Neonatal necrotizing enterocolitis
NEC is the most common life-threatening emergency of the gastrointestinal tract in the newborn period. The disease is characterized by various degrees of mucosal or transmural necrosis of the intestine. The cause of NEC remains unclear but is most likely multifactorial. The incidence of NEC is 1-5% of infants in neonatal intensive care units (NICUs). Both incidence and case fatality rates increase with decreasing birthweight and gestational age. Because very small, ill preterm infants are particularly susceptible to NEC, a rising incidence may reflect improved survival of this high-risk group of patients.
Clinical Manifestations
Infants with NEC have a variety of signs and symptoms and may have an insidious or sudden catastrophic onset (Table 96-1). The onset of NEC is usually in the 2nd or 3rd week of life but can be as late as 3 mo in VLBW infants. Age of onset is inversely related to gestational age. The 1st signs of impending disease may be nonspecific, including lethargy and temperature instability, or related to gastrointestinal pathology, such as abdominal distention and gastric retention. Obvious bloody stools are seen in 25% of patients. Because of nonspecific signs, sepsis may be suspected before NEC. The spectrum of illness is broad, ranging from mild disease with only guaiac-positive stools to severe illness with bowel perforation, peritonitis, systemic inflammatory response syndrome, shock, and death. Progression may be rapid, but it is unusual for the disease to progress from mild to severe after 72 hr.
Diagnosis
A very high index of suspicion in treating preterm at-risk infants is crucial. Plain abdominal radiographs are essential to make a diagnosis of NEC. The finding of pneumatosis intestinalis (air in the bowel wall) confirms the clinical suspicion of NEC and is diagnostic; 50-75% of patients have pneumatosis when treatment is started (Fig. 96-4). Portal venous gas is a sign of severe disease, and pneumoperitoneum indicates a perforation (Figs. 96-4 and 96-5). Hepatic ultrasonography may detect portal venous gas despite normal abdominal roentgenograms .
Neonatal necrotizing enterocolitis
NEC is the most common life-threatening emergency of the gastrointestinal tract in the newborn period. The disease is characterized by various degrees of mucosal or transmural necrosis of the intestine. The cause of NEC remains unclear but is most likely multifactorial. The incidence of NEC is 1-5% of infants in neonatal intensive care units (NICUs). Both incidence and case fatality rates increase with decreasing birthweight and gestational age. Because very small, ill preterm infants are particularly susceptible to NEC, a rising incidence may reflect improved survival of this high-risk group of patients.
Clinical Manifestations
Infants with NEC have a variety of signs and symptoms and may have an insidious or sudden catastrophic onset (Table 96-1). The onset of NEC is usually in the 2nd or 3rd week of life but can be as late as 3 mo in VLBW infants. Age of onset is inversely related to gestational age. The 1st signs of impending disease may be nonspecific, including lethargy and temperature instability, or related to gastrointestinal pathology, such as abdominal distention and gastric retention. Obvious bloody stools are seen in 25% of patients. Because of nonspecific signs, sepsis may be suspected before NEC. The spectrum of illness is broad, ranging from mild disease with only guaiac-positive stools to severe illness with bowel perforation, peritonitis, systemic inflammatory response syndrome, shock, and death. Progression may be rapid, but it is unusual for the disease to progress from mild to severe after 72 hr.
Diagnosis
A very high index of suspicion in treating preterm at-risk infants is crucial. Plain abdominal radiographs are essential to make a diagnosis of NEC. The finding of pneumatosis intestinalis (air in the bowel wall) confirms the clinical suspicion of NEC and is diagnostic; 50-75% of patients have pneumatosis when treatment is started (Fig. 96-4). Portal venous gas is a sign of severe disease, and pneumoperitoneum indicates a perforation (Figs. 96-4 and 96-5). Hepatic ultrasonography may detect portal venous gas despite normal abdominal roentgenograms .
Constipation in Infants & Children By Dr. Vivek Rege
Pediatric Surgeon & Pediatric Urologist, BhatiaHospital, Saifee Hospital, Fortis Hospitals, B J Wadia Hospital for Children
Chronic Diarrhea
references include the American Academy of Family Physicians AAFP
Special Thanks to my colleague Hadi Al Qurain for his participation in preparing this presentation
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
HOT NEW PRODUCT! BIG SALES FAST SHIPPING NOW FROM CHINA!! EU KU DB BK substit...GL Anaacs
Contact us if you are interested:
Email / Skype : kefaya1771@gmail.com
Threema: PXHY5PDH
New BATCH Ku !!! MUCH IN DEMAND FAST SALE EVERY BATCH HAPPY GOOD EFFECT BIG BATCH !
