Importance of Mesenteric lymphadenitis

1. Dr.ANJANA.K.S

2. INTRODUCTION
 Mesenteric lymphadenitis refers to inflammation of the
mesenteric lymph nodes
 It is considered if a cluster of three or more lymph
nodes, each measuring 5 mm or greater, is detected in
the right lower quadrant mesentery.
 Clinically often difficult to differentiate from acute
appendicitis, particularly in children
 Can be divided into two distinct groups:
Primary and
Secondary.

3.  Primary mesenteric adenitis
-defined as right-sided mesenteric lymphadenopathy
without an identifiable acute inflammatory process or with
only mild (<5 mm) wall thickening of the terminal ileum.
 Secondary mesenteric adenitis
- defined as lymphadenopathy associated with a
detectable intraabdominal inflammatory process.

4. PATHOPHYSIOLOGY
 Frequent association with upper respiratory tract infection-
the theory of swallowing pathogen-laden sputum.
 Microbial agents gain access to lymph nodes via the
intestinal lymphatics.
 Organisms multiply & depending on the virulence of the
invading pathogen, varying degrees of inflammation and
suppuration may be seen.
 Feco-oral transmission occurs in yersenia infection and can
act as a common source of infection.

5.  Grossly, nodes are enlarged and often soft.
 The adjourning mesentery may be edematous, with or
without exudates
 Microscopically, the nodes show nonspecific hyperplasia and,
in suppurative infection, necrosis with numerous pus cells.
 Swelling of the lymphoid tissue of Peyers patches can act as
etiological factor for mesenteric adenitis induced
intussusception in children.

7. ETIOLOGY
 Chronic (or Subacute) Presentation
(i) Inflammatory bowel diseases
(ii) Systemic inflammatory diseases (SLE and sarcoidosis)
(iii) Malignancy
(iv) HIV infection
(v) Tuberculosis
 Acute Presentation
(i) Appendicitis
(ii) Secondary lymphadenitis of infectious origin
(iii) Zoonotic infections: yersiniosis & nontyphoidal
Salmonella infection
(iv) Enteric fever
(v) Infectious mononucleosis

8. CLINICAL PRESENTATION
 More common in males than females, with a peak incidence
of 5 to 10 yrs.
 It commonly presents as pain abdomen of chronic duration
 Seen in 20% of patients undergoing appendicectomy.
 Reduced risk of ulcerative colitis in adulthood.
 It often follows or occurs in association with an upper
respiratory illness.

9. SYMPTOMS
 Abdominal pain-
-usually severe,but the patient does not appear to be
severely prostrated.
-The character varies from a discomfort to a severe colic.
-The distribution is like that of appendicitis, is felt both
in the periumbilical region and in the right iliac fossa.
 Fever
 Malaise and anorexia
 Nausea and Vomiting
 Shift in stool frequency and consistency.

10. SIGNS
 Flushed appearance
 Fever –mild to moderate degree
 RIF tenderness- with or without rebound tenderness
 Voluntary guarding rather than rigidity.
 Rectal tenderness
 Signs of upper respiratory tract infection.

11. DIFFERENTIAL DIAGNOSIS
 The presentation may clinically mimic
 Acute appendicitis,
 Tubercular lymphadenitis
 Intussusception
 Constipation,
 Inflammatory bowel diseases,
 Meckel’s diverticulum,
 Ovarian torsion,
 Basal pneumonia
 Henoch-Sch¨onlein syndrome,and
 Urinary tract infection
 Malignancies-lymphoma

12. WORK UP
 Complete blood count
 ESR
 Serology
 Urinalysis may be useful to exclude urinary tract infection.
 Blood culture
 Stool culture
 Abdominal ultrasonography is the main stay of diagnosis.
 CT/MRI

13.  Sonography findings-
-multiple, enlarged, hypoechoic mesenteric lymph nodes
- absence of a thickened blind ending tubular structure in
the right lower quadrant.
- The radiological definition for mesenteric
lymphadenitis suggested is a cluster of 3 or more lymph
nodes with short-axis diameter of 5mm or more in the right
lower quadrant and in the para-aortic region without an
identifiable acute inflammatory process.
-slight thickening of the terminal ileum wall and caecum in a
minority of cases

15.  Lymphnode enlargement is also found in some cases of
appendicitis(especially if perforated)but generally the nodes
are not as numerous nor as large
 Malignancies, most frequently non-Hodgkin lymphomas,
have abdominal masses and may result in right lower
quadrant tenderness.
-Concurrent involvement of mesenteric, retroperitoneal and
pelvic lymph nodes is common in these cases.
 Mesenteric lymph nodes were detected in 14% of
symptomatic children, but enlarged mesenteric lymph
nodes in children with acute pain represents a non-
specific finding.

16.  Histopathology
In patients subjected to laparotomy –lymph node
for inflammation & culture to be sent.

17. TREATMENT
 This is a benign, self limiting condition that does not
require medical or surgical intervention but follow up is
necessary in these patients.
 General supportive care- hydration and pain medication
after excluding surgical causes of acute abdomen.
 Specific anti-microbial agents are indicated by
microbiological tests, such as tuberculosis or typhoid
fever.
 ????..Empirical broad spectrum antibiotics
 Reassure patients and families stating that affected patients
recover completely without residuals within 2–4weeks.

