Paeds GI, nutrition and genitourinary (ILA 4) Flashcards
(155 cards)
1
Q
Define possetting
A
non forceful return of small amounts of milk which is often accompanied by the return of swallowed air “wind”
2
Q
Define regurgitation
A
non forceful return of large amounts
3
Q
Define vomiting
A
forceful ejection of gastric contents
4
Q
List the differentials for vomiting in an infant
A
colic **
GORD **
feeding problems
gastroenteritis or any infection
dietary problems e.g. cows milk protein intolerance
intestinal obstruction - pyloric stenosis, atresia, intussusception, volvulus, Hirschprungs
5
Q
List the differentials for vomiting in a pre school child
A
gastroenteritis infection e.g. UTI, meningitis coeliac disease appendicitis intestinal obstruction torsion of testes renal failure
6
Q
List the differentials for vomiting in a school age/ adolescent child
A
gastroenteritis infection e.g pyelonephritis, sepsis, meningitis crohns, ulcerative colitis coeliac disease appendicitis bulimia/ anorexia pregnancy migraine renal failure DKA
7
Q
Outline the red flags to identify in a vomiting child
A
signs of dehydration
weight loss / faltering growth
bile stained
haematemesis
abdominal tenderness and distension
blood in stool
bulging fontanelle, seizures
projectile vomiting
8
Q
List the signs of dehydration
A
tachycardia tachypnoea dry mucuous membranes reduced skin turgor decreased urine output irritable, lethargic sunken eyes
9
Q
List the signs of hypernatraemic dehydration
A
jitteriness increased muscle tone hyper reflex drowsiness convulsions
10
Q
How is dehydration managed?
A
50 ml/kg of low osmolarity rehydration solution over 4 hours
plus ORS solution for maintenance
continue breastfeeding
11
Q
What is the normal frequency of defection in a child depending on their age?
A
first few weeks of life -> 4 stools per day
1 year old -> 2 per day
breast fed infants -> common not to pass stools for several days
> 3 y/o -> same as adults -> 3 stools per day to 3 stools a week
12
Q
List the causes of constipation
A
idiopathic constipation **
dehydration low fibre in diet drugs e.g. opiates problems with toilet training stress
babies… hirschprungs disease, anorectal abnormalities, hypothyroidism, hypercalcaemia
13
Q
How can constipation present and what would you look for in the history?
A
- STOOL PATTERN
<3 complete stools per week - SYMPTOMS WITH DEFAECATION
distress, straining, blood with stool, pain, poor appetite that improves on passing stool - HISTORY
previous constipation, previous anal fissure
14
Q
identify the red flag clinical features of constipation
A
failure to pass meconium in first 24 hours of life -> Hirschsprungs
faltering growth -> hypothyroidism, coeliac
abdo distension -> Hirschsprungs
abnormal lower limb neurology
15
Q
How is constipation managed?
A
- behavioural - toileting routine, star charts, bowel habit diary
- diet and lifestyle - increase fluid intake and fibre intake
- laxatives 1st line = Movicol paediatric plain (if fails to work after 2 weeks, add Senna a stimulant)
- maintenance laxatives until regular bowel movements 1st line = Movicol
16
Q
List the surgical causes for acute abdominal pain
A
acute appendicitis inguinal hernia meckel diverticulum pancreatitis trauma interssusception intestinal obstruction
17
Q
List the medical causes for acute abdominal pain
A
gastroenteritis UTI hence schonlein purport DKA hepatitis constipation inflammatory bowel disease psychological
18
Q
Define recurrent abdominal pain?
A
pain sufficient to interrupt normal activities and lasts for >3 months
19
Q
List the differentials for recurrent abdominal pain
A
UNKNOWN
GI - crohns, ulcerative colitis, constipation, gastritis, peptic ulcer, IBS, malrotation
GYNAE- endometriosis, dysmenorrhoea, PID, ovarian cysts
PSYCHOLOGICAL- stress, bullying, abuse
URINARY TRACT- UTI, hepatitis, gall stones, pancreatitis
20
Q
How is recurrent abdominal pain managed?
A
- identify any serious causes without multiple investigations e.g. urine microscopy, ultrasound
- full history and examination
- reassure parents
21
Q
What is Gastro-Oesophageal reflux disease?
