 feet proximal to caecum
2% of population
What is a true diverticulum
contains all three layers of the intestinal wall
What are the complications of Meckles Diverticula?
Ulcers from HCI secretion
Perforation
Food impaction
Peritonitis/Peritoneal adhesions
Intussusception/ volvulus
What are the signs and symptoms of meckels diverticula?
Asymptomatic
Painless Rectal Bleeding
Abdominal pain/distention
Billious Vomiting
Constipation
How is the diagnosis of Meckles diverticula made?
Incidental (Abdo USS or CT or Surgery)
Technitium 99 scan
What might you see on Ultrasound for Meckle’s Diverticulum?
Small fluid filled pouch @ distal small intestine
What is the treatment for Meckles diverticulum?
Surgical resection
NG Tube if Acutely unwell
What is cows milk protein allergy?
Hypersensitivity reaction vs proteins in cow’s milk affeting under 3’s
What is the pathophysiology of cows milk protein allergy?
IgE mediated
Rapid reaction to cows’ milk protein
Non-IgE mediated
Slow reaction over several days
Process in non allergic and does not involve the immune system
In whom is Cow’s milk protein allergy more common in?
Formula fed babies
History of Atopy
What is the presentation of cow’s milk protein allergy?
Presents before 1 year of age
Apparent when weaned off breast milk
Present in breastfed babies if mother consuming dairy
GASTRO SYMPTOMS
Bloating and wind
Abdo pain/ Diarrhoea and vomiting
General allergic symptoms
Hives/ Eczema/ Facial Swelling
Cough/ wheeze/ sneeze
Watery eyes
Severe = Anaphylaxis
What is the management of cows’ milk protein allergy?
Breastfeeding? Avoid Dairy
Replace formula with special hydrolysed formula designed for Cow’s milk allergy
–> severe cases infants may require elemental formulas made up of basic amino acids
How is cows milk protein allergy diagnosed?
1) History and examination
2) Skin prick testing
Gold = Avoiding cow’s milk should fully resolve the symptoms
Whats the difference between Cow’s milk intolerance and Cow’s milk allergy?
Intolerance = No Allergic Features
Allergy = Allergic Features
Allergic Features
Rash, Angioedema, Sneezing and Coughing
Describe the process of Bilirubin Excretion
RBC Breakdown
Blood = Haem and Unconjugated Bilirubin
Liver = Unconj. Bilirubin converted to Conjugated
GI Tract/ Urine = Excretion
Describe why physiological jaundice can occur
1) High concentration of red blood cells in the fetus and neonate
- w/ fragile RBC and Less developed Liver
2) Rapid breakdown of fetal RBC = releasing lots of bilirubin
3) Jaundice 2-7 days of age, usually reoslves by 10 days
If Jaundice <24hrs of birth = Pathalogy
What are the causes of neonatal jaundice
Increased production of bilirubin
- Haemolytic disease of the newborn
- ABO incompatibility
- Haemorrhage/ Intraventriculary Haemorrhage
- Cephalo-haematoma
- Polycythaemia
- Sepsis and DIC
- G6PD deficiency
Decreased clearance of bilirubin
- Prematurity
- Breast milk jaundice
- Neonatal cholestasis
- Extrahepatic biliary atresia
- Endocrine disorders (hypothyroid and hypopituitary)
- Gilbert syndrome
When is Jaundice seen as pathological in a neonate?
When its presents in the first 24 hours of life - urgent investigations and management needed
Why might jaundice present in the first 24 hours of life in a neonate?
Neonatal sepsis
Why is physiological jaundice exaggerated in premature neonates?
Immature Liver
What does physiological jaundice in premature neonates increase the risk of?
Kernicterus - brain damage due to the high bilirubin levels crossing B-B Barrier
Why are babies who are breastfed more likely to develop jaundice?
Components of Breastmilk
- inhibit the ability of the liver to process bilirubin
Inadequate Feeding
- Risk of Dehdration
- Slow stool passage = bilirubin absoprtion in intestines
Which disease is a cause of haemolysis and jaundice in neonates?