18. SURGERY
 Indications
-suppuration or abscess
-signs of peritonitis
-if acute appendicitis cant be excluded
 During laparotomy-appendicectomy is usually performed.

19.  Write total parenteral nutrition order for a 3yr old boy with
weight 10kg who gets all his drugs and infusions in 200ml of
5% dextrose..

20. Energy
 Guidelines from the American Society for Parenteral
and Enteral Nutrition (ASPEN) outline the following
age- and weight-based energy requirements.
 Preterm neonate – 90 to 120 kcal/kg/day
 <6 months – 85 to 105 kcal/kg/day
 ≥6 to 12 months – 80 to 100 kcal/kg/day
 ≥1 to 7 years – 75 to 90 kcal/kg/day
 ≥7 to 12 years – 50 to 75 kcal/kg/day
 ≥12 to 18 years – 30 to 50 kcal/kg/day

21. Protein
 Targets for protein intake for pediatric patients with
normal organ function for age are as follows:
 Preterm neonate – 3 to 4 g/kg/day
 Infants (1 to 12 months) – 2 to 3 g/kg/day
 Children (>10 kg, or age 1 to 10 years) – 1 to 2 g/kg/day
 Adolescents (11 to 17 years) – 0.8 to 1.5 g/kg/day

22. Fat
 Between 20 and 50 percent of energy needs
 For most patients, start to provide fat at 1 g/kg per day.
 If tolerated, the fat dose can be advanced to 3 g/kg per
day (or 2 g/kg/day for older children) if needed to
provide adequate energy intake.

23. Electrolytes
 Daily electrolyte and mineral requirements for
parenteral nutrition in pediatric patients
Electrolyte Preterm neonates Infants/children Adolescent
Sodium 2 to 5 mEq/kg 2 to 5 mEq/kg 1 to 2 mEq/kg
Potassium 2 to 4 mEq/kg 2 to 4 mEq/kg 1 to 2 mEq/kg
Calcium
2 to 4 mEq/kg
(= 1 to 2
mmol/kg)*¶
0.5 to 4 mEq/kg
(= 0.25 to 2
mmol/kg)*¶
10 to 20 mEq total
daily dose
(= 5 to 10
mmol)*¶
Phosphorus 1 to 2 mmol/kg 0.5 to 2 mmol/kg 10 to 40 mmol
Magnesium 0.3 to 0.5 mEq/kg 0.3 to 0.5 mEq/kg 10 to 30 mEq

24.  3yr old boy with weight 10kg who gets all his drugs and
infusions in 200ml of 5% dextrose.
 Fluids: 100ml/kg x 10kg = 1000mL
Energy: 10Kg x 100Kcal/Kg = 1000Kcal/day
 Protein: 10Kg x 2gm = 20gm/day (Energy= 20 x 4= 80 Kcal)
= 100mL
 Lipid: 10Kg x 3gm = 30gm/day (Energy= 30 x 10=300 Kcal)
= 150mL over 24 hours
200 ml 5% Dextrose –calorie= 10 x 3.4=34Kcal
Fluid left after lipid & infusion = 1000 – (150ml +200ml) =
650ml

25.  Carbohydrate
Remaining energy = 1000 - (300+80 +34)
= 590Kcal
45% of the energy = (45/100)X590= 265Kcal
Carbohydrate = 265/3.4 = 78gm
25 %D = 300ml(each 100ml 25g)
 Sodium = 3mEqX10kg = 30mEq
100mL contains 51.3mEq
(30X100)/51.3 = 60mL
 Potassium = 3mEq X 10Kg = 30mEq = 15mL (each ml contains
2mEq)

26.  Calcium = 10Kg X 2mEq = 20mEq
each mL of Calcium gluconate contains 0.45mEq
(28 X 1)/0.45 = 44mL
 Magnesium = 10kg X 0.3mEq=3mEq=1 ml
(1ml = 4mEq)
MVI=5ml(max)

27. Calculation of GIR) for parenteral
nutrition
1. Calculate grams of glucose in
the parenteral nutrition (PN)
prescription
Energy (kcals) from
carbohydrates ÷ 3.4 kcal/g =
grams glucose
2. Convert to milligrams of
glucose
Grams glucose x 1000 = mg
glucose
3. Calculate milligrams of
glucose per kilogram
Mg glucose ÷ body weight (kg)
= mg glucose/kg
4. Calculate milligrams of
glucose per kilogram per
minute
= glucose infusion rate
(GIR)
Mg glucose/kg ÷ minutes of
infusion = mg
glucose/kg/minute
(where minutes of infusion =
1440 if infusion is continuous
over 24 hours)

28.  GIR
78 x 1000 =78000
78000/10=7800mg/kg
7800/1440=
5.41mg/kg/min

29. To Calculate for each 650 ml @ 27ml/hr
25D =300mL in 650mL 3%NaCl =60ml
AMINOVEN =100mL in 650mL KCl = 15mL
MVI = 5mL of adult MVI Calcium Gluconate = 44mL
Magnesium = 1mL Sterile water = Remaining volume
150ml intralipid over 18 hours
GIR = 5.41mg/kg/min

