acute abdominal pain in pediatrics. include background and approach also there are three cases included, intussusception, Hirschsprung's disease and DKA.
The neonatal bowel obstruction is suspected based on polyhydramnios in utero, bilious vomiting, failure to pass meconium in the first day of life, and abdominal distension.The presentations of NBO may vary. It may be subtle and easily overlooked on physical examination or can involve massive abdominal distension, respiratory distress and cardiovascular collapse.Unlike older children, neonates with unrecognized intestinal obstruction deteriorate rapidly.
Neonatal bowel obstruction is grouped into two general categories: high, or proximal, obstruction and low, or distal obstruction, both of which are suspected by failure to pass meconium at birth. High obstruction can be suspected based on the double bubble sign. Cases without distal gas are usually related to duodenal atresia, while high obstruction with distal gas need an upper gastrointestinal series because of the need to distinguish duodenal web, duodenal stenosis and annular pancreas from midgut volvulus, the latter being a surgical emergency. Confirmation is ultimately by surgical intervention.
Jejunal and ileal atresia are caused by in utero vascular insults, leading to poor recanalization of distal small bowel segments, a condition in which surgical resection and reanastamosis are mandatory. Hirschsprung disease is due to an arrest in neural cell ganglia, leading to absent innervation of a segment distal bowel, and appears as a massively dilated segment of distal bowel on contrast enema. Surgical resection is necessary for this condition as well. Imperforate anus also requires surgical management, with the diagnosis made by inability to pass the rectal tube through the anal sphincter.[6] Supportive intravenous hydration, gastric decompression, and ventilatory support may be needed due to poor neonatal nutrition resulting from dysfunctional bowel absorption.
A low obstruction is suspected on plain film, but needs follow up with a gastrografin enema, which itself can be therapeutic. The differential for low obstruction is ileal atresia, meconium ileus, meconium plug syndrome and Hirschsprung disease. In cases of meconium ileus or ileal atresia, the colon distal to the obstruction is hypoplastic, usually less than 1 cm in caliber, as development of normal colonic caliber in utero is due to the passage of meconium, which does not occur in either of these conditions. When diffusely small caliber is seen, it is referred to as microcolon. Radiographs in meconium ileus classically demonstrate a bubbly appearance in the right lower quadrant due to a combination of ingested air and meconium. If, on contrast enema, reflux into the dilated distal small bowel loops can be achieved, the study is both diagnostic and therapeutic, as the ionic contrast medium can dissolve the meconium to allow passage of enteric content into the unused colon.
If contrast cannot be refluxed into the distal small bowel, ileal atresia remains a diagnostic possibility.
With early intervention, morbidity and mortality.
acute abdominal pain in pediatrics. include background and approach also there are three cases included, intussusception, Hirschsprung's disease and DKA.
The neonatal bowel obstruction is suspected based on polyhydramnios in utero, bilious vomiting, failure to pass meconium in the first day of life, and abdominal distension.The presentations of NBO may vary. It may be subtle and easily overlooked on physical examination or can involve massive abdominal distension, respiratory distress and cardiovascular collapse.Unlike older children, neonates with unrecognized intestinal obstruction deteriorate rapidly.
Neonatal bowel obstruction is grouped into two general categories: high, or proximal, obstruction and low, or distal obstruction, both of which are suspected by failure to pass meconium at birth. High obstruction can be suspected based on the double bubble sign. Cases without distal gas are usually related to duodenal atresia, while high obstruction with distal gas need an upper gastrointestinal series because of the need to distinguish duodenal web, duodenal stenosis and annular pancreas from midgut volvulus, the latter being a surgical emergency. Confirmation is ultimately by surgical intervention.
Jejunal and ileal atresia are caused by in utero vascular insults, leading to poor recanalization of distal small bowel segments, a condition in which surgical resection and reanastamosis are mandatory. Hirschsprung disease is due to an arrest in neural cell ganglia, leading to absent innervation of a segment distal bowel, and appears as a massively dilated segment of distal bowel on contrast enema. Surgical resection is necessary for this condition as well. Imperforate anus also requires surgical management, with the diagnosis made by inability to pass the rectal tube through the anal sphincter.[6] Supportive intravenous hydration, gastric decompression, and ventilatory support may be needed due to poor neonatal nutrition resulting from dysfunctional bowel absorption.