Contact me on Threema or skype to start big business!!
Hot-sale products:
NEW HOT EUTYLONE WHITE CRYSTAL!!
5cl-adba precursor (semi finished )
5cl-adba raw materials
ADBB precursor (semi finished )
ADBB raw materials
APVP powder
5fadb/4f-adb
Jwh018 / Jwh210
Eutylone crystal
Protonitazene (hydrochloride) CAS: 119276-01-6
Flubrotizolam CAS: 57801-95-3
Metonitazene CAS: 14680-51-4
Payment terms: Western Union,MoneyGram,Bitcoin or USDT.
Deliver Time: Usually 7-15days
Shipping method: FedEx, TNT, DHL,UPS etc.Our deliveries are 100% safe, fast, reliable and discreet.
Samples will be sent for your evaluation!If you are interested in, please contact me, let's talk details.
We specializes in exporting high quality Research chemical, medical intermediate, Pharmaceutical chemicals and so on. Products are exported to USA, Canada, France, Korea, Japan,Russia, Southeast Asia and other countries.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
1. Chronic diarrhea in children
By
Mohammed Ayad
Member of the royal college of pediatric
and child health.
2. Chronic diarrhea in children
Definition
Causes
diagnosis
History
Examination
Investigations
treatment
Specific disorders
3. Definition
Diarrhea
In children, a stool output that
exceeds 10 mL/kg/day is considered diarrhea.
A more practical definition
is that diarrhea is present when stools increase
in frequency, fluidity (water content), or volume,
in comparison with the previously
established “normal” pattern.
4. What is chronic diarrhea?
It is defined as diarrhea which exceeds 2 to 3
weeks.
Despite considerable advances in the
understanding and management of diarrheal
disorders in childhood, they are still responsible
for a major burden of childhood deaths globally,
with an estimated2.5 million deaths.
5. Causes of chronic diarrhea
In fact, there are many causes of chronic
diarrhea, however, the best way to discuss this
point is to classify these causes according to
these two vital factors:-
1- age.
2- prevalence.
6. Chronic diarrhea in infants
Common causes:-
Post-infectious secondary lactase deficiency.
Coeliac disease.
Cow’s milk allergy.
Toddlers diarrhea.
Infections as giardiasis and HIV.
Cystic fibrosis.
8. Chronic diarrhea in older children
Common causes
Post-enteritis syndrome.
Coeliac disease.
Lactose intolerance.
Infections as giardiasis and HIV.
Irritable bowel syndrome.
Inflammatory bowel disease.
10. Chronic diarrhea in adolescents
Common causes
Inflammatory bowel disease.
Giardiasis.
Laxative abuse ( anorexia nervosa ).
Irritable bowel disease.
Constipation with encopresis.
Rare causes
Secretory tumors.
Addison disease.
11. Diagnosis
Diagnosis of the cause of chronic diarrhea is a
challenge which needs smart effort.
Diagnosis usually starts with taking a good history in
which doctors know what they want to ask and
why. This is followed by examination which needs a
plan too. The last stage of this process is
investigations and differential diagnosis.
Here we will discuss in a great way how to diagnose
these cases, however, chronic diarrhea is a
symptom which usually needs a multidisciplinary
team.
12. History
History is the most important step, it usually
makes the DD narrow and gives clues to the
cause of chronic diarrhea.
Personal history
Age :- it is essential as what we explained
before.
Sex :- IBD in pediatrics is common in MALE.
Residence :- Africa and poor countries, suspect
infections and HIV.
13. HISTORY OF THE PRESENT ILLNESS
Onset:- just before 6m of age…...> coeliac disease.
After 1 yr. ……> cow’s milk allergy. Preceded by
gastroenteritis …..> post infectious diarrhea.
Course and duration is important.
Most patients were completely free before this
episode.
Stool character is extremely important:-
This is to differentiate what is called secretory and
osmotic diarrhea. These two types of diarrhea can
be differentiated by history, examination and
investigation. And each type has its own causes.
14.
15. Osmotic diarrhea
MALABSORPTION OF WATER-SOLUBLE NUTRIENTS
-Glucose-galactose malabsorption Congenital
, Acquired Disaccharidase deficiencies.
