Newman HYHO Flashcards
(23 cards)
Most helpful study to quantify the severity of reflux?
24-hour intra-esophageal pH and IMPEDANCE monitoring.
i. We talked in class about how pH and manometry is better than pH alone…but the absolute BEST is pH and impedance testing…the impedence testing measures the direction of bolus movement in the esophagus via measurement of changes in resistance to alternating electrical current when a bolus passes by a pair of metallic rings mounted on the catheter. IMPEDENCE MONITORING WAS NOT MENTIONED IN CLASS…BUT IT IS IMPORTANT TO KNOW.
Presentation of Gastroesophageal reflux in Peds patient
a. Caused by “floppiness” of the lower esophageal sphincter.
b. Inability to “keep it down” can cause slowing of weight gain and sometimes even weight loss.
c. Get a detailed history of vomiting: timing with intake, force of emesis, amount, appearance, onset, what makes it worse/better, previous occurrence, associated symptoms (diarrhea, gas, bloating, retching, etc.)
d. A detailed history of feeding/eating is essential: schedule, type of food, amount ingested
e. Persistent reflux of acidic stomach contents up into the esophagus can cause esophagitis resulting in fussiness and sometimes (not commonly) resulting in feeding aversion.
f. GER: the happy spitter, gaining weight, refluxes while smiling
what are signs or symptoms of gastroesophageal reflux disease in peds?
GER with signs/symptoms like fussiness, arching, crying, esophagitis on endoscopy, slow weight gain or weight loss.
what is the most common location for intussusception for children?
Most are ileo-colic with the ileum invaginating into the colon at the ileocecal junction
presentation of peds patients with intussception?
Blood supply to intestines in that area becomes compromised
80% of kids will have rectal bleeding (or “currant jelly stools”)
fairly sudden onset of intermittent severe abdominal pain and emesis
Frequently associated with a right upper quadrant “sausage-like” mass
One of the most common causes of intestinal obstruction in infancy
Often reduced with an air enema
what are the presentations of Pyloric stenosis in Peds?
HYPOCHLOREMIC, HYPOKALEMIC, METABOLIC ALKALOSIS
Most common age 2-4 wks of life
Boys 4:1 over girls
Projectile vomiting
Dehydration
Poor wt gain or losing wt
Palpable olive in epigastric area
Peristaltic abdominal waves with eating
what characteristics are suggestive of disease for Hirschsprung disease?
Failure to pass meconium within the first 24-48 hours of like
Palpable stool in throughout abdomen
Empty rectal vault
Hx of never having an unassisted stool
how is a definitive diagnosis determined for Hirschsprung disease?
Rectal Biopsy
what is the significance of unconjugated billirubin that is not bound to albumin?
It is lipid soluble and can cross the BBB and cause Billirubin Induced Neurologic Dysfunction also called kernicterus
what is elevated conjugated bilirubin suggestive of?
Problems in the liver/biliary tree
what is the function of the Direct coombs test?
performed directly on rbc’s from the patient. It is used in situations where hyperbilirubinemia is felt to result from hemolysis, especially ABO incompatibility in newborns. It is a test that looks for antibodies directly on the rbc’s of the baby.
what is the function of the indirect coombs test
performed on the serum from a blood sample and is used to look for antibodies that could bind to certain rbc’s, leading to problems if blood mixing should occur (as in transfusions).
what is the significance of stool passage in newborn as it relates to enterohepatic function
The passage of stool is an important way that the infant gets rid of excess bilirubin.
Stool remaining in the gut for a longer period of time allows for more breakdown of conjugated bilirubin and more reabsorption into the blood.
what babies are at risk for hyperbilirubinemia secondary to blood group incompatibillity
The babies most at risk for hyperbili are those born to moms who are Type O or Rh negative.
since the moms have the antibodies against type A, B, and Rh
what are the most common causes of Non-Pathologic unconjugated hyperbilirubinemia in a baby
physiologic jaundice (increase hemolysis of rbc’s…non pathologic)
Breast feeding/breast milk jaundice
Prematurity
what are the most common causes of Pathologic unconjugated hyperbilirubinemia? in peds
Increased bili production”
- Erythrocyte enzyme deficiencies
- ABO incompatibility
- Rbc structural defects
ii. Deficiency of hepatic uptake
iii. Impaired conjugation of bilirubin:
1. Gilbert syndrome
2. Crigler-Najjar syndrome type 1
3. Severe UGT1A1 deficiency
Increased enterohepatic circulation
what is the difference between Crigler-Najjar type 1 and type 2
a. Type 1 (total UDPGT deficiency) results in SEVERE hyperbilirubinemia with high risk of BIND/Kernicterus
b. Type 2 (partial UDPGT deficiency) results in mild hyperbilirubinemia with low risk of BIND/Kernicterus
what to think if you see elevated conjugated bilirubin levels in an infant and what are its symptoms
b. S/Sx of biliary atresia:
i. Cholestatic jaundice (conjugated hyperbili)
ii. Hepatomegaly
iii. Acholic stools
what is the pathophysiology behind bilirubin induced neurologic dysfunction
aka Kernicterus
a. Lots of free (not bound to albumin) unconjugated bilirubin. Free unconjugated bilirubin in lipid soluble and can cross the BBB. At extremely high levels, the bilirubin that has crossed the BBB can be deposited in the basal ganglia/brainstem resulting in permanent neurologic dysfunction.
what are the 3 phases of bilirubin toxicity in a neonate
a. Phase 1 (first 1-2 days): poor suck, high pitched cry, listless, poor tone, yellow skin, if high enough can seize
b. Phase 2 (3-5 days); hypertonia of muscles, opsithotonus (rigid arching), retrocollis, can be fever
c. Phase 3 (end of first week and beyond): hypertonia
what are the characteristics of breast feeding jaundice
i. A combination of baby knowing how to nurse and mom’s milk not coming in right away
ii. Basically a physiologic jaundice that is exacerbated by mild to moderate dehydration and increased enterohepatic circulation in the baby.
iii. When everything calms down…baby learns, mom’s milk comes in…all is well.
what are the characteristics of breast-milk jaundice
i. Not completely understood
ii. Likely some factor in the breast milk that inhibits the conjugation of bilirubin.
iii. Can last 3-6 weeks
iv. If the hyperbili is lasting beyond the 6-8 week period, consider other things
v. It will go away…try to nurse through it
how does phototherapy decrease the levels of bilirubin in infants?
a. It isomerizes unconjugated bilirubin making it water soluble
b. Water soluble isomers can be eliminated by the body without conjugation by the liver.