INTRODUCTION Dislocation of the hip is a common injury to the hip joint. Dislocation occurs when the ball–shaped head of the femur comes out of the cup–shaped acetabulum set in the pelvis. This may happen to a varying degree. A dislocated hip, much more common in females than in males, is a condition that can either be congenital or acquired Definition • A dislocation is an injury in which a bone is displaced from its proper position CLASSIFICATION The relationship of the femoral head to the acetabulum is used to classify the dislocation. The three main patterns are posterior, anterior, and central. POSTERIOR HIP DISLOCATION  Posterior dislocations account of more than 90% of dislocations and occur when the knee and hip are flexed and a posterior force is applied at the knee.  Posterior hip dislocations occur typically during MVAs, especially head-on collisions, when the knees of the front-seat occupant strike the dashboard. Energy is transmitted along the femoral shaft to the hip joint. If the leg is struck while in an adducted position, a posterior dislocation may result. If the leg is in neutral or an abducted position when struck, an anterior dislocation or fracture/dislocation may occur. In the latter case, the posterior wall of the acetabulum is fractured, making subsequent reduction less stable. Several classification systems are used to describe posterior hip dislocations. • The Thompson-Epstein classification is based on radiographic findings. o Type 1 – With or without minor fracture o Type 2 – With large, single fracture of posterior acetabular rim o Type 3 – With comminution of rim of acetabulum, with or without major fragments o Type 4 – With fracture of the acetabular floor o Type 5 – With fracture of the femoral head • The Steward and Milford classification is based on functional hip stability. o Type 1 – No fracture or insignificant fracture o Type 2 – Associated with a single or comminuted posterior wall fragment, but the hip remains stable through a functional range of motion o Type 3 – Associated with gross instability of the hip joint secondary to loss of structural support o Type 4 – Associated with femoral head fracture

2. Malabsorption
Syndrome

3. INTRODUCTION

4. Malabsorption
Syndrome
• Maldigestion: impaired breakdown
of nutrients (carbohydrates, protein,
fat) to absorbable split-products
(mono-, di-, or oligosaccharides; amino
acids; oligopeptides; fatty acids;
monoglycerides)
• Malabsorption: defective mucosal
uptake and transport of adequately
digested nutrients including vitamins
and trace elements.

5. DEFINITION

6. DEFINITION
• Malabsorption Syndrome is a
clinical term that encompasses
defects occurring during the
digestion and absorption of
food nutrients by the
gastrointestinal tract

8. Risk Factors
Medical conditions affecting the
intestine
• Use of laxatives
• Excessive use of antibiotics
• Intestinal surgery
• Excessive use of alcohol
• high incidence of intestinal
parasites.

10. Due to infective agents
• HIV related malabsorption
• Traveller's diarrhoea
• Parasites e.g. Giardia lamblia ,
roundworm, hookworm
• Tropical sprue
• Whipple's disease
• Intestinal tuberculosis

11. Due to structural defects
• Inflammatory bowel diseases, as
in Crohn's Disease
• Fistulae, diverticulae and
strictures
• Infiltrative conditions such as
amyloidosis, gastroenteritis
• Radiation enteritis Systemic
sclerosis and collagen vascular
diseases
• Short bowel syndrome

12. •Due to surgical
structural changes
• Gastrectomy;
• Vagotomy
• Bariatric surgery (Weight
loss surgery)

13. Due to mucosal abnormality
• Coeliac disease
• Cows' milk intolerance
• Soya milk intolerance
• Fructose malabsorption

14. • Due to digestive failure Pancreatic
insufficiencies:
– Cystic fibrosis
– Chronic pancreatitis
– Carcinoma of pancreas
• Zollinger-Ellison syndrome
• Bile acid/Bile salt malabsorption
– Terminal ileal disease such as
Crohn's disease
– Obstructive jaundice
– Bacterial overgrowth
– Primary bile acid diarrhe

15. Due to enzyme deficiencies
• Lactase deficiency inducing
lactose intolerance
(constitutional, secondary or
rarely congenital)
• Sucrose intolerance
• Intestinal disaccharidase
deficiency
• Intestinal enteropeptidase
deficiency

16. External Causes
• Hyperthyroidism
• Hypothyroidism
• Addisons' disease
• Diabetes mellitus
• Hyperparathyroidism
• Hypoparathyroidism
• Carcinoid syndrome

17. Cont..
• Widespread skin disease
• Malnutrition.
• Collagen diseases.
• Eating disorders.

19. • The main purpose of the gastrointestinal tract is to digest and absorb
nutrients (fat, carbohydrate, protein, and fiber), micronutrients
(vitamins and trace minerals), water, and electrolytes. Digestion
involves both mechanical and enzymatic breakdown of food.
Mechanical processes include chewing, gastric churning, and the
to-and-fro mixing in the small intestine. Enzymatic hydrolysis is
initiated by intraluminal processes requiring gastric, pancreatic, and
biliary secretions. The final products of digestion are absorbed
through the intestinal epithelial cells.
• Malabsorption constitutes the pathological interference with the
normal physiological sequence of digestion (intraluminal process),
absorption (mucosal process) and transport (postmucosal events) of
nutrients.[6]

21. • Flatulence and abdominal
distention
– Bacterial fermentation of unabsorbed food
substances releases gaseous products, such
as hydrogen and methane, causing flatulence.
– Flatulence often causes uncomfortable
abdominal distention and cramps.