EXCESSIVE INTAKE OF CARBONATED FLUID
EXCESSIVE INTAKE OF NONABSORBABLE
SOLUTES -Sorbitol Lactulose Magnesium hydroxide
stops with fasting, has a low pH, positive for reducing
substances
17. Associated symptoms
No symptoms, well child …> toddlers diarrhea.
Abdominal distension and weakness…. Coeliac disease.
Severe abdominal pain …..> IBD.
Bloody diarrhea…..> IBD.
Vomiting and rash…. Eosinophilic enteritis.
Attacks of constipation ……> hirschsprung and IBS.
Vomiting, weight loss and behavioral changes…>
anorexia nervosa.
Infant with severe napkin dermatitis resistant to most
treatment ….. Acrodermatitis enteropathica.
Oral ulcers…..> IBD.
18. Non GIT symptoms
Recurrent respiratory tract infections…..> CF.
Weakness, fatigue and weight loss…> IBD, Addison
and HIV.
Skin pigmentation….> Addison.
Headache and mood changes….> IBS.
Eczema…..> cow’s milk allergy and eosinophilic
enteritis.
Joint pain and arthritis….> IBD.
Generalized lymphadenopathy….> HIV.
Recurrent fever and weight loss….TB.
19. Family and other history
Same illness or respiratory problems….> CF.
IBD and IBS.
IMMUNODEFICIENCY….> HIV.
Travelling abroad….> infections.
Excessive juice intake.
History of previous cardiac operations …..>
intestinal Lyphangectasia.
20. Dietetic history
Dietetic history
record a detailed history of feeding, prior to the onset of the
disease and during the disease.
It may provide vital clues to the etiology, e.g., cow's milk
protein intolerance, lactose intolerance, gluten enteropathy.
Soy protein intolerance, egg protein enteropathy.
Overfeeding, concentrated formula feeds> osmotic diarrhea..
Chewing gums and chocolates
plenty of undiluted fruit juices (e.g., pineapple juice has an
osmolality of 900 mOsm/L and apple juice 650 mOsm/L
21. Stool history
Odorless blood tinged stools - shigellosis
frequent mucoid stools in a healthy child without blood -
IBS
Nocturnal diarrhea is usually associated with organic
disease rather than IBS.
Infant having chronic diarrhea, with a history
of delayed passage of meconium and if
constipation preceded diarrhea,-
Hirschsprung's disease
22. Drug history
History of laxative abuse ……. Anorexia nervosa.
History of prolonged course of antibiotics…..>
pseudomembranous colitis.
23. Red flags
Poor weight gain or weight loss.
Continuous diarrhea.
night stools.
Acid stools…… burning sensation with severe
inflammation and crying.
Blood and mucous in stool.
Failure to thrive.
Associated symptoms of systemic diseases like
fever, rash and arthritis.
24. Examination
Examination has a great role too. But, you should be
systematic and know what exactly are you looking for.
General examination
Weight and height should be measured and put on the
appropriate charts. Weight loss is seen in many disorders
like CF, Coeliac disease, IBD. However, weight and height
are usually normal in toddlers diarrhea.
Pallor …… IBD, CF, Coeliac disease.
Fever….. IBD, CF.
Clubbing ….> IBD, CF.
25. Ear effusion and adenoids……..> CF.
Oral ulcers…..> IBD.
Oral pigmentation…..> Addison.
Peri-oral rash……> acrodermatitis enteropathica.
Chest scars ….> lobectomy scar for CF. median
sternotomy scar ……> intestinal lymphangectasia.
Signs of bronchiectasis…..> CF.
Arthritis….> IBD.
Characteristic feature of coeliac disease……see later.
Recurrent infections usually need massive
treatment….> immunodeficiency ( HIV ).
27. Coeliac disease
Dermatitis Herpetiformis bumps and blisters
resemble herpes lesions, hence the name
“herpetiformis”, but are NOT caused by the herpes
virus. Symptoms of DH tend to come and go, and it
is commonly diagnosed as eczema. Symptoms
normally resolve when on a strict, gluten-free diet.
DH affects 15 to 25 percent of people with celiac
disease who typically have no digestive symptoms.
31. INVESTIGATIONS
INVESTIGATIONS which can be done in these
cases are extremely wide and good pediatrician
is able to narrow them so as to reach a
diagnosis. So investigations are usually depend
on what history and examination point to.
However, there are some investigations which
are usually done in most cases which are
** stool examination.
** CBC, ESR and CRP.
32. Stool examination
Fresh stool sample should be collected and
examined. Specific tests should be taken seriously.
