Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

Approch to metabolic alkalosis

8,825 views

Published on

Published in: Health & Medicine
  • Follow the link, new dating source: ❤❤❤ http://bit.ly/2ZDZFYj ❤❤❤
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here
  • Dating for everyone is here: ❶❶❶ http://bit.ly/2ZDZFYj ❶❶❶
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here

Approch to metabolic alkalosis

  1. 1. Approach to Metabolic Alkalosis<br />DR. ASHRAF ALAWADI<br /> Associated Prof. of pediatrics-Alazhar Univ.<br /> Head of pediatric department -UDHjEDDAH<br />
  2. 2. CASE (1) History<br />A 22 month-old boy presented with the problem of <br /><ul><li> weakness, easy fatigability
  3. 3. Failure to thrive
  4. 4. Vomiting
  5. 5. The boy was born preterm and small for date, there was no history of polyhydramnios.</li></li></ul><li> History<br /><ul><li>Past medical history was remarkable for frequent episodes of vomiting.
  6. 6. No family history of similar condition.
  7. 7. The parents are first-degree relatives.</li></li></ul><li>Physical Examination<br /><ul><li>Generalized hypotonia
  8. 8. high blood pressure (130/95 mmhg)*ULN(108/72 for his age).
  9. 9. Wight:9.2kg(<5th centile)
  10. 10. Moderate dehydration
  11. 11. normal male genitalia
  12. 12. His examination was otherwise unremarkable.</li></li></ul><li>Investigation<br />CBC (w.B.C 9.01, Hb11.4, plat 481.)<br />S.Na 135 mmol/l. S. K 2.8 mmoi/l<br />Ca 8.6 mg/dl. S.Mg 1.9mg/dl<br />Phosphorus 5.2 mg/dl. S.chloride 109 mg/dl<br />urea 32 mg/dl. Creatinine 0.6mg/dl<br />CK184u/l. RBS 110 mg/dl<br />ABG(ph7.51,pco2;42.6,Hco3;34.5,BE 10.5)<br />
  13. 13. Investigation<br />U.Na 32 mmol/l U.K 42 mmol/l<br />U.CL 63.2 mmol/lU.Mg 24mg/l<br />U.Phosphorus 242 mg/ l U.Ca 45 mg/l<br />U.Creatinine 116mg/l<br />urinary ca/creatinine ratio 0.387mg/mg<br />Gastrographine study showed mild degree of GERD<br />
  14. 14. <ul><li>6 days old term baby with history of :
  15. 15. vomiting since birth
  16. 16. with refusal to feed for 2 days
  17. 17. no bowel motion x 1 day.
  18. 18. He was delivered by NSVD to a Primigravida mother
  19. 19. with BW 3.1 kg</li></ul>CASE (2)History<br />
  20. 20. Vital signs stable .<br />blood pressure<br />Weight 2.85 kg<br /> lethargic<br />hypoactive,<br />dehydrated , <br />icteric <br />no signs of respiratory distress <br />Abdomen : soft & lax with positive bowel sounds<br />Rest of examination was unremarkable<br />Physical Examination<br />
  21. 21. CBG : pH 7.544, PCO2 37.4 , PO2 45.7, HCO3 31, BE 8.6<br />CBC : Hb 17.2, Hct 50.3, WBC 8.7, Plt 414, ESR 1, CRP 9<br />Blood CS -ve, BUN 68.3, Cr 1.8, TSB 17.1, RBS 71.3, Na 140.7, K 4.6<br />Urine Analysis -ve, CXR unremarkable<br />U/S Abd. : distended stomach <br />urine Chloride 4 mmol/L<br />Investigation<br />
  22. 22. CT Abdomen and Barium Meal suggestive of bowel malrotation<br />Laparotomy done which diagnosis case as Annular Pancreas and duodenal obstruction release <br />Investigation<br />
  23. 23. Summary<br />Case 1<br />Case 2<br />A 22 month-old boy presented with<br /><ul><li>weakness, easy fatigability
  24. 24. Failure to thrive, Vomiting
  25. 25. Past history for frequent episodes of vomiting
  26. 26. Metabolic Alkalosis
  27. 27. Hypertension
  28. 28. Hypokalemia
  29. 29. Urine chloride>20Meq/L
  30. 30. 6 days old term presented with
  31. 31. history of vomiting since birth
  32. 32. with refusal to feed for 2 days
  33. 33. no bowel motion x 1 day.</li></ul>Weight 2.85 kg ,dehydrated<br /> lethargic, hypoactive,<br /><ul><li>Metabolic Alkalosis
  34. 34. normotensive
  35. 35. Normokalemic