A
involuntary passage of gastric contents into the oesophagus
caused by inappropriate relaxation of the lower oesophageal sphincter as a result of functional immaturity
22
Q
How does GORD present?
A
recurrent regurgitation ** = non forceful regurgitation of large volumes of milk
well child
dry cough
unhappy lying flat , crying after feeds
23
Q
Who does GORD most commonly affect?
A
very common in infancy, usually resolved by 12 months old
24
Q
Outline the possible complications of GORD
A
failure to thrive
oesophagitis
pulmonary aspiration
dystonic neck posturing
25
How is GORD managed conservatively, medically and surgically?
1. add thickening agent e.g. Nestargel to feeds
2. add 1-2 trial of Gaviscon (alginate therapy) to feeds + smaller more frequent feeds, position head up after feeds
3. add PPI or H2 receptor antagonist to feeds
26
How is pyloric stenosis caused?
hypertrophy of the pyloric muscle causing gastric outlet obstruction and impaired gastric emptying
27
Describe the classic presentation of pyloric stenosis
```
present at 2-7 weeks of age
most commonly boys
projectile vomiting (non bilious)
hunger after vomiting
weight loss
dehydration
```
28
Which metabolic changes would you expect to see in a child with pyloric stenosis?
metabolic alkalosis
hypokalaemia
hyponatraemia
hypochloraemia
29
Which investigation confirms a diagnosis of pyloric stenosis?
ultrasound
30
How is a baby with pyloric stenosis assessed?
1. gastric peristalsis
2. pyloric mass felt - like an "olive"
3. ultrasound** - confirm diagnosis
4. dehydration
31
How is pyloric stenosis managed?
1. IV fluids, correct electrolyte imbalance
| 2. pyloromyotomy "ramstedts procedure"
32
What are the symptoms and signs of acute appendicitis?
```
abdominal pain - initially central/colicky and then localises to RIF (Mcburneys point)
fever
vomiting
anorexia
persistent tenderness
```
33
Outline the necessary investigations for acute appendicitis
1. raised CRP and raised WCC
| 2. ultrasound
34
How is acute appendicitis managed?
appendicectomy!!!1
if suspect perforation, IV fluids and IV antibiotics
35
What is interssusception?
"telescopic bowel"
invagination of the proximal bowel into a distal segment
most common is ileum passing into caecum through the ileocaecal valve
36
Describe the common presentation of interssusception
age 3 months - 2 years old , more common in boys
few days history of severe colicky pain - draw knees in and pale
**intermittent screaming with lethargy in between**
**red currant jelly stool **
billious vomiting
37
What would you expect to find on examination of a child with interssusception?
sausage shaped mass palpable in RLQ**
abdominal distension
38
How is interssusception diagnosed?
ultrasound * - doughnut, target sign , "alternating echogenic and hypoechogenic rings"
39
How is interssusception managed?
1. ABC
2. fluid resus and alert HDU
2. surgery - rectal air insufflation
40
What is meckels diverticulum?
ill remnant of the vitello intestinal duct
can contain ectopic gastric mucosa or pancreatic tissue
41
How is meckels diverticulum remembered?
RULE OF 2...
2 feet from ileo-caecal valve
2% of population
2cm long
(presents with rectal bleeding and anaemia)
42
How is meckels diverticulum managed?
1. technetium scan
| 2. surgical resection
43
What is the most common viral cause of gastroenteritis?
rotavirus infection (60%)
44
List the bacterial causes of gastroenteritis?
campylobacter jejuni infection - abdo pain, most common
shigella - blood in stool, tenesmus
salmonella - blood in stool, tenesmus
cholera - profuse, watery, rapidly deteriorating
E.coli - profuse, rapidly deteriorating, most common cause of traveller diarrhoea
staph aureus- cause acute food poisoning, resolves in 2 days
45
How might gastroenteritis present?
```
loose/watery stools
vomiting
abdominal pain (Campylobacter)
dehydration
history of travel abroad/ contact with someone with diarrhoea
```
46
Which symptoms would suggest a shigella or salmonella cause of gastroenteritis?
blood and pus in stool
high fever
tenesmus
47
How is dehydration measured during diarrhoeal illness?
dehydration measured by degree of weight loss..
<5% weight loss = no dehydration clinically
5-10% weight loss= clinically dehydrated
>10% weight loss= shock
48
How is gastroenteritis managed?