Occult blood in stool…..> IBD and Cow’s milk allergy.
Reducing substance…..> carbohydrate
malabsorption.
Maldigested fat ….> CF.
STOOL PH.
This is beside the routine examination for
amoebiasis and giardiasis.
33. Other investigations should e modified according
to each case. It depends on
1- age of the child.
2- most probable causes.
3- availability of these investigations.
So we will now discuss the most common causes
of chronic diarrhea according to age and how to
diagnose and manage them at a glance.
34. Chronic diarrhea in infants
1-carbohydrate intolerance and Post-infectious
secondary lactase deficiency.
2-Coeliac disease.
3-Cow’s milk allergy.
4-Toddlers diarrhea.
5-Infections as giardiasis and HIV.
6-Cystic fibrosis.
7- acrodermatitis enteropathica.
35. Carbohydrate intolerance
Primary
Congenital lactose intolerance.
Glucose-galactose malabsorption.
Very rare, Usually starts early with watery,
explosive diarrhea and failure to thrive.
Reduced substance in stool is positive.
36. Secondary lactose intolerance
Usually post-infectious ( rota virus).
Bloating, abdominal discomfort and flatulence that
occur from 1 hour to a few hours after ingestion of
milk or dairy products may signify lactose
intolerance.
Stool characteristics: Loose, watery, acidic stool
often with excessive flatus and associated with
urgency that occurs a few hours after the ingestion
of lactose-containing substances is typical.
37. Investigations
Reducing substances in the stool is positive and the
stool is acidic with PH <5.5.
Breath hydrogen test :-
Carbohydrate malabsorption results in bacterial
fermentation of the unabsorbed sugar.
Thus, carbohydrate malabsorption can be
determined by measuring the exhaled hydrogen
concentration after a carbohydrate load is
administered.
MANAGEMENT
Lactose free diet.
41. Diarrhea - 45-85% of patients
Flatulence - 28% of patients
Borborygmus - 35-72% of patients
Weight loss - 45% of patients; in infants and
young children with untreated celiac disease,
failure to thrive and growth retardation are
common
Weakness and fatigue - 78-80% of patients;
usually related to general poor nutrition
Severe abdominal pain - 34-64% of patient.
42. investigations
The American College of Gastroenterology (ACG)
recommends that antibody testing, especially
immunoglobulin A anti-tissue transglutaminase
antibody (IgA TTG), is the best first test for
suspected celiac disease, although biopsies are
needed for confirmation; in children younger
than 2 years, the IgA TTG test should be
combined with testing for IgG-deamidated
gliadin peptides.
43. Other laboratory tests include the following:
Electrolytes and chemistries - Electrolyte
imbalances; evidence of malnutrition
Hematologic tests - Anemia, low serum iron level,
prolonged prothrombin time (PT)
Stool examination - Fat malabsorption
Oral tolerance tests - Lactose intolerance
Serology - Immunoglobulin A (IgA) antibodies.
Histologic Findings:- villous atrophy.
45. management
The primary treatment of celiac disease is
dietary. Removal of gluten from the diet is
essential, although complete avoidance of
gluten-containing grain products is relatively
difficult for patients to achieve and maintain;
certain products, such as wheat flour, are
virtually ubiquitous in the American diet.
A small percentage of patients with celiac
disease fail to respond to a gluten-free diet. In
some patients who are refractory,
corticosteroids may be helpful.
46. Cow’s milk protein allergy
usually starts after the first year when children are
given milk products.
Typical symptoms are
Vomiting, diarrhea, colic and constipation may
occur.
Other rare presentations are wheezes, cough,
atopic eczema and behavioral changes like
irritability, crying and milk refusal.
A challenge with milk free times may have a good
indicators. However, histopathological examination
is a diagnostic test.
47. Toddlers diarrhea
Called chronic non specific diarrhea of childhood.
It is a common problem. Occurs to children mainly
above 2 years.
It is a benign condition.
Usually, the children have no failure to thrive and
they present in a good nutritional state. Abdominal
pain may be present in a minority.
The stools are foul smelling, watery, and contain
mucus with undigested vegetable material. The
parents are likely to report a short mouth to anus
transit time.
48. Golden roles
In developed countries toddler diarrhea is the most frequent
cause of chronic diarrhea in 1–5 year old children
Toddler diarrhea has a typical dietary and clinical history
Breath hydrogen tests have no place in the diagnostic process
Treatment includes normalization of feeding patterns
according to the “four Fs”: Fat, Fibre, Fluid, and Fruit juices.