  36. 36. Urine chloride<15Meq/L</li></li></ul><li>Outcome<br />Case1 (Liddle syndrome)<br />Case 2 (Annular Pancreas )<br />the diagnosis of Liddle syndromewas concluded<br />It is an autosomal dominant form of hypertension characterised by hypokalemia and suppressed renin and aldosterone levels due to volume expansion<br />He was started on Ameloride 5 mg daily and oral potassium. Since then he is showing remarkable improvement in his condition<br /> his wt;11.5kg and normalization of the blood pressure and serum potassium. <br />The muscle power improved.<br />the diagnosis of Annular Pancreas was concluded<br /><ul><li>Laparotomy done and duodenal obstruction release Since then he is showing remarkable improvement in his condition
  37. 37. Discharge home with good general condition</li></li></ul><li>What are the most likely causes of Hypertension and hypokalemic metabolic alkalosis?<br />
  38. 38. Metabolic alkalosis with Hypertension<br />      Hyperaldosteronism (1ry)<br />      Renal artery stenosis<br />      Renin secreting tumor <br />      Liddle syndrome <br />     11β-HSD deficiency<br />   11β-Hydroxylas deficiency<br />      17α-OH/17,20-lyase deficiency.<br />Licorice abuse<br />
  39. 39.      what is the significance of urinary chloride?<br />
  40. 40. Approach to m.alkalosis<br /> Metabolic alkalosis<br />Chloride responsive Chloride resistant<br /> (Urine chloride<15Meq/L) Urine chloride>20Meq/L<br /><ul><li>   Postdiureticstherapy
  41. 41.    Vomiting Normal B.P Hypertension
  42. 42.    Low chloride intake
  43. 43.    Pyloric stenosis
  44. 44.    Chloride loosing diarrhea
  45. 45.    Cystic fibrosis
  46. 46.    GIT fistula/drainage</li></li></ul><li>Metabolic alkalosis(highurinechloride) Chloride resistant <br /> Hypertension<br />Hyperaldosteronism(1ry)<br /> Renal artery stenosis<br /> Renin secreting tumor <br />Liddle syndrome <br /> 11β-HSD deficiency <br />11β-Hydroxylase deficiency.<br />  17α-OH/17,20-lyase def . . Licorice abuse <br /> Normotensive<br />Bartter syndrome <br />Gitelman syndrome <br />HyperprostaglandinE2        <br />Diuretics therapy <br />Alkali loading<br /> <br />
  47. 47. Classification of met. alkalosis<br /> A- Chloride responsive metabolic alkalosis (Urine chloride<15Meq/L) <br />   Pyloric stenosis<br />   Chloride loosing diarrhea <br />   Cystic fibrosis<br />   GIT fistula/drainage <br />   Postdiuretics therapy<br />   Vomiting<br />   Low chloride intake <br />
  48. 48. Classification of met. alkalosis<br />B-Chloride resistant metabolic alkalosis (Urine chloride>20Meq/L) <br />Normotensive <br />Bartter syndrome <br />Gitelman syndrome <br />Hyperprostaglandin E2        <br /> severe hypokalemia. <br />  Diuretics therapy <br /> Alkali loading<br />
  49. 49. B-Chloride resistant metabolic alkalosis (Urine chloride>20Meq/L)<br />Hypertension<br /><ul><li>Hyperaldosteronism(1ry)
  50. 50. Renal artery stenosis
  51. 51. Renin secreting tumor
  52. 52. Liddle syndrome
  53. 53. 11β-HSD deficiency
  54. 54. 11β-Hydroxylase deficiency
  55. 55.   17α-OH/17,20-lyase deficiency.
  56. 56. Licorice abuse</li></li></ul><li>What further diagnostic tests<br /> should be done? <br />
  57. 57. DD according to Aldosterone and Renin level<br />◘ Condition associated with high Aldosterone, high renin<br />   Renin secreting tumor <br /> Renal artery stenosis<br /> Bartter syndrome <br />    Gitelman syndrome<br />◘ Condition associated with high Aldosterone low renin <br />Hyperaldosteronism (1ry) <br /> Adrenal carcinoma<br /> ◘<br />
  58. 58. ◘ Condition associated with low Aldosterone, low renin <br />Liddle syndrome<br />17α-OH/17,20-lyase deficiency.<br /> 11β-Hydroxylase deficiency.<br /> 11β-Hydroxysteroid dehydrogenase<br /> (11B-HSD) deficiency.<br />

×