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PAEDIATRICS REVISION
44

We are covering Common gastrointestinal disorders Infections and allergies Neonates.

Jan 21, 2016

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Evan Williamson
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PAEDIATRICS REVISION We are coveringCommon gastrointestinal disordersInfections and allergiesNeonates

Common GI disorders

IntussusceptionInvagination of proximal bowel into a distal segmentCommonest cause of obstruction in infants after neonatal period3 months 2 years

PresentationHistory:Paroxysmal, severe, colicky painDraws up legsRefuse feedsVomitingRedcurrant jelly stool O/E:Sausage shaped mass Abdo distension

Complications: Shock Perforation, PeritonitisGut Necrosis Investigations: X-ray, USSTreatment:Fluid resusIf signs of peritonitis: rectal air insufflationIf doesnt work: operative reduction

Vomiting DefinitionsPossetingSmall, milk, non-forceful, burpingRegurgitationLarger, milk, non-forcefulVomitingForceful, gastric contents

Gastro-oesophageal refluxCommon in infancy due to: Fluid dietHorizontalShort intra-abdo length of oesophagusRelaxed LOS

Complications:Failure to thriveOesophagitis (haematemesis, iron deficiency)Aspiration pneumonia

Investigation: none. ?pH, endoscopy, biopsy, contrast studyManagement: Feed thickening + upright posturingMeds: PPI, H2 receptor antagonistSurgery: fundoplication

A 6 week old baby boy has seen a multiple doctors over the past 2 weeks because of vomiting. He has been started on omeprazole and thickened feeds to treat a presumptive diagnosis of reflux.

His parents are concerned as he remains unwell. They bring him to A+E for another review. His vomiting is worse and occurs after every feed. He has less wet nappies, lethargy and some weight loss.

Differential Diagnoses of the vomiting childLETS PLAY CLASSIFY OR DIEVITAMIN DV:intracranial haemorrhageI: UTI, gastroenteritis, pneumonia, otitis media, meningitisT: trauma, non-accidental injuryA:coeliacM: GORD, pyloric stenosis, intussusceptionI: Feeding problems, over feedingN:intracranial tumourD: malrotation of midgut

Mechanical causes gastroesophageal reflux disease, pyloric stenosis, malrotation with midgut volvulus, intussusception, incarcerated hernia, and tracheoesophageal fistulaCNS causes hydrocephalus, intracranial hemorrhage, and intracranial tumourOther occult trauma or non-accidental injury, toxic ingestion or envenoming (e.g. redback spider), and Munchausens by proxy

Most common causes of non-bilious vomiting: GORD, pyloric stenosis, infection (UTI/gastroenteritis)

V:vascularI:infective/InflammatoryT:traumaticA:autoimmuneM:metabolicI:iatrogenic/IdiopathicN:neoplastic

12Back to the history....A 6 week old baby boy has seen a multiple doctors over the past 2 weeks because of vomiting. He has been started on omeprazole and thickened feeds to treat a presumptive diagnosis of reflux.

His parents are concerned as he remains unwell. They bring him to A+E for another review. His vomiting is worse and occurs after every feed. He has less wet nappies, lethargy and some weight loss.

He projectiles vomits on you, what is the likely diagnosis?What are the risk factors?What would be consistent with this in the history?

Pyloric stenosis hypertrophy, unknown aetiologyRFs: caucasian, male, FHx, first bornVomiting during/after feeds, increasing in freq and force, projectile, Hunger (after feeds), Wt loss.

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AlkalosisMetabolicHypokalaemicHypochloraemicHypochloraemic Hypokalaemic Metabolic AlkalosisHypochloraemic Hypokalaemic Metabolic AlkalosisPersistent emesis causes progressive loss of fluids rich in hydrochloric acid, which causes the kidneys to retain hydrogen ions in favor of potassium.

16Other investigations?Test feedUSManagement?FluidsPyloromyotomyTest feed: See peristalsis wave from L to RPyloric mass in RUQ (olive)US

IV fluids (0.45% saline + 5% dextrose + K+)Pyloromyotomy

17Pyloric StenosisHypertrophy2-7 weeks oldRFs: male, FHx

Vomiting, increasing in freq and force, projectileHungerWt lossHypochloraemic Hypokalaemic Metabolic Alkalosis

Persistent emesis causes progressive loss of fluids rich in hydrochloric acid, which causes the kidneys to retain hydrogen ions in favor of potassium.18Test feed: See peristalsis wave from L to RPyloric mass in RUQ (olive)US

ManagementIV fluids (0.45% saline + 5% dextrose + K+)PyloromyotomyInfections3yo boy bought to GP by his mum, 5 day history of fever. Yesterday noticed a rash and today complaining of a sore throat and rubbing his eyes.O/E: macular papular rash on torsoBilateral conjuctivitisRed, cracked lips, strawberry tongueSwollen red palmskawasakis21Kawasaki disease criteria

Kawasakis Disease: a vasculitis3yo boy, 5 day fever, rash, sore throat, red eyesO/E: macular papular rash on torsoBilateral conjuctivitis (without exudate)Red, cracked lips, strawberry tongueSwollen red palms (changes in extremeties - desquamation)Cervical lymphadenopathy

Must have fever > 5days plus 4 of 5 criteria23KawasakisBloods:Inflammatory markersIncr plateletsComplications:Coronary vessel aneurysm (so do echo!)Management:IVIGAspirin

Measles:CoughCoryzaConjunctivitsKopliks Spots Rash spreads from behind the ears to bodyMumps:Parotid glandComplications: meningitis, orchitis, hearing lossRubella:Fever, rash starts on face, dangerous in pregnancy (cataracts, deafness, congenital heart disease)

Self-limiting, supportive treatment

Things we have not coveredSepticaemia, meningitis, encephalitisHerpesChickenpoxEBV, CMV, parvovirusTBHIVSkin infections (impetigo, scalded skin)Immunisation schedule

AllergyFood allergies Symptoms 10 mins after eating: itch, swelling, wheeze, rashGI: diarrhoea, vomiting, failure to thrive, colicNon-IgE mediatedEczemaNon-IgE mediated

Eczema HerpeticumHSV1 Vesicular lesions on eczema FeverLethargy, distressVery serious, needs antivirals

Review eczema!NeonatesNeonatal Jaundice2w if term >3w if preterm