A low obstruction is suspected on plain film, but needs follow up with a gastrografin enema, which itself can be therapeutic. The differential for low obstruction is ileal atresia, meconium ileus, meconium plug syndrome and Hirschsprung disease. In cases of meconium ileus or ileal atresia, the colon distal to the obstruction is hypoplastic, usually less than 1 cm in caliber, as development of normal colonic caliber in utero is due to the passage of meconium, which does not occur in either of these conditions. When diffusely small caliber is seen, it is referred to as microcolon. Radiographs in meconium ileus classically demonstrate a bubbly appearance in the right lower quadrant due to a combination of ingested air and meconium. If, on contrast enema, reflux into the dilated distal small bowel loops can be achieved, the study is both diagnostic and therapeutic, as the ionic contrast medium can dissolve the meconium to allow passage of enteric content into the unused colon.
If contrast cannot be refluxed into the distal small bowel, ileal atresia remains a diagnostic possibility.
With early intervention, morbidity and mortality.
Femoral hernia is the third common hernia after inguinal and incisional hernias. The swelling in femoral hernia is below and lateral to pubic tubercle. It is more common in females. Strangulation is very common in this hernia.
Femoral hernia is the third common hernia after inguinal and incisional hernias. The swelling in femoral hernia is below and lateral to pubic tubercle. It is more common in females. Strangulation is very common in this hernia.
General suggestions in ordering body CT in ED; vascular occlusion; aneurysm/pseudoaneurysm; bleeding and active contrast extravasation; extraluminal air
PELVIC INFLAMMATORY DISEASE (PID)
This presentation is prepared as a case based discussion.
References include American Academy of Family Physicians AAFP
I WOULD LIKE TO DEDICATE SPECIAL THANKS TO
DR ALI AL KHALAF FOR REVISING THIS MATERIAL
SOAP NotePatient Initials RA Pt. Encounter Number .docxpbilly1
SOAP Note
Patient Initials: RA Pt. Encounter Number: 1
Date: 10/1/20 Age: 23 Sex: female
Allergies: NKA Advanced Directives: none
SUBJECTIVE
CC: “I have been having heavy periods for 4-5 months now. I feel tired and dizzy most days”
HPI: 23-year-old came to the clinic today complaining of heavy menstrual periods happening for the past 4 to 5 months. Accompanying the heavy flow, patient states that she has moderate cramps. Pt describes the pain as stabbing and its 3 out of the 0-10 scale. Patient does not take any medications for the pain. The pain is decreased by applying warm compresses to the lower abdominal area. In addition, patient complains of feeling dizziness and tiredness most of the times.
Current Medications: none
PMH Medication Intolerances: NONE Chronic Illnesses/Major traumas: NONE Screening Hx/Immunizations Hx: Vaccinations up to date, most recent pap smear 12/19 – negative Hospitalizations/Surgeries: None
Family History:Father: Alive, No medical history Mother: Alive, Htn
Social History: Patient is a full-time college student and part time employee at Publix as cashier. Pt lives at home with parents and denies having had a sexual partner for the past year. Patient denies the use of cigars, alcohol, or illegal drugs.
ROS
GeneralDenies recent weight loss, fever, change in appetite or headaches. She denies chills or night sweats. CardiovascularDenies palpitations, chest pain, orthopnea, and claudication. Reports episodes of hypotension.
SkinDenies bruising, skin rash, or discoloration. Denies changes in moles or skin breakdown. RespiratoryDenies shortness of breath, abnormal sputum, cough, or wheezing.
EyesDenies pain, redness, loss of vision, double or blurred vision GastrointestinalDenies abdominal pain, decreased appetite, nausea, or vomiting. Denies food intolerances and changes in stool
EarsDenies ear pain, ear infections, or tinnitus Genitourinary/GynecologicalDenies dysuria, flank pain, and hematuria. Denies abnormal vaginal discharge or itching. Denies STI history. Reports heavy menstrual periods lasting 5 to 6 days, associated with cramping; every 28 days. OBSTETRIC/GYNECOLOGICAL Hx:Menarche: 11 years LMP: 09/15/20 G 0 T 0 P 0 A 0 L 0 Birth Control/Type: NoneMenopause: no Sexually Active: yes STD Hx: None
Nose/Mouth/ThroatDenies nasal pain, congestion, epistaxis, or postnasal drip. Denies pain in mouth, bleeding gums, or dry mouth. Denies pain in throat, hoarseness, difficulty or painful swallowing. MusculoskeletalDenies muscle pain or joint pain. Denies limited range of motion
BreastDenies breast tenderness, discharge, redness, or lumps. NeurologicalDenies headache, dizziness, seizures, or memory loss.