1. no investigations necessary - stool culture if blood/ septic child
2. fluids and rehydration solutions
3. monitor nutrition
49
What is Hirschprungs disease?
absence of ganglionic cells from myenteric plexus of large bowel
due to developmental failure of the parasympathetic Auerbach and Meissner plexuses
50
How does Hirschsprungs disease present?
failure to pass meconium within 48 hrs of life
constipation
abdominal distension
bilious vomiting later
51
How is hirschsprungs disease diagnosed?
suction rectal biopsy
52
How is hirschsprungs disease managed?
1. rectal washout and enema
| 2. surgical resection
53
What is intestinal malrotation?
obstruction of the small bowel
| congenital anomaly of rotation of the midgut
54
if a few day old child presents with billious vomiting, what must be ruled out?
INTESTINAL MALROTATION
55
How does intestinal malrotation present?
billious vomiting
1-7 days old child
abdominal pain
(if this is presentation, must rule this out!)
56
How is intestinal malrotation diagnosed?
upper GI contrast study =1st line and diagnostic
57
How is intestinal malrotation treated?
surgical correction by Ladds procedure
58
When is chronic diarrhoea (Toddlers diarrhoea) suspected?
stools varying in consistency e.g. explosive, loose or formed
children well and thriving
no precipitating dietary factors
grow out of symptoms by 5 y/o
59
How is coeliac disease caused?
gliadin in gluten causes a immunological response in the proximal small intestine to cause shorter villi and flat mucosa
60
What is associated with coeliac disease?
family history
autoimmune diseases e.g. type 1 diabetes, hypothyroidism, graves, psoriasis, SLE
61
Which gastrointestinal symptoms are seen with coeliac disease and when do they present?
present at 8-24 months of age AFTER introduction of wheat containing food...
diarrhoea/ malabsorptive stools
abdominal distension and bloating
failure to thrive
buttock wasting
62
Outline other multi system symptoms and signs of coeliac disease
```
anaemia - iron or folate deficiency
growth failure
dermatitis herpetiformis
hyposplenism
osteomalacia
mouth ulcers
```
63
What is the diagnostic sign of coeliac disease?
IgA tissue transglutaminase antibodies
64
How is coeliac disease managed?
remove gluten from the diet!!
| avoid wheat, barley, rye and symptoms will resolve
65
Describe the pathology of crohns disease
granulomatous inflammation of the distal ileum and proximal colon
transmural
normal bowel areas in between areas of diseased areas
'cobblestone appearance"
66
Describe the classic presentation of crohns disease
```
abdominal pain
diarrhoea
lethargy and fatigue
weight loss
growth failure/ delayed puberty
```
67
List the extra intestinal manifestations of crohns disease
```
erythema nodosum
iron deficiency anaemia
uveitis
perianal skin tags
arthralgia
conjunctivitis
clubbing
mouth ulcers
```
68
How is crohns disease investigated?
1. endoscopy and biopsy
2. raised CRP and ESR
3. small bowel imaging
69
How is crohns disease managed medically?
1. immunosuppressant medication e.g. aziothioprine, methotrexate - to maintain remission
2. long term supplemental enteral nutrition
if treatment fails, anti-tif agents e.g. infliximab or surgery
70
What is ulcerative colitis?
recurrent inflammation and ulceration of the mucosa of the colon
extends from rectum proximal
continuous diseases
crypt damage - abscess, loss of crypts
71
How does ulcerative colitis present?
```
colicky pain
diarrhoea
weight loss
rectal bleeding
growth failure
```
72
In ulcerative colitis, what are you at increased risk of?
adenocarcinoma of the colon
so need regular colonoscopic screening
73
How is UC investigated?
endoscopy and colonoscopy and biopsy
| widespread ulceration, pseudopolyps, crypt abscesses
74
How is UC managed depending on severity of disease?
mild = aminosalicylates e.g. mesalazine
aggressive = systemic steroids for acute attacks and immunomodulatory therapy for remission (azathioprine)
severe = colectomy with ileostomy
75
List of the causes of nutrient malabsorption
```
biliary atresia
lymphatic leakage
short bowel syndrome - necrotising enterocolitis
crohns / UC
cystic fibrosis
coeliac disease
lactose intolerance
```
76
What is cows milk protein allergy associated with?
atopy
| IgA and IgG deficiency
77
What are the symptoms of cows milk protein allergy?