30. Osmolarity calculation
 1mL AMINOVEN (10%) = 1mmol
 DEXTROSE = gm of glucose/198 X 1000
 50%D = 2.52mmol/mL
 30%D = 1.51mmol/mL
 10%D = 0.505mmol/mL
 5%D = 0.25mmol/mL
 1mL 3% NaCl =1.05mmol
 1mL KCl = 4mmol
 1mL Calcium gluconate = 0.22mmol
 1mL MVI(adult) =4.11
 1mL Magnesium =4.06

31.  Write diatery advice for a child with
a)CKD
b)Type 1 DM

32. CKD
 Dietary management:
 The goals are:
a) to reduce nitrogen intake
b) to maintain nitrogen balance
c) to cover essential amino acid requirement
d) to supply enough calories
i) Energy: Infant 100-120 kcal/kg/day
Children 80-100 kcal/kg/day

33.  ii) Protein:
-High protein will aggravate acidosis, hyperkalaemia and
hyperphosphataemia.
- Low protein will reduce BUN, improve renal function
and reduce symptoms like nausea, vomiting, muscle cramps,
convulsion, neuropathy etc.
-Milk is rich in phosphate and meat is rich in potassium.
Protein intake is based upon the extent of CRF,
mild/moderate or severe
 iii)Fluids:
- Fluids should be given without producing water retention.
If fluid retention occurs, give diuretic and restrict sodium

34.  Sodium:
Excess intake will lead to hypertension and fluid
retention.
-Restrict salt intake to 300-600 mg/day in infants and to
1-2 g/day in older children.
 Potassium:
-Restrict potassium intake
-Hypokalaemia can occur at any time.
-Give small dose of potassium or fruit juice if serum K is
low normal or low.

35.  Model diet in mild-moderate CRF
 a) Fluid: According to thirst or insensible loss + last day’s
output or up to two-third maintenance 800 ml
 b) Calories: RDA for height age
 c) Protein: 1.4 x 15 = 21 g.
 d) Sodium: Restrict to 500 mg/day (no added salt).
 e) Potassium: Fruit juice can be given if S. K+ is normal

36.  DIET ADVICE IN A CHILD WITH TYPE 1 DM

37.  Maintain adequate carbohydrate, fat and protein ratio:
carbohydrate 50- 60%,
protein 10-15% and
fat 20-30%.
 Avoid fasting and feasting.
 High fibre, low fat diet with adequate carbohydrate and
protein is ideal.
 Ensure appropriate timings to prevent ups and downs in
blood sugar values.
 The calories will have to be spread over as breakfast 20%,
lunch 20%, dinner 30% and midmorning, midafternoon and
evening snacks 10% each.
 One snack may be omitted and 10% may be added to the
lunch (e.g., midafternoon) if three snacks cannot be taken

38.  1. Meal Planning
 The goal is to ensure normal growth and to keep
FBS <115 mg/dl, PPBS < 126-140 mg/dl,
S. cholesterol < 200 mg/dl,
S. LDL cholesterol < 130 mg/dl,
HDL > 50 mg/dl,
S. triglyceride < 160 mg/dl and
glycated Hb (6-8 g) within normal limits.
 There should not be wide fluctuations in blood sugar
 Timing of meals and composition of diet should be relatively
fixed and at the same time without monotony.
 Sodium should be restricted to 3-5 g/ day if there is
hypertension and cholesterol should be restricted to 300
mg/day.

39.  BMR is roughly 22 kcal/kg ideal weight.
 Bitter things like bitter gourd may stimulate beta cells of the
pancreas.
 a) Carbohydrate:
- Avoid rapidly absorbed mono- and disaccharides and
refined sugars like glucose, sugar, honey, sweets, sweet drinks
etc., and encourage complex carbohydrates.
-Tubers should be restricted.
- Whole wheat is considered better than rice
 b) Fibre:
- Fibre delays carbohydrate absorption and decreases
hyperglycaemia.

40.  The suggested intake is 20-35 g/ day.
-It increases insulin receptors and decreases insulin
requirement.
-Fibre relieves constipation.
-Whole wheat, coriander, carrot, brinjal, cauliflower,
ladies finger, mango etc., contain 1-3% fibre;
-Ragi, pulses, ground nut, peas, guava etc., contain 3-5%
fibre.
Low fat:
-Low fat increases insulin binding and reduces LDL and
VLDL cholesterol.
-Better to give vegetable fat that contains PUFA.

41.  Avoid animal fat, hydrogenated oil (Dalda) etc.
 Fish and chicken are preferred than beef and egg.
 Turmeric, Bengal gram, onion and garlic reduce cholesterol.
 d) Fruits:
-When the blood sugar is well controlled, half to one fruit can
be allowed at the expense of a snack or after exercise.
-The fruit can be selected based upon the carbohydrate content
of the fruit.

43. THANK YOU………..