Heme/Lymph/EndoPt denies bruising PsychiatricDenies mood changes, irritability, or changes in concentration. Denies hav.
PANEL DISCUSSION ON ENDOMETRIOSIS RELATED INFERTILITY (EVIDENCE BASED)Lifecare Centre
PANEL DISCUSSION ON ENDOMETRIOSIS RELATED INFERTILITY (EVIDENCE BASED)
MODERATOR
DR SHARDA JAIN
DR JYOTI AGARWAL
DR ILA GUPTA
UMA RAI
RAJ BOKARIA
JYOTI AGARWAL
JYOTI BHASKER
RENU CHAWLA
DIPTI NABH
VANDANA GUPTA
Please note, the MCQs(Multiple choice questions) on this video are according to the specifications and syllabus of Specialty Certificate Examination (SCE) in Gastroenterology and the European Section and Board of Gastroenterology and Hepatology Examination (ESBGHE). However, they provide useful knowledge in the relevant subject area in general. Hence, it is recommended you to go through these videos and gather some information to gain success in future medical and surgical field examinations.
https://www.youtube.com/watch?v=1o3JdzgBM9g
https://www.youtube.com/watch?v=7k5kba0TNRM
https://www.youtube.com/watch?v=kcGi5_xm0Uk
Drs. Lena, Avery, and Davis’s CMC Abdominal Imaging Mastery Project: July CasesSean M. Fox
Dr. Kelsey Lena is an Emergency Medicine Resident and Drs. Michael Avery and Joshua Davis are Surgery Residents at Carolinas Medical Center in Charlotte, NC. They are interested in medical education. With the guidance of Drs. Kyle Cunningham and Michael Gibbs, they aim to help augment our understanding of emergent abdominal imaging. Follow along with the EMGuideWire.com team as they post these monthly educational, self-guided radiology slides. This month’s topics include:
• Malignant Bowel Obstruction
• Liver Laceration
• Sigmoid Volvulus
Patient Information Please see attachment for Rubrics and Soap T.docxssuser562afc1
Patient Information
Please see attachment for Rubrics and Soap Template
Family Medicine 27: 17-year-old male with groin pain
User:
Beatriz Duque
Email:
[email protected]
Date:
September 5, 2020 11:01PM
Learning Objectives
The student should be able to:
Elicit focused history of patients presenting with scrotal pain.
Demonstrate the ability to perform proficient testicular examination and to elicit signs specific to identify or exclude testicular torsion.
Develop a differential diagnosis for adolescent male presenting with scrotal pain.
Identify appropriate laboratory and radiological studies as it relates to the differential diagnosis of scrotal pain. Outline the algorithmic approach to testicular pain.
Discuss management of testicular torsion.
Recognize sexually transmitted infections as a cause of testicular pain among adolescent males.
Discuss the importance of counseling to prevent sexually transmitted infections.
Discuss epidemiology and USPSTF recommendations for screening for common testicular cancers.
Knowledge
Important Features of the History for a Patient in Pain
The following acronym can be helpful:
LAQ CODIERS:
L
ocation
A
ssociated symptoms
Q
uality
C
haracter
O
nset
D
uration
I
ntensity
E
xacerbating factors
R
elieving factors other
S
ymptoms
HEEADSSS Adolescent Interview
Home
Education / Employment
Eating
Activities
Drugs
Sexuality
Suicide / Depression Safety / Violence
Scrotal Exam Findings
Cremasteric reflex
Cremasteric reflex can be assessed by lightly stroking or pinching the superior medial aspect of the thigh. An intact cremasteric reflex causes brisk ipsilateral testicular retraction. Absence of the cremasteric reflex is a sensitive but nonspecific finding for testicular torsion. It can be absent on physical exam in normal testes. It should be assessed after inspection and before palpation of the testicles.