Haemolytic disease of the new born
What causes haemolytic disease of the newborn?
Incompatibility between the rhesus D antigens on the surface of RBC of the mother and fetus
What is the pathophysiology of haemolytic disease of the newborn
Rhesus D Negative Mother? Assume baby is Rhesus D Positive
Baby presents D Antigen, Mother does not
If baby’s blood interacts w/ mother’s it can cause the mother to become sensitised
Sensitising the mother produces antigens vs Rhesus D in subsequent pregnancies
The mother’s blood now with antigens can cross placenta and target a “Positive Baby”
This leads to haemolysis causing anaemia and jaundice
When is jaundice termed as prolonged?
More than 14 days in full-term babies
More than 21 days in premature babies
Which investigations should be carried out for neonatal jaundice?
FBC and blood film (Polycythaemia or Anaemia)
Conj. Bilirubin: Raised in Hepatobilliary disease
Blood type testing (ABO Incompatability/Rhesus)
Direct Coombs Test (direct antiglobulin test) for haemolysis
Thyroid function : Hypothyroidism
Blood and urine cultures
Glucose-6-phosphate-dehydrogenase (G6PD) levels for G6PD deficiency
what is the management of neonatal jaundice?
Monitor Bilirubin levels and plot on threshold charts (Gestational age @ birth)
- X Axis = Age of baby
- Y Axis = Total Billirubin
Commence Treatment if threshold met…
- Phototherapy (blue light)
- Exchange transfusion
What is kernicterus
Brain damage caused by excessive bilirubin levels
What is the pathophysiology of kernicterus?
1) Bilirubin crosses the blood brain barrier
2) Direct damage to the central nervous system
Permanent CNS Damage? Cerebral Palsy, LD and Deafness
What is the presentation of kernicterus?
- Less responsive
- Floppy/ Drowsy baby
- Poor feeding
What are some medical causes of abdominal pain in children?
Constipation
UTI/ Pyelonephritis
Coeliac/ IBD/ IBS
Mesenteric adenitis
Abdominal migraine
Henoch-Schonlein purpura
Tonsilitis
Diabetic ketoacidosis
Infantile colic
Adolescent Girls
Dysmenorrhea (period pain)
Mittelschmerz (ovulation pain)
Ectopic pregnancy
Pelvic inflammatory disease
Ovarian torsion
Pregnancy
Name some surgical causes of abdominal pain
- Appendicitis causes central abdominal pain spreading to the right iliac fossa
- Intussusception causes colicky non-specific abdominal pain with redcurrant jelly stools
- Bowel obstruction causes pain, distention, absolute constipation and vomiting
- Testicular torsion causes sudden onset, unilateral testicular pain, nausea and vomiting
What are the red flags for serious abdominal pain?
Persistent/ Bilious vomiting
Severe chronic diarrhoea
Fever
Rectal bleeding
Weight loss or faltering growth
Dysphagia (difficulty swallowing)
Night time pain
Abdominal tenderness
Name some initial investigations that may indicate abdominal pathology
Anaemia
Inflammatory bowel disease or coeliac disease
Raised ESR/CRP
Inflammatory bowel disease
Raised anti-TTG or anti-EMA antibodies
Coeliac disease
Raised faecal calprotectin
Inflammatory bowel disease
Positive urine dipstick
Urinary tract infection
What is infantile colic?
Self-limiting condition seen in infants less than 3 months old
Bouts of excessive crying and pulling up of the legs
Worse in the evening with no obvious cause
what happens in acute pyelonephritis?
Complicated UTI
Ascending Bacetrial Infection that affects the tissue of the kidney
Scarring of the tissue w/ reduction in kidney function
what is cystitis?
Inflammation of the bladder
What are the symptoms of a UTI?
–> Could only be a fever
BABIES - present non specifically
- fever
- lethargy
- irritability
- vomiting
- poor feeding
- urinary frequency
OLDER INFANTS/CHILDREN
- fever
- abdo pain - suprapubic
- vomiting
- dysuria
- urinary frequency
- incontinence
How is a diagnosis of acute pyelonephritis made?