49. treatment
After a thorough clinical history and a simple physical
examination, the diagnosis is often obvious. The main
message to the parents is reassurance on underlying
serious gastrointestinal disorders and normalisation of
the diet. Kneepkens and Hoekstra proposed a
normalisation of the child’s feeding pattern according to
the “four Fs”: Fat, Fibre, Fluid, and Fruit juices.As it
seems that these children represent the end of a
spectrum of normality, the dietary treatment will often
be close to the borders of normal nutritional
recommendations. Fat intake should be increased to at
least 35%, even 40%, of total energy intake. Restoration
of a pattern with well defined meals and snacks
provides the opportunity for significant increases of
50. Fruit juices, in particular clear apple juice, and
other squashes should be limited to restore
appetite at meal times. Drinks between meals are
acceptable, but overconsumption should be
discouraged. In almost all patients the efficacy of
these dietary measures is such that it may even
serve as a confirmation of the diagnosis. Some
authors have used aspirin, loperamide or
mebeverine for cases refractory to dietary
measures. Their effects last as long as they are
given. As a consequence, medication seems to be
unwarranted for a condition that does not hamper
the child to thrive.
51. Giardiasis
A very common disorder. Has a wide range of
manifestations, as acute and chronic diarrhea,
abdominal pain, malabsorption syndrome and
nausea.
Stool examination is the role. Stool antigen may
be important.
Treatment
Metronidazole.
52. Cystic fibrosis
AR disorder.
Most patients have respiratory symptoms as
recurrent pneumonia, and adenoid.
Those patients have pancreatic insufficiency
which lead to diarrhea with greasy stool.
Failure to thrive.
Genetic diagnosis and sweat chloride test are
the main investgations.
53. Acrodermatitis enteropathicaa
AR disorder.
Presented with peri-oral rash, chronic diarrhea,
recurrent infection and napkin rash resistant to
treatment.
Usually starts at the time of weaning.
Tent red hair and alopecia.
Diagnosis
Serum Zink in the WBCS OR IN THE BLOOD.
Management
Serum Zink.
54.
55. Chronic diarrhea in older children
Common causes
Post-enteritis syndrome.
Coeliac disease.
Lactose intolerance.
Infections as giardiasis and HIV.
Irritable bowel syndrome.
Inflammatory bowel disease.
56. Post enteritis syndrome
Persistent diarrhea after gastroenteritis is caused by
Continuing infection.
Further infection.
Carbohydrate intolerance.
Post infection malabsorption syndrome.
Usually subsides, but severe cases may persist to
longer periods.
Stool analysis and stool culture.
Treatment of the cause.
57. Inflammatory bowel disease
This is of two types
Crohn’s disease and ulcerative colitis.
20%% of cases presents under 20 years old.
It has intestinal and extra intestinal
manifestations.
58.
59.
60.
61. Clinical picture
Diarrhea
Abdominal pain
Growth deceleration
Weight loss
Anorexia.
Colonic Crohn disease may be clinically
indistinguishable from ulcerative colitis (UC), with
manifestations that include the following:
•Bloody mucopurulent diarrhea
•Cramping abdominal pain
•Urgency to defecate
62. Perianal involvement in Crohn disease may
produce the following:
Simple skin tags, fissures, abscesses, and
fistulae
•Painful defecation
•Bright-red rectal bleeding
•Perirectal pain, erythema, or discharge
64. investigations
BLOOD
CBC… anemia.
ESR and CRP….. Elevated.
Hypoalbuminaemia.
Imaging studies
A single-contrast upper GI radiologic series with
small-bowel follow-through (SBFT).
MRI.
65. endoscopy
Colonoscopy with several colonic and
terminal ileal biopsies is considered a
standard diagnostic procedure.
Upper endoscopy, or
esophagogastroduodenoscopy (EGD),
should be part of the first-line investigation.
Video capsule endoscopy is increasingly
being used to evaluate for small-bowel
Crohn disease in children.