Blue dot sign
Tenderness limited to the upper pole of the testis suggests torsion of a testicular appendage, especially when a hard, tender nodule is palpable in this region. A small bluish discoloration known as the "blue dot sign", may be visible through the skin in the upper pole. This sign is virtually pathognomonic for appendiceal torsion when tenderness is also present.
Prehn sign
Prehn reported that physical lifting of the testicles relieves the pain caused by epididymitis but not pain caused by testicular torsion. A positive Prehn sign is pain that is relieved by lifting of the testicle; if present this can help distinguish epididymitis from testicular torsion.
Causes of Testicular Torsion
Congenital anomaly
A congenital anomaly that results in failure of normal posterior anchoring of the gubernaculum, epididymis, and testis is called a bell clapper deformity because it leaves the testis free to swing and rotate within the tunica vaginalis of the scrotum much like the gong (clapper) inside of a bell, causing an intravaginal torsion. A large mesentery betwee.
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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.
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.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
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.
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
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
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
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
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!
2. Outline Continued
What are the important points about the history?
What are the physical findings?
What is the differential diagnosis?
What further workup is needed?
How is patient managed?
4. Case 1
6mo infant with vomiting, poor po intake,
abdominal distension
Previous 32wk gest age & hypospadias
Non-bilious emesis
Looks ill
Some respiratory problems as neonate
No history of surgeries, no meds
Physical exam---
10. Incarcerated Hernia
If unable to reduce: urgent operative exploration
(NPO)
If able to reduce without sedation: urgent surgical
referral with repair soon
If extremely difficult (sedation, surgical referral):
repair next day
Watch child for obstructive symptoms
16. Intussusception
Inversion of the bowel upon itself secondary to a
lead point
Juvenile intussusception most often idiopathic
Also secondary to Meckel’s
Presents 6 months to 2 years of age
As early as 1 month
Incarceration. lethargy
17. Management
Nonoperative reduction:
Therapeutic enemas :
Hydrostatic: With barium or water-soluble contrast
Pneumatic: With air insufflation; this is the
treatment of choice in many institutions, and the
risk of major complications with this technique is
small
18. Case 3
6yo male, otherwise healthy, presents to
pediatrician with abdominal pain and nausea
19. Case 3
6yo male, otherwise healthy, presents to
pediatrician with abdominal pain and nausea
Dad says pt started complaining about abd pain
yesterday after school (1st
day of school)
Ate dinner but then woke up around midnight c/o
pain again
Vomited once this am
Walks hunched over
H/O occasional constipation
20. DemographicsDemographics
Most common acute surgical condition
Life-time risk: 8.7% in boys; 6.7% in girls[1]
Age specific risk: extremely low neonates to peak 12-18
years
Up to 50 % initially misdiagnosedUp to 50 % initially misdiagnosed
ƒ < 2 yrs. : perforation rate approaches 100 %< 2 yrs. : perforation rate approaches 100 %
ƒ 3 to 5 yrs. = 71 %3 to 5 yrs. = 71 %
ƒ 6 to 10 yrs. = 40 %6 to 10 yrs. = 40 %
ƒ Most commonly misdiagnosed as AGE ,Most commonly misdiagnosed as AGE , localizedlocalized
tenderness is never a feature of AGEtenderness is never a feature of AGE
21. Alvarado ScoreAlvarado Score
Abdominal pain that migrates to the right iliac fossa
Anorexia (loss of appetite) or ketones in the urine
Nausea or vomiting
Pain on pressure in the right iliac fossa
Rebound tenderness
Fever of 37.3 °C or more
Leukocytosis, or more than 10000 white blood cells per
microliter in the serum
Neutrophilia, or an increase in the percentage of
neutrophils in the serum white blood cell count
RIF pain and leucocytosis score 2 points each
0-3: Sensitivity no AA 96% -› Discharge
4-6: Sensitivity of AA 36% -› Imaging
>7: Sensitivity of AA 78% -› +/- theatre
22. DiagnosisDiagnosis
Classic Triad
WBC 11-16000/mm³ significantly higher in
cases of perforation[8]
RBC’s, WBC’s and protein common in
urine
No evidence CRP superior to WBC count
in children – unnecessary expence[9]
Normal WBC and CRP doesn’t exclude
Dx [10]
8/Guraya S.Y., Al-Tuwaijri T.A., Khairy G.A., et al: Validity of leukocyte count to predict the severity of acute appendicitis.