```
loose stools
vomiting
failure to thrive
atopic history
GORD
```
78
If the stools are bloody with cows milk protein allergy, what would be suspected?
cows milk protein colitis
79
How is cows milk protein allergy managed?
1. eliminate from diet - if symptoms improve then diagnose
2. hydrolysed feeds
3. amino acid based feeds
80
what is the difference between hydrolysed feeds and amino acid based feeds?
hydrolysed feeds = break the milk protein up into pieces
amino acid based feeds = made with individual amino acids so well tolerated
81
How does lactose intolerance present and who it is associated with?
associated with oriental backgrounds
explosive watery stools
abdominal distension
audible bowel sounds
flatulence
82
How is lactose intolerance diagnosed?
1. lactose hydrogen breath test
| 2. eliminate from diet
83
How is lactose intolerance managed?
1. eliminate lactose from diet
2. lactose free formula and milk free diet
3. calcium and vitamin D supplements
84
How long does WHO recommend mothers breast feed for?
6 months
85
What are the advantages of breastfeeding?
reduces incidence of necrotising enterocolitis in preterm babies
helps with bonding/ loving relationship
reduces breast cancer risk in women
reduced incidence of obesity, diabetes and hypertension in babies
passive immunity
86
What are the limitations of breastfeeding?
puts pressure on mother if fail to establish feeds
restrictive for mother
cannot tell how much a baby is taking from breast
difficult for preterm babies
transmission of infection and drugs e.g. HIV, hep B, CMV
vitamin K deficiency
87
Describe the physiology of breast feeding
1. baby uses rooting, sucking and swallowing reflexes to feed
2. hypothalamus sends impulses to pituitary gland
3. anterior pituitary secretes prolactin which stimulates milk production in acini of breast
4. posterior pituitary secretes oxytocin which contracts myoepithelial cells in alveoli, forcing milk into larger ducts
88
List some of the properties of breast milk
```
IgA
bifidus factor
lysozyme
lactoferrin
macrophages
lymphocytes
protein
calcium phosphorus
```
89
When is pasteurised cows milk given to a child?
at 1 years old
90
When should specialised formula be used?
cows milk protein allergy
lactose intolerance
cystic fibrosis
neonatal cholestatic liver disease
91
When should weaning start?
solid foods recommended to be introduced at 6 months of age
start with pureed fruit, root vegetables or rice
92
Define "faltering growth"
"dropping centiles" - either growth faltering or weight faltering
fall across 1+ centiles if <9th gentile at birth OR
fall across 2+ centiles if 9th-91st centile at birth OR
weight under 2nd gentile regardless of birth weight
93
Outline the possible causes of failure to thrive
FEEDING PROBLEMS
ineffective suckling in breast fed infants
ineffective bottle feeding
post natal depression
insufficient food/ quantities of milk offered
NON ORGANIC
neglect/ abuse
psychosocial deprivation
ORGANIC
suckling - cleft palate, cerebral palsy
vomiting - GORD
malabsorption - coeliac, cystic fibrosis
increased requirements - HIV, congenital heart disease, thyrotoxicosis
94
How is faltering growth assessed?
1. growth and weight chart
2. examination for any organic illness
3. history of diet, feeding, development
95
What are the possible causes of diarrhoea in children?
```
inflammatory bowel e.g. crohns, UC
coeliac disease
chronic constipation
side effects of antibiotics
gastroenteritis
bowel obstruction
toddler diarrhoea
cows milk intolerance
hyperthyroidism
```
96
List the anomalies of the urinary tract detectable during antenatal ultrasound screening
```
renal genesis
multicystic dysplastic kidneys
polycystic kidney disease
horseshoe kidney / pelvic kidney
duplex system
bladder extrophy
urine flow obstruction
```
97
How is polycystic kidney disease inherited?
autosomal dominant
98
What complications can polycystic kidney disease cause?
