Vomit Description

Bilious

Varies

Bilious

■ FINBINGS/KRV WORDS

. Currant-jelly.stoo(s(blood and roucus), palpable sausagti-shaped mass,-diagnose and treat with barium enema

Hrvjrutnrt babies,-fever, rectal bleeding/air in.bowel wall;'

■ treav with NFQ, wogafittfc tube,- IV fluids', antibiotics '

. Cystic .fibrosis iraoifestatio»' (as is rectal prolapse).

Sudden oiwet'of pa'iti, distention., rectal .bleeding, perito-■'is'itis, "fed's.beak" on abdominal x-.-ray; neat with surgery

■Rule ©f.2s*;GI- ulceration, or'bleeding; use Meckel's scan'

Physical exam detects- bpwel loops in- inguiaat canal

*Jtuk; of 2s for Meckel V.diverticulum: -2% of population'affected (ntost common Qt tract abnortnjiity-^ramwiin of the -OTOplMl«irter "sciitetic duct), 2 Inches long, within-2 feet of ileocolic junction,'-presents i-n first 2 years of life, Meckel's diverticulum may cause-lmmi ■susceptiou, obstruction, or volvulus,

Diaphragmatic hernia: more common in males and. on the left side. The main point to know is that bowel herniates into the thorax, compressing and impeding lung development (pulmonar y hypoplasia develops). Patients present with respiratory distress and have bowel sounds in the chest/bowel loops in the thorax on chest x-ray.

Omphalocele vs..gastroschisis: omphalocele :is in the midline. Sac contains multiple abdominal organs, the umbilical ring is absent, and other anomalies are common. Gastroschisis is to the right of the midline. Only small bowel is exposed (no true hernia sac), the umbilical ring is present, and other anomalies are rare.

Henoch -Sdionlein purpura may present with GI bleeding and abdominal pain. Look for his tory of upper respiratory infection, characteristic rash on lower extremities and buttocks, swelling in hands and feet, arthritis, and/or hematuria/proteinuria. Treat supporti vely.

Note: Children (more than adults) develop nausea and vomiting and/or diarrhea with any systemic illness.'I licy also may develop inflammatory bowel disease or irritable bowel, syndrome and often have GI complaints with anxiety or psychiatric problems (separation anxiety, reluctance to go to school, depression, child abuse).

Neonatal jaundice: may be physiologic or pathologic.The first step is to measure total, direct, and indirect bilirubin.The main concern is kernicterus, which, is due to high levels of unconjugated bilirubin and. subsequent deposit into the basal ganglia. Look for poor feeding, seizures, flac eidity, opisthotonos, and/or apnea to accompany severe jaundice.

Physiologic jaundice: in 50% of normal infants; even more common in premature infants. Bilirubin is mostly unconjugated. In preterm infants, bilirubin is < 15 mg/dl, peaks at 3—5 days and may be elevated for up to 3 weeks. In full-term, infants, bilirubin is < 12 mg/dl, peaks at 2-4 days, and returns to normal by 2 weeks.

Pathologic jaundice: levels rise higher than normal and continue to rise or fail to decrease appropriately. Any jaundice present at birth is pathologic.

1. Breast milk jaundice: breast-fed infants with peat bilirubin of 10-2,0 mg/dl occurring at 2-3 weeks of age. Treat with temporary cessation of breast feeding (switch to bottle) until j aundice reso I v es.

t. Illness: infection/sepsis, hypothyroidism, liver insult, cystic fibrosis, and other illnesses may prolong neonatal jaundice and lower-the threshold for kernicterus. The youngest, sickest infants are at greatest risk for hyperbilirubinemia and kernicterus.

3, Hemolysis: from Rh incompatibility or congenital red cell diseases that cause hemolysis in the neonatal period. Look for anemia, peripheral smear abnormalities, family history, and higher level of unconjugated bilirubin.

4. Metabolic: Crigler-Najjar syndrome causes severe unconjugated hyperbilirubinemia, Gilbert's disease causes mild unconjugated hyperbilirubinemia, and Rotor and Dubin-Johnson syndromes cause conjugated hyperbilirubinemia.

5, Biliary atresia: full-term infants with clay- or gray-colored stools and high levels of conjugated bilirubin. Treat with surgery.

6. Medications: avoid sulfa drugs in neonates (displaces bilirubin from albumin and may precipitate kernicterus).

Treatment for unconjugated hyperbilirubinemia that persists, rises higher than fS mg/dl, or rises rapidly is phototherapy to convert the unconjugated bilirubin to a water-soluble form that can be excreted, The last resort is exchange transfusion (do not even think about it unless the level of unconjugated bilirubin is > 20 mg/dl).

Note: Any infant born to a mother with active hepatitis B should get the first immunization shot and hepatitis B immunoglobulin at birth.

You must understand the hypothalamic-pkuitary axis so that you can distinguish primary from secondary disorders. In primary endocrine disturbances, the gland itself is malfunctioning (e.g., from tumor, inflammation., enzyme deficiency), but the pituitary and hypothalamus are functioning normally and exhibit the appropriate response to the gland's action. For example, thyroid-stimulating hormone (TSH) is low in Graves' disease, because the thyroid is malfunctioning and overprodtices thyroid, hormone. The appropriate response is for the pituitary to secrete less TSH because of feedback inhibi tion. In a secondary endocrine disturbance, the gland is perfectly normal, but the pituitary or hypothalamus is malfunctioning. For example, if the pituitary secretes low levels of TSH or the hypothalamus secretes low levels of thyrotropin-releasing hormone (TRH) in. patients with, hypothyroidism, the pituitary or hypothalamus is malfunctioning, because it should be secreting high levels ofTSH or TRII when the level of thy roicl hormone is inadequate.

Hypothyroidism: look for classic symptoms of fatigue, bradycardia, menstrual disturbances (usually metrorrhagia), slow speech, cold intolerance, constipation, carpal tunnel syndrome, decreased reflexes, anemia of chronic disease, and/or coarse hair. Hypothyroidism may be associated hypercholesterolemia, which resolves with treatment. Check thyroid function tests (TSH, thyroxine [T4 ], free thyroxine index [ FIT J). Usually TSH is high, andT4 (primary) is low. Treat with thyroid hormone (synthetic T4).

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