22. • Edema
–Hypoalbuminemia from chronic protein
malabsorption or from loss of protein
into the intestinal lumen causes
peripheral edema.
–Extensive obstruction of the lymphatic
system, as seen in intestinal
lymphangiectasia, can cause protein
loss.

23. • Anemia
– Depending on the cause, anemia resulting
from malabsorption can be either microcytic
(iron deficiency) or macrocytic (vitamin B-12
deficiency).
– Iron deficiency anemia often is a
manifestation of celiac disease.

24. • Bleeding disorders
– Bleeding usually is a
consequence of vitamin K
malabsorption and subsequent
hypoprothrombinemia.
– Ecchymosis ,
– malena
– hematuria.

25. • Metabolic defects of bones
– osteopenia or osteomalacia.
–Bone pain
– pathologic fractures
–Malabsorption of calcium can
lead to secondary
hyperparathyroidism.

26. • Neurologic manifestations
– tetany,
– Trousseau sign
– Chovostek sign.
– motor weakness (pantothenic acid,
vitamin D)
–peripheral neuropathy (thiamine),
–a sense of loss for vibration and
position (cobalamin),
–night blindness (vitamin A), and
–seizures (biotin).

27. Physical Signs of Malabsorption
• General Manifestations
–orthostatic hypotension.
–fatigue.
–Signs of weight loss
– muscle wasteing

28. • Dermatologic manifestations
–Pale skin may reveal anemia.
–Ecchymoses due to vitamin K
deficiency may be present.
–Dermatitis
–Pellagra,
– alopecia

30. Possible Complications
Long-term malabsorption can result in:
• Anemia
• Gallstones
• Kidney stones
• Osteoporosis and bone disease
• Malnutrition and vitamin deficiencies

31. Investigations

32. Blood tests
• Specific vitamins (A, D, E & K)
• IgA
• Serum studies

33. Tests for steatorrhea
• Quantitative test
– 72hr stool fat collection
• Qualitative tests
– Sudan lll stain
– Acid steatocrit – a gravimetric
assay
– NIRA (near infra reflectance
analysis)

34. Schilling test
– To determine the cause of
cobalamine(B12)
malabsorbtion
– The test
• Administering 58Co-labeled
cobalamine
– Cobalamine 1mg i.m. 1hr after
ingestion to saturate hepatic
binding sites
• Collecting urine for 24 hr
(dependant on normal renal &
bladder function)
• Abnormal - <10% excretion in 24
hrs

35. D-xylose test
– A Pentose monosacharide
absorbed
exclusively at the proximal
SB
• The test
– After overnight fast, 25gm D-
xylose
– Urine collected for next 5 hrs
– Abnormal test - <4.5 gm
excretion
Drugs(ASA,indometacin,
Neomycin)

36. Endoscopy
• Gross morphology – gives diagnostic clue
– Reduced duodenal folds and scalloping
of duodenal mucosa – celiac disease
• Use of vital dyes to identify villous atrophy,

38. management
• Replacement of nutrients, electrolytes
and fluid may be necessary.
• In severe deficiency, hospital admission
may be required for nutritional support
and detailed advice from dietitians.
• Use of enteral nutrition by naso-gastric
or other feeding tubes
• Tube placement may also be done by
percutaneous endoscopic gastrostomy,
or surgical jejunostomy

39. Cont..
• Pancreatic enzymes are
supplemented orally in
pancreatic insufficiency. Dietary
modification is important in
some conditions: Gluten-free
diet in coeliac disease.
• Lactose avoidance in lactose
intolerance.

40. Cont..
• Antibiotic therapy to treat Small
Bowel Bacterial overgrowth.
• Cholestyramine or other bile acid
sequestrants will help reducing
diarrhoea in bile acid
malabsorption.

45. bibliography
• Dutta Parul, “pediatric nursing’’,2nd edition: New
Delhi, jaypee publication,(2009)
• Ghai O.P, “Essential pediatrics’’,6th edition: New
Delhi, CBS Publication,(2004)
• Kyle Terri, “Essential of pediatric nursing’’,1st edition
: New Delhi, wolter kluwer publication,(2009)
• Siddhartha and Brunner, “medical surgical
nursing”:12th edition , New Delhi, wolter kluwer
publication,(2009)
• www.google.com
• www.gi system.co.in
• www.mas.slideshare.com
•