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Welcome Applicants!! . Morning Report: Thursday, January 26th. GI Bleeding in Infants and Children. Initial Approach. Step 1: ABCs!! Assess hemodynamic status of the patient Orthostatic changes- best indicator of significant blood loss Step 2: Establish severity of bleeding

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welcome applicants

Welcome Applicants!!

Morning Report: Thursday, January 26th

initial approach
Initial Approach
  • Step 1: ABCs!! Assess hemodynamic status of the patient
    • Orthostatic changes- best indicator of significant blood loss
  • Step 2: Establish severity of bleeding
    • Coffee ground emesis, melena: lower rate of bleeding
    • Bright red blood: ?higher rate of bleeding
ugi vs lgi bleeding
UGI vs. LGI Bleeding
  • Step 3: Determine the location of the bleeding
    • UGI: bleeding above the ligament of Treitz
      • Hematemesis
    • LGI: bleeding distal to the ligament of Treitz
      • Bloody diarrhea
      • Bright red blood mixed with or coating stool
    • Hematochezia, melena, or occult blood loss can be due to both UGI or LGI bleeds
      • Passing NGT can determine if the blood is originating from the UGI tract or LGI tract
is it blood
Is It Blood?
  • Simulates bright red blood
    • Food coloring
    • Colored gelatin or children’s drinks
    • Red candy
    • Beets
    • Tomato skins
    • Antibiotic syrups
  • Simulates melena
    • Bismuth or iron preparations
    • Spinach
    • Blueberries
    • Grapes
    • Licorice
pathogenesis
Pathogenesis

Cytoprotective factors:

Mucous layer

Local bicarb secretion

Mucosal blood flow

Cytotoxic factors:

Acid

Pepsin

Medications

Bile acids

Infection with H.Pylori

clinical presentation
Clinical Presentation
  • Epigastric abdominal pain
  • Recurrent vomiting (at least 3x/mo)
  • Symptoms associated with eating (anorexia/ wt loss)
  • Pain awakening the child at night
  • Heartburn
  • Oral regurgitation
  • Chronic nausea
  • Excessive belching/ hiccuping
  • FHx of PUD, dyspepsia, or IBS
history
History
  • Symptoms?
  • Dietary history?
    • Specific foods that worsen pain?
  • Medications?
  • Alcohol or tobacco use?
  • Doses of acid-suppressive meds?
physical exam
Physical Exam
  • Height, weight and BMI PLOT!
  • HEENT
    • Funduscopic exam
    • OP: aphthous ulcers Crohn’sdz, dental enamel erosion GER, Eating d/o
  • Lungs
    • Wheezing GER
  • Abdomen
    • Splenomegaly portal HTN
  • Rectum
    • Perianal disease Crohn’sdz
  • Extremities
    • Clubbing Crohn’sdz, Russell sign Eating d/o
evaluation
Evaluation
  • Screening labs
    • CBC with diff
    • ESR
    • LFTs
    • Electrolytes
    • Stool for O&P
    • UA
  • Endoscopy
    • Indications
      • Evidence of GI bleeding
      • Abnormality on UGI
      • Odynophagia
      • Refusal to eat
      • Persistant unexplained vomiting
      • Lack of response to medications
the basics
The Basics…
  • Gram negative

bacillus

  • Transmission fecal-oral, gastric-oral, or oral-oral
  • *Organism associated with a significant proportion of duodenal ulcers & chronic active gastritis
    • To a lesser extent, gastric ulcers
  • Also linked to the development of gastric adenocarcinoma and lymphoma
epidemiology
Epidemiology
  • 50 % of the world’s population is infected
    • Most are asymptomatic
  • Infection most common in developing countries
    • Incidence 3-10% in developing countries
    • Incidence 0.5% in industrialized countries
  • Asian Americans, African Americans and Hispanic individuals living in North America have a prevalence of infection similar to that of a developing country
    • Ethnic or genetic predisposition?
risk factors
*Risk Factors
  • Poor socioeconomic status
  • Family overcrowding
  • Child care attendance
  • Poor hygiene
  • Living with an infected family member
testing
*Testing
  • The ideal test does not yet exist!
    • Endoscopy with biopsies from the prepyloricantrum= gold standard
      • Histologic identification
      • Culture
      • Immunologic detection of H.Pyloriurease
      • PCR
    • Urease breath test
    • Anti-H. Pylori IgG
    • Stool antigen testing
testing1
*Testing
  • Stool antigen testing
    • Sensitivity and specificity> 98%
    • Sample easy to obtain
    • Less expensive than the urease breath test
  • The AAP says…don’t test for it if you are not going to treat it!!
    • Active peptic ulcer disease
    • History of ulcers
    • MALT lymphoma or gastric cancer
treatment
*Treatment
  • Goals
    • Eradicate the organism
    • Heal the ulcer
    • Prevent recurrence of infection and the emergence of resistant organisms
  • Two antimicrobials + PPI
    • First line: clarithromycin+ Amoxicillin OR metronidazole+ PPI
    • Alternative (age>8): tetracycline+ metronidazole+ bismuth subsalicylate+ H2 blocker
treatment1
*Treatment
  • Length of treatment: 14days
  • Cure rates 75-90%
  • To check for eradication,

wait 6 weeks-3 months after

the completion of therapy

    • Urease breath test
    • Stool antigen test
a question
A Question…
  • A 12 yo boy who has a h/o recurrent abdominal pain presents to your office for an annual health supervision visit. The boy complains of periumbilical pain, unrelated to meals, occuring twice a month and lasting 15 minutes. PE is normal. FOBT is negative. His father, who is a physician, asks if the boy should undergo testing for H. Pylori. Of the following, a TRUE statement about H. Pylori infection is:
    • A. All children who have positive H. Pylori serologies should undergo endoscopy
    • B. Antibiotic therapy for H. Pylori is most effective when combined with a PPI
    • C. H. Pylori is difficult to detect on gastric histology without special immunofluorescent staining
    • D. H. Pylori infection is less prevalent in children from the developing world
    • E. H. Pylori organisms rarely develop antibiotic resistance
thanks for your attention
Thanks for your attention!!

Noon Conference:

Pseudoasthma, Dr. Pepiak