Paed + Surgery

• Colon Cancer: From the cecum to the sigmoid colon.

• Rectal Cancer: Last 15 cm of the GI tract, ending at the anal verge.

Adenocarcinoma for both.

1. Change in bowel habits (diarrhea/constipation).

2. Occult blood in stool (right-sided) or rectal bleeding (left-sided).

3. Abdominal pain, iron-deficiency anemia, unintentional weight loss.

1. Rectal bleeding (bright red blood).

2. Tenesmus (feeling of incomplete evacuation).

3. Painful defecation and pelvic pain in advanced stages.

1. Occult bleeding → iron-deficiency anemia.

2. Vague abdominal pain.

3. Late obstruction (exophytic growth).

• Narrow stools ("pencil-thin").

• Gross rectal bleeding or hematochezia.

• Early obstruction (circumferential growth).

: Tenesmus and rectal bleeding.

: Colonoscopy with biopsy.

• in rectal cancer : typical apple core lesion.

Carcinoembryonic Antigen (CEA).

: Surgery (colectomy with lymphadenectomy).

• Colonoscopy every 10 years. after age 45

• Fecal immunochemical test (FIT) annually.

• CT colonography every 5 years.

peritoneal carcinomas

bowel obstruction

bowel perforation

prolonged bleeding

1. Bowel Obstruction

   • Common in left-sided tumors (circumferential growth).

   • Symptoms: Abdominal distension, constipation, vomiting.

2. Perforation

   • Tumor necrosis weakens the bowel wall.

   • Leads to peritonitis, fecal contamination, and sepsis.

3. Bleeding

   • Chronic occult bleeding → iron-deficiency anemia.

   • Rarely, massive hematochezia (severe acute bleeding).

4. Fistula Formation

   • Tumor invasion creates abnormal connections (e.g., colovesical fistula).

   • Symptoms: Pneumaturia in colovesical fistula.

5. Abscess Formation

   • Secondary to tumor perforation or necrosis.

   • Presents with localized pain and fever.

1. Achieve R0 resection (complete removal with clear margins).

2. Perform adequate lymphadenectomy (removal of ≥12 lymph nodes).

Segmental Colectomy

• Removes tumor and regional lymph nodes.

• Types:

  • Right Hemicolectomy: For cecum and ascending colon tumors.

  • Left Hemicolectomy: For descending colon tumors.

  • Sigmoid Colectomy: For sigmoid colon tumors.

1. Stable patient: Perform colectomy with primary anastomosis.

2. Unstable patient: Create a diverting stoma (e.g., colostomy).

3. Definitive resection is performed later in a staged approach.

1. Emergency surgery to prevent peritonitis and sepsis.

2. Options:

   • Hartmann’s Procedure: Resect tumor, end colostomy, and leave rectal stump.

   • Reconnect bowel in a second-stage surgery.

3. Primary anastomosis is avoided in unstable patients

• Perform segmental resection of the affected colon.

• Preoperative embolization may stabilize bleeding in selected cases.

Pedunculated

Sessile- broad based polyp without stalk

hematochezia (bright red stools, also seen in left sided colon cancer + rectal cancer)

change in bowel habits, mucous in stool

palapable rectal polyp

Colonoscopy + polpyectomy

<1cm —> cold snare polypectomy

>1cm —> hot snare (especially if pedunculated)

High risk:

snare polpyectomy

if more than 2cm —> endoscopic mural resection

1. Clinical Criteria:

   • Presence of >100 colorectal adenomatous polyps.

2. Genetic Testing:

   • Confirmatory testing for APC mutation. (autosomal dominant)

3. Associated Syndromes

   • Turcot Syndrome:

     • FAP + central nervous system tumors (e.g., medulloblastoma).

Inflammation or infection of diverticula. Most commonly in the sigmoid colon

Left lower quadrant pain

Uncomplicated: no infection, abscess, perforation

Complicated: abscess, fistula, perforation, obstruction

perforation —> peritonitis

left lower quadrant pain

fever (if infection)

alterted bowel habits (constipation, diarrhea)

nausea + vomitting

SIGNS:

LLQ tenderness on palpation

guarding or rebound tenderness ( peritonitis)

Lab:

• leukocytosis

• elevated CRP

Imaging:

• CT with contrast

• if signs suggestive of divierticulitis, avoid colonoscopy

Bleeding (painless hematochezia + signs of anemia)

Diveriticulitis

CHronic inflammation (treat like Chrohn’s disease)

Abscess

Perforation

• NPO + antibiotics + emergency surgery

Uncomplicated:

• clear liquid diet

• oral antibiotics ( ciproflaxcin + metrondiazole)

Complicated:

• hospitalization

• percutaneous drainage for abscess >3cm

• Emergency surgery:

  • in perforation or peritonitis (if hemodynamically stable —> laparoscopic or open colectomy & primary anastomosis)

  • Hartmann’s procedure (also done in colon cancer)

Ileus is a condition characterized by intestinal hypomotility (reduced or absent bowel movement) It often affects the small or large bowel.

1. Paralytic Ileus: Complete lack of bowel motility. due to muscle not moving

2. Mechanical Ileus: Functional obstruction caused by a physical blockage.

Small bowel:

• hernias

• intussception

• adhesions

Large bowel:

• volvulus

• cancer

Small bowel:

• paralytic ileus

Large bowel:

• dilated cecum (colonic pseudoobstruction)

C- Colicky pain, cramping

A- abdominal distention

V- vomitting

O- Obstipation

1. Abdominal pain (colicky or dull).

2. Abdominal distension (bloating).

3. Nausea and vomiting.

4. Constipation or inability to pass gas.

5. Absence of bowel sounds (hypoactive or absent) presnet in functional ileus, mechanical ileus has bowel sounds

• post surgical

• hypokalemia

• due to pain medication (opoids)

• peritonitis

• Clinical Diagnosis: History of surgery, medications, or infections.

• Imaging:

  • Abdominal X-ray: Gas-filled loops of bowel, no transition zone.

    • presence of transition zone —> mechanical ileus

  • CT scan: More detailed, shows underlying cause.

• Lab tests: Check electrolyte abnormalities (e.g., low potassium).

1. Supportive care:

   • NPO (nil per os): No oral intake.

   • IV fluids: Correct dehydration and electrolyte imbalances.

   • Electrolyte correction: Especially for potassium, magnesium.

2. Treat underlying causes: Discontinue offending medications, treat infections.

3. Surgical intervention: Rare, for complications like peritonitis or bowel ischemia. (laparotomy)

A fistula is an abnormal connection or passage that forms between two organs, vessels, or between an organ and the skin. It can be caused by inflammation, infection, injury, or surgical complications.

1. Enterocutaneous Fistula: Between the intestine and skin.

2. Colovesical Fistula: Between the colon and bladder (e.g., in diverticulitis).

3. Colovaginal Fistula: Between the colon and vagina.

4. Arteriovenous Fistula: Abnormal connection between an artery and vein.

5. Tracheoesophageal Fistula: Between the trachea and esophagus, often congenital in infants.

6. Rectovaginal Fistula: Between the rectum and vagina, often caused by trauma or childbirth.

• nflammatory Bowel Disease (IBD): e.g., Crohn’s disease.

• Diverticulitis (leading to colovesical fistula).

• Trauma or injury: Surgery, accidents, or childbirth.

• Infections or abscesses: Infections may create a passage between two organs.

• Cancer: Tumor growth may create abnormal passages.

• Radiation therapy: Can lead to tissue necrosis and fistula formation.

Persistent discharge

Abdominal pain or discomfort

Infections or abscesses

Recurrent urinary or gastrointestinal symptoms:

1. Clinical Examination: Look for abnormal discharges or symptoms suggestive of abnormal connections.

2. Imaging:

   • CT scan: Excellent for detecting abdominal or pelvic fistulas, especially in inflammatory diseases like Crohn's.

   • Fistulography: Special imaging for evaluating fistulas, especially in the gastrointestinal system.

   • Colonoscopy/Endoscopy: To visualize fistulas in the GI tract.

   • Cystoscopy: For diagnosing colovesical fistulas (via visualization of the bladder).

   • MRI: Useful in evaluating complex or deep fistulas, especially rectovaginal fistulas.

1. Colovesical Fistula:

   • Symptoms: Pneumaturia (passing gas in urine), recurrent urinary tract infections, fecaluria (stool in urine).

   • Cause: Diverticulitis or Crohn’s disease.

2. Enterocutaneous Fistula:

   • Symptoms: Foul-smelling drainage from the skin, weight loss, malnutrition, abdominal pain.

   • Cause: Surgery, inflammatory bowel disease, cancer.

3. Colovaginal Fistula:

   • Symptoms: Passage of gas or stool through the vagina, vaginal discharge.

   • Cause: Trauma, childbirth, diverticulitis, or cancer.

4. Rectovaginal Fistula:

   • Symptoms: Stool or gas passing through the vagina, vaginal discomfort.

   • Cause: Childbirth trauma, surgery, radiation.

5. Arteriovenous Fistula:

   • Symptoms: Abnormal pulsatile mass, heart failure symptoms, bruits over the fistula site.

   • Cause: Trauma, surgery, or congenital.

• Conservative Management:

  • Nutritional support (especially in enterocutaneous fistulas).

  • Antibiotics: To prevent or treat infections.

  • Drainage: If there is abscess formation.

  • Medication: Somatostatin to decrease fluid secretion

• Surgical Treatment:

  • Fistula repair surgery: Often required, especially for complex fistulas (e.g., colovaginal or colovesical).

    • lysis of adhesions

    • resection of diseases bowel and connecting healthy parts

  • Stoma: In some cases (e.g., diverticulitis with a colovesical fistula).

• Medical Management:

  • Biological therapy: For fistulas caused by Crohn’s disease (e.g., infliximab).

  • Radiation therapy: In some cases for radiation-induced fistulas.

Not done for all cases, cannot be done in complex fistula/ it is the opening of a fistula allowing it to drain and heal with time + use of sitz baths, wound care and antibiotics.

1. A sudden infection of the pararectal spaces, often caused by bacterial infection (e.g., E. coli or Staphylococcus).

2. Cause: Anorectal abscess (which often leads to paraproctitis if not drained)

1. Severe perianal pain: Localized to the anal or rectal region.

2. Swelling and redness: Around the anus, may be associated with an abscess.

3. Fever: Often present with systemic signs of infection.

4. Tenderness: On palpation, especially in the perianal area.

5. Abscess formation: May develop if infection is not treated promptly.

6. Difficulty sitting or walking due to pain.

7. Painful defecation.

Clinical examination

Imaging

• ultrasound or CT scan

1. Incision and drainage of abscesses to relieve pressure.

2. Antibiotics: Broad-spectrum antibiotics for infection control.

3. Pain management: Analgesics for symptom relief.

4. sitz bath

5. stool softeners

1. A long-standing infection or inflammation of the pararectal spaces, often due to incomplete healing of an acute abscess or a recurrent issue.

2. Cause: Chronic anal fistulas often develop as a result of chronic paraproctitis, with persistent drainage or an abscess that does not resolve properly.

1. Recurrent or persistent anal drainage: May be mucopurulent or serous.

2. Fistula formation: Abnormal connection between the anal canal and skin, causing leakage of stool or pus.

3. Faint perianal swelling: May occur without the severe acute symptoms seen in acute paraproctitis.

4. Intermittent pain or discomfort: Often less severe than in acute paraproctitis, but can worsen with defecation.

5. Chronic itching: Due to prolonged drainage or irritation of the skin.

6. Absence of systemic symptoms: Unlike acute paraproctitis, fever is not common in chronic paraproctitis.

DRE

transrectal ultrasound or endoscopy

MRI or CT

1. Surgical intervention: Surgical drainage of abscess and repair of any fistula (e.g., fistulotomy, fistulectomy, or seton placement for complex fistulas).

2. Antibiotics: Not typically required unless there's a secondary infection.

3. Management of fistulas: If a fistula is present, surgical treatment is needed to prevent recurrence.

4. Pain management: If there's any discomfort, analgesics can be used.

Hemorrhoids are swollen veins in the lower rectum or anus that can be internal or external. They are common and can be classified based on severity. The treatment options depend on the type (internal or external) and severity (grade 1 to 4).

Located above the dentate line

covered by mucosa

classficiation:

• I no prolapse, may cause internal bleeding

• II prolapse, during straining

• III Prolapse required manual reduction

• IV irreducible prolapse

DGE

proctoscopy or ansocopy

flexible sigmoidoscopy or colonoscopy

Lifestyle:

• high fiber

• increased fluid

• daily exercise

• avoid fatty, spicy food

• sitz bath

1. Rubber Band Ligation:

   • The most common treatment for internal hemorrhoids.

   • A small rubber band is placed at the base of the hemorrhoid, cutting off blood supply. The hemorrhoid shrinks and falls off in 1–2 weeks.

   • Effective for grade 1 and 2 hemorrhoids.

2. Sclerotherapy:

   • An injection of a sclerosing solution into the hemorrhoid to shrink it.

   • Used for smaller hemorrhoids and can be combined with rubber band ligation.

3. Infrared Coagulation:

   • A laser or infrared light is used to coagulate the blood vessels in internal hemorrhoids.

   • Used for grade 1 or 2 hemorrhoids.

• hemorrhoidectomy (surgical removal of hemorrhoids)

• Stapled Hemorrhoidopexy

  • A circular stapling device is used to remove a portion of the hemorrhoidal tissue and fix the prolapsed hemorrhoids back into place.

• Doppler guided hemorrhoidal artery ligation

  • A Doppler probe is used to identify and ligate the arteries supplying blood to the hemorrhoids, reducing their size.

  • 
    

Use the "Assess, Adjust, Review" cycle:

1. Assess: Symptom control, modifiable risk factors, comorbidities, inhaler technique, adherence, patient preferences, and goals.

2. Adjust: Treat modifiable risks, consider non-pharmacological strategies, adjust medications, provide education and skills training.

3. Review: Check symptoms, exacerbations, side effects, lung function, and patient satisfaction.

As-needed low-dose ICS-formoterol.

As-needed short-acting beta₂-agonist (SABA), used if adherence to inhaled corticosteroids (ICS) is ensured.

Asthma is a heterogeneous disease characterized by chronic inflammation. It involves respiratory symptoms such as:

• Wheeze

• Shortness of breath

• Chest tightness

• Cough

These symptoms vary over time and intensity and are associated with variable expiratory airflow limitation.

1. History: Allergens, triggers, and symptom patterns.

2. Symptoms: Wheezing, cough, chest tightness, shortness of breath, worse at night or early morning.

3. Provocation: Symptoms triggered by exercise, laughter, allergens, cold air