```
haematuria
renal failure
hypertension
cysts in the liver and pancreas
cerebral aneurysms
mitral valve prolapse
```
99
Where can urine flow obstruction occur?
pelvicouteric or vesicoureteric junction
bladder neck
posterior urethra
100
What are the consequences of urine flow obstruction?
thickened bladder wall
hydronephrosis
bladder neck obstruction
101
What does Potter syndrome result from?
multi cystic dysplastic kidneys
| bilateral renal genesis
102
How does potter syndrome manifest?
primary problem is kidney failure causing reduced fetal urine excretion and oligohydramnios
causes facial features of low seat ears, beaked nose and lung hypoplasia
103
Which investigations are carried out to assess renal function
1. plasma creatinine concentration
2. estimated glomerular filtration rate - good measure of renal function
3. EDTA GFR
4. creatinine clearance
5. plasma urea concentration - raised levels are symptomatic
104
Which radiological investigation if preferred to assess renal anatomy?
ultrasound
shows anatomy, urinary tract dilatation, stones, nephrocalcinosis
105
What are the most common causative organisms of an UTI?
E.coli ***
Pseudomonas
Proteus
Klebsiella
106
What are the risk factors for an UTI?
urinary tract abnormality
incomplete bladder emptying e.g. infrequent voiding, incomplete micturition, constipation
vesicoureteric reflux
107
What is vesicoureteric reflux and how is it caused?
developmental abnormality of vesicoureteric junction
reflux can cause ureteric dilatation which causes incomplete bladder emptying, renal damage and pyloneprhitis
Causes: family history, after an UTI, bladder pathology
108
How might an infant with an UTI present?
```
fever
vomiting
poor feeding
irritable
lethargic
sepsis !!!!
```
109
How might an older child with an UTI present?
```
dysuria
increased frequency of urination
abdominal pain/ loin tenderness
fever
vomiting
haematuria
cloudy, offensive urine
```
110
How is an UTI first diagnosed?
1st line = urine dipstick -> screening test, +ve leucocytes or nitrates
if +ve = clean catch urine sample MC&S
111
Which investigation should be done routinely in all children with an UTI?
ultrasound within 6 weeks
to identify structural abnormalities, obstruction or scarring
DMSA (for renal scarring) after 3 months if USS atypical or under 3 y/o OR micturating cystourethrogram if <1y/o
112
Outline the conservative advice given for children with an UTI
```
high fluid intake
regular voiding
ensure complete bladder emptying training
good perineal hygiene
prevent constipation
probiotics encouraged
```
113
Who should you refer to the hospital with an UTI?
<3 months old
children at high of serious illness
suspect sepsis
114
Which antibiotic should be prescribed for a child <3 months with an UTI?
IV cefotaxime
115
Which antibiotic should be prescribed for children >3 months with upper UTI/ pyelonephritis ?
oral co-amoxiclav for 7-10 days
OR
IV cefotaxime for 2-4 days and then oral for up to 7-10 days in total
116
Which antibiotic should be prescribed for children with a lower UTI or cystitis?
trimethoprim
| nitrofurantoin
117
what are the features of an upper UTI or acute pyelonephritis?
temp >38 degrees
loin pain
loin tenderness
bacteriuria
118
What are the two types of haematuria?
1. glomerular haematuria
| 2. lower urinary tract haematuria
119
What is the difference between glomerular and lower urinary tract haematuria?
glomerular haematuria = brown coloured, with proteinuria
lower urinary tract haematuria = bright red colour, no proteinuria
120
List the non glomerular causes of haematuria
```
infection e.g. schistomiasis, TB
trauma
stones
sickle cell disease
bleeding disorders
renal vein thrombosis
HSP
```
121
list the glomerular causes of haematuria
acute/ chronic glomerulonephritis
familial nephritis
IgA nephropathy
nephritic syndrome
122
If the urine is red in colour/ +ve haemoglobin on dipsticks, which tests should be done?
urine microscopy and culture
ultrasound
FBC, U&E, clotting screen, creatinine
123
When is a renal biopsy indicated?
persistent proteinuria
recurrent macroscopic haematuria
renal function abnormal
124
What are the 2 types of proteinuria?
1. transient proteinuria
| 2. persistent proteinuria
125
What is the difference between transient and persistent proteinuria?
transient can occur during febrile illness or after exercise
persistent is significant and need to measure urine protein: creatinine in early morning
126
What are the possible causes of proteinuria?
```
orthostatic proteinuria
nephrotic syndrome
increased glomerular filtration pressure
hypertension
henoch schlonlein purpura
UTI
chronic renal disease
```
127
What is the triad for nephrotic syndrome?
1. proteinuria
>1g/m^2/24 hours
2. hypoalbuminaemia
<25g/L
3. peripheral oedema
e. g. scrotal, periorbital, ascites, ankle
128
What is the aetiology of nephrotic syndrome?