A temperature greater than 38°C
Loin pain or tenderness
how should a sample for urine dipstick be taken?
Clean catch sample
- Straight into bottle
- Urine Collection Pad> Bag
- In and Out Catheter
- Suprapubic Aspiration
What do the results on a urine dipstick show?
Nitrites
Gram-negative bacteria (such as E. coli) break down nitrates, a normal waste product in urine, into nitrites. The presence of nitrites suggest bacteria in the urine.
Leukocytes
White blood cells found in the urine. A urine dipstick tests for leukocyte esterase, a product of leukocytes that give an indication about the number of leukocytes in the urine.
Nitrites ++ Leukocytes ++ = UTI
Nitrites ++ = UTI
Leukocytes ++ = Non UTI unless Clincial
What investigations should be carried out for acute UTI’s
1) Urine dipstick
2) MSU sample to the microbiology lab to be cultured and have sensitivity testing.
whats the management for UTI’s
Less Than 3 Months
Immediate IV antibiotics (Ceftriaxone) w/ full septic screen
Consider Lumbar Puncture
Older Than 3 Months
Sepsis/ Pyelonephritis? IV Antibiotics
Systemically well? Oral Antibiotics
- Trimethoprim
- Nitrofurantoin
- Cefalexin
- Amoxicillin
What are the investigations for recurrent UTI’s?
1) Ultrasound Scans
- <6 Months w/ 1st UTI <6 weeks of infection
- Any child w/ Recurrent UTI while infected
- Any child w/ Atypical UTI while infected
Other
- DMSA scans - kidney damage/scaring
- MAG - Visualise Reflux
- MCUG - Micturating Cystourethrogram
What is nocturnal and diurnal enuresis?
nocturnal enuresis - unable to control bladder at night
Diurnal enuresis - unable to control the bladder function during the day
Whats the difference between primary and secondary nocturnal enuresis?
Primary nocturnal enuresis - The child has never managed to be consistently dry
Secondary nocturnal enuresis - Child begins to wet themselves when they have previously been dry for at least 6 months
What are the causes of primary nocturnal enuresis?
–> variation of normal development especially if the child is less than 5 years old - most common
–> Overactive bladder. Frequent small-volume urination prevents the development of bladder capacity.
–> Fluid intake prior to bedtime, particularly fizzy drinks, juice and caffeine, which can have a diuretic effect
–> Failure to wake due to particularly deep sleep and underdeveloped bladder signals
–> Psychological distress, for example, low self-esteem, too much pressure or stress at home or school
–> Secondary causes such as chronic constipation, urinary tract infection, learning disability or cerebral palsy
What is the management of primary nocturnal enuresis?
–> Reassure parents of children under 5 years that it is likely to resolve without any treatment
–> Lifestyle changes: reduced fluid intake in the evenings, pass urine before bed and ensure easy access to a toilet
–> encouragement and positive reinforcement. Avoid blame or shame. Punishment should very much be avoided.
–> Treat any underlying causes or exacerbating factors, such as constipation
–> Enuresis alarms
–> Pharmacological treatment - Desmopressin - analogue of ADH, oxybutynin - anticholinergic (reduces contractility) and imipramine - TCA
What are the causes of secondary nocturnal enuresis?
Urinary tract infection
Constipation
Type 1 diabetes
New psychosocial problems (e.g. stress in family or school life)
Maltreatment - deliberate bedwetting
How is secondary nocturnal enuresis managed?
treating the underlying cause e.g constipation/UTI easy to treat
what are the two different types of Diurnal enuresis?
–> Urge incontinence is an overactive bladder that gives little warning before emptying
–> Stress incontinence describes leakage of urine during physical exertion, coughing or laughing.
What are some potential causes of diurnal enuresis?
Recurrent urinary tract infections
Psychosocial problems
Constipation
What is the pathophysiology of nephrotic syndrome?
–> basement membrane becomes highly permeable to protein, allowing proteins to leak from the blood into the urine
In which ages is nephrotic syndrome most common?
2 to 5 years
What does nephrotic syndrome present with?
Frothy urine
generalised oedema
pallor