Saudi Med J 2005; 26:1945-1947.
9/Rodríguez-Sanjuán J.C., Martín-Parra J.I., Seco I., et al:
C-reactive protein and leukocyte count in the diagnosis of acute appendicitis in children. Dis Colon Rectum 1999; 42:1325-
23. Do We Need Imaging Studies?Do We Need Imaging Studies?
NEJMNEJM : Suspected Appendicitis Jan. 2003: Suspected Appendicitis Jan. 2003
Patients with classic presentation should goPatients with classic presentation should go
to O.R. Diagnostic accuracy approaches 95to O.R. Diagnostic accuracy approaches 95
%%
If equivocal or suspect perforation : CTIf equivocal or suspect perforation : CT
US reserved for pregnant women or highUS reserved for pregnant women or high
suspicion of GYN diseasesuspicion of GYN disease
If study indeterminate, observe withIf study indeterminate, observe with
repeated exams or laparoscopyrepeated exams or laparoscopy
24. Radiological imagingRadiological imaging
Abdominal X-ray, no benefit except in setting
of bowel obstruction and young patients
Ultrasound, safe, non-invasive, radiation and
contrast free, but operator dependent
Review of multiple paediatric series
(N=5000+)
Sensitivity 78-94% Specificity 89-98%[13]
CT Scan Sensitivity and Specificity 95%[14]
MRI extremely accurate (no radiation) [15]
13/Vignault F., Filiatrault D., Brandt M.L., et al: Acute appendicitis in children: Evaluation with US. Radiology 1990; 176:501-504.
14/Horton M.D., Counter S.F., Florence M.G., et al:
A prospective trial of computed tomography and ultrasonography for diagnosing appendicitis in the atypical patient. Am J
Surg 2000; 179:379-381.
15/Horman M., Paya K., Eibenberger K., et al:
MR imaging in children with nonperforated acute appendicitis: Value of unenhanced MR imaging in sonographically selected cases. AJR
Am J Roentgenol 1998; 171:467-470.
25. Medical ManagementMedical Management
Treatment starts with IV fluid and
antibiotics
Uncomplicated appendicitis: current
evidence suggests single pre-op dose
sufficient[16]
Post-op antibiotics indicated in
perforation
Duration of treatment determined by
resolution of symptoms
CDC guidelines for peritonitis 7-10 days
16/Mui L.M., Ng C.S., Wong S.K., et al: Optimum duration of prophylactic antibiotics in acute non-perforated appendicitis. Aust
NZ J Surg 2005; 75:425-428.
26. Antibiotic regimensAntibiotic regimens
Triple therapy
(ampicillin,gentamycin,metronidazole)
Piptaz as effective as triples[17]
Ceftriaxone and metronidazole daily as
effective as triples (cost and time benefit)
[18]
Early transition to oral antibiotics as
effective as prolonged IV’s [19]
17/Nadler E.P., Reblock K.K., Ford H.R., et al: Monotherapy versus multi-drug therapy for the treatment of perforated appendicitis in children.
Surg Infect (Larchmt) 2003; 4:327-333.
18/St Peter S.D., Little D.C., Calkins C.M., et al: A simple and more cost-effective antibiotic regimen for perforated appendicitis. J Pediatr
Surg 2006; 41:1020-1024.
19/Adibe O.O., Barnaby K., Dobies J., et al: Postoperative antibiotic therapy for children with perforated appendicitis: Long course of intravenous
antibiotics versus early conversion to an oral regimen. Am J Surg 2008; 195:141-143.