Minimal change disease ** (80%)
focal segmental glomerulonephritis
membranous glomerulonephritis
infections
HSP
129
What can cause minimal change disease?
hodgkins lymphoma
NSAIDs
HIV, hepatitis, syphilis
130
What are the 3 types of nephrotic syndrome and their differences?
1. steroid sensitive nephrotic syndrome **
precipitated by resp infection
2. steroid resistant nephrotic syndorme
can't treat with steroids, treat oedema with diuretics, salt restriction
3. congenital nephrotic syndrome
rare, first 3 months of life, need nephrectomy or dialysis and renal transplant
131
How is nephrotic syndrome investigated?
urine dipstick
urine microscopy and culture
UandE, FBC, ESR, creatinine, albumin
hepatitis B and C screen
132
How is nephritic syndrome managed?
high dose of oral corticosteroids (prednisolone)
+ fluid balance, manage electrolytes, penicillin prophylaxis (as lose immunoglobulins so at risk of infection), pneumococcal vaccination
133
How is steroid resistant nephrotic syndrome managed?
TREAT THE OEDEMA
1. diuretics
2. salt restriction
3. ACE-I
4. NSAIDs
134
What is nephritic syndrome?
inflammation of the kidneys causing...
1. haematuria
2. hypertension
3. proteinuria
+ oliguria, blurred vision, uraemia
135
What is nephritic syndrome commonly caused by in children?
Alport syndrome
IgA nephropathy "bergers disease"
often following an URTI
post streptococcal glomerulonephritis
Henoch Schonlein Purpura
Haemolytic Uraemic syndrome
136
What is henoch schonlein purpura?
IgA mediated small vessel vasculitis
137
What is the triad for henoch schonlein purpura?
1. purpura - raised like sandpaper, over buttocks and extensor surfaces
2. arthritis - knees and ankles
3. abdominal pain
138
What is henoch schonlein purpura associated with?
IgA nephropathy
| following a URTI
139
What would you expect to see on the urine dipstick of someone with HSP?
proteinuria
| haematuria
140
How is HSP managed?
oral prednisolone
| complications: HTN, abnormal kidney function
141
What is the classical triad for haemolytic uraemic syndrome?
1. acute renal failure (decreased urine output, abdo pain)
2. thrombocytopenia
3. microangiopathic haemolytic anaemia
142
What are the complications of haemolytic uraemic syndrome?
hypertension
| chronic renal failure
143
What can cause haemolytic uraemic syndrome?
```
bloody diarrhoea- E.coli ***
tumours
pregnancy
SLE
HIV
```
144
How is haemolytic uraemic syndrome managed?
supportive
fluids
plasma exchange if severe
145
How is dehydration managed fluids wise?
10-20ml/kg of 0.9% saline bolus stat
146
What is the rate of maintenance fluids?
Rate (ml/hour) = total daily requirement / 24
147
Which fluids are used for maintenance fluids?
0.9% saline + 5% dextrose + 10mmol KCl
148
How is total daily fluid requirements (24hr) calculated)?
1st 10kg body weight = 100ml/kg/day
2nd 10kg body eight = 50ml/kg/day
remainder body weight= 20ml/kg/day
149
How is vesico ureteric reflux diagnosed?
** micturating cystourethrogram **
then do DSMA to look for renal scarring
150
list the signs of shock
```
decreased LOC
cold extremities
mottled
weak peripheral pulse
hypotension
prolonged cap refill time
```
151
Describe the pathological features of coeliac in the small intestine?
villous atrophy
epithelial cell hyperplasia
mucosal inflammation
increase depth of crypts
152
what is biliary atresia?
destruction or absence of the extra hepatic biliary tree and intrahepatic biliary ducts leading to chronic liver failure
153
How does biliary atresia present?
```
neonatal jaundice
faltering growth
pale stools
dark urine
hepatomegaly
```
154
How is biliary atresia diagnosed?
laparotomy by operative cholangiography **
ultrasound
conjugated bilirubin high
155
How is biliary atresia managed?
must be operated on within 60 days of life (surgical bypass of fibrotic ducts / Kasai procedure)
complications of surgery: cholangitis, malabsorption of fats, cirrhosis, liver transplant if unsuccessful