66. management
The general goals of treatment for children with
Crohn disease are as follows:
To achieve the best possible clinical, laboratory,
and histologic control of the inflammatory
disease with the least adverse effects from
medication
To promote growth with adequate nutrition
To permit the patient to function as normally as
possible (eg, in terms of school attendance and
participation in activities)
67. •Step-up approach
Patients with mild disease are treated with
preparations of 5-aminosalicylic acid (5-ASA),
antibiotics, and nutritional therapy
If no response occurs or if the disease is more severe
than was initially thought, corticosteroid and
immunomodulatory therapy with 6-mercaptopurine (6-
MP) or methotrexate (MTX) is attempted
Infliximab is effective in patients who have an
inadequate response to conventional therapy and in
patients who have fistulizing Crohn disease ..
Adalimumab is a safe and effective substitute for
patients who are allergic to infliximab or develop high
titers of human antichimeric antibodies (HACA)
Surgery is considered when medical therapy fails
68. Indications for surgery include the following:
Intractable disease with growth failure
Obstruction or severe stenosis
Abscess requiring drainage
Perianal fistulae
Intractable hemorrhage
Perforation
69. Irritable bowel syndrome
Irritable bowel syndrome (IBS) is defined as chronic
or recurrent abdominal pain, altered bowel habits,
and bloating, with the absence of structural or
biochemical abnormalities to explain these
symptoms. Irritable bowel syndrome is part of a
broader group of disorders known as functional GI
disorders. It is the most common GI diagnosis
among gastroenterology practices in the United
States and is one of the top 10 reasons for visits to
primary care physicians.
70.
71. The characteristics of abdominal pain vary
between patients and even within an
individual patient.
The pain can be dull, achy, colicky, or
sharp.Pain can occur anywhere in the
abdomen but is commonly located in the
hypogastric or periumbilical regions.
The pain has no specific pattern but may be
aggravated by stress and food and partially
relieved after defecation.
72. Altered bowel habits include constipation, diarrhea,
or alternating constipation with diarrhea.
Stools are usually of small volume and pasty.
Constipation is associated with small, hard, pelletlike
stools. Diarrhea characteristically occurs during
waking hours and often is precipitated by meals.
Mucus can be a component of the stool in as many
as 50% of patients with irritable bowel syndrome.
In some patients, defecation is associated with a
sense of incomplete evacuation that can lead to
repeated trips to the bathroom and prolonged
straining.
73. Symptoms of abdominal distension (ie, bloating,
increased belching, flatulence).
Dyspeptic symptoms are present in as many as
30% of pediatric patients with irritable bowel
syndrome.
Extraintestinal manifestations are rare in
children.
74. Take care
The following clinical features should alert the
physician to the possibility of a disorder other than
irritable bowel syndrome:
Frequent awakening by symptoms
Steady progressive course
Fever
Weight loss
Arthritis
Rectal bleeding
Persistent vomiting.
76. investigations
They are usually not needed except if exclusion of
other disorders is mandatory.
Recent studies have suggested that determining the
level of fecal calprotectin in stool may help
distinguish irritable bowel syndrome from
inflammatory bowel disease. A negative
calprotectin result favors a functional disorder
rather than an inflammatory process, thereby
sparing many patients from having extensive work-
up and invasive investigations, such as colonoscopy.
77. treatment
Educate the child and parents that irritable
bowel syndrome is a chronic illness that cannot
be cured. At the same time, reassure them that
it is not a life-threatening condition and it does
not lead to physical impairment. Tell the patient
and the family that the symptoms are real and
respond to their worries and concerns.
Reassurance is more effective if offered after a
careful history and physical examination and a
conservative diagnostic evaluation.
78. Dietary modification
Some patients with irritable bowel syndrome report
exacerbation of their symptoms after ingestion of
certain foods. Elimination of certain foods, such as
sorbitol, fructose, and gas-forming legumes,
achieves relief in some patients with irritable bowel
syndrome, especially those with excess gas.
A recent study in adult patients with irritable bowel
syndrome revealed that a diet low in fermentable
oligosaccharides, disaccharides, monosaccharide,
and polyols (FODMAP) is effective in reducing
functional GI symptoms.
79. Treatment of chronic diarrhea
In fact, treatment of the cause is the main role.
But there are some points to be checked early:-
1- assess hydration status and treat dehydration
if present.
2- make sure that the child is safe and there are
no threatening signs.
3- good communication with parents and
reassurance is extremely vital.
80. At the end of this presentation
Chronic diarrhea is a great challenge which
needs extensive history, examination and
investigations, however, good pediatrician
should minimize the DD so as to reach a
diagnosis as soon as possible.
Although most cases are benign, there are some
dangerous causes.
Pediatric gastroenterologist has a major role in
diagnosis of most cases.