27. AnalgesiaAnalgesia
Sir Zachary Cope's 1921 textbook of surgery saidSir Zachary Cope's 1921 textbook of surgery said nono
wayway
Prospective studies (both EM and Surgery literature)Prospective studies (both EM and Surgery literature)
now show appropriatenow show appropriate use of IV narcoticsuse of IV narcotics
does not decrease diagnosticdoes not decrease diagnostic
accuracy, and may improve examaccuracy, and may improve exam
28. Analgesia, cont'd.Analgesia, cont'd.
Journal of American College of Surgeons :Journal of American College of Surgeons :
Jan. 2003Jan. 2003
Prospective, randomized, double blind studyProspective, randomized, double blind study
Adults with abd. pain got up to 15 mgAdults with abd. pain got up to 15 mg
morphine vs. placebomorphine vs. placebo
Increased pain relief, with noIncreased pain relief, with no
change in diagnostic accuracychange in diagnostic accuracy
Not all surgeons read their own literature, so give them a chance to come in a reasonableNot all surgeons read their own literature, so give them a chance to come in a reasonable
time frame or give the medstime frame or give the meds
29. Surgical ManagementSurgical Management
Acute Appendicitis
Acute appendicitis cured with surgery
Prompt appendicectomy treatment of
choice
Appendicitis can be treated with
antibiotics alone[20]
Antibiotics change from emergency to
elective
Appendicectomy in the middle of the
night not justified[21]
20/ Styrud J., Eriksson S., Nilsson I., et al: Appendectomy versus antibiotic treatment in acute appendicitis: A prospective
multicenter randomized controlled trial. World J Surg 2006; 30:1033-1037.
21/Surana R., Quinn F., Puri P.: Is it necessary to perform appendectomy in the middle of the night in
children?. BMJ 1993; 306:1168.
30. " No single evaluation can" No single evaluation can
substitute for the diagnosticsubstitute for the diagnostic
accuracy of the experiencedaccuracy of the experienced
physician."physician."
31. Meckel’s
In newborns and infants present as bowel
obstruction (volvulus, intussusception)
Bleeding most common presentation in children
Painless, massive, requiring transfusion
Bleeding due to peptic ulceration at the base of
diverticulum
32.
33. Meckel’s
Can diagnose with a Technetium scan
Pretreatment with Cimetidine enhances uptake
of tracer and improves sensitivity
Often have to repeat scan more than once
If a 1-3 year old has two significant LGI bleeds
requiring transfusion, exploration warranted even
if scan negative
Polyps usually don’t need transfusion
Clinical features. Swelling/buldge/intermittent /painless/Buldge Is particularly while crying & resolves during night. :DD-hydroceal/lymphnode/hernia
Most hernias are conginential & are indirect inguinal hernias ,60% occur on right side/30%on left 10%bl
Testis starts to migrate by 28 weeks gestration
As a rule forcefull manual reduction is recommended in all cases of incarceration (except sings of toxicity), keep patient sediated & tendelburgs position-90% chances of reduction –if fails urgent OT
Manuer:particular leg is externally rotated ,1st two fingers are kept over external inguinal ring (hernial bulge) then apex of hernia is grasped by 1st two fingers & thumb then prolonged steady pressure applied…reducing hand needs to be kept in place for few seconds.
Incarceration is entrapment of viscus &second most common cause of bowel obstruction & leading to strangulation.what we need to do in ER is differentiate hydroceal from hernia by transilumination test or by doing PR examination.SILK SIGN –palpation of hernia over cord –inguinal hernia.usg can be used to D/B hydroceal & hernia
All pedia hernias require surgery to prevent incarceration /strangulation-there is 60 % chance of incarceration of hernia in pedia group.tender firm mass ,child is fussy unwilling to feed ,crying,skin over hernia is edematous ,erythematous& discolored, labs leucocytosis -
Traid:vomitting +abdominal pain+passage of blood per rectum. Occurs rarely in malnourished baby
Dance sign is hall mark presentation
USG is hall mark –target sign & pseudo kidney sign …………………. Usg has 97% sensitivity & specificity
XRAY shows crescent /meniscus sign & target sign ,barium enema is most reliable ……….should do lateral decubitus xray
Lead point can be meckels diverticula, lymph node ,HSP there is submucosa bleed which can act as lead point
Enema is contraindicated if perforation or gangre is suspected …also should be avoided in childrens &gt;3 years of age due to possibility of surgical leag point
Initially there is visceral pain followed by somatic pain (after 17 hrs) after 36 hours there are chances of perforation
Xray:very low sensitivity & specificity –appendicolith can be seen in 2%cases,psoas obliteration/mass …USG non compressible tube,tenderness & diameter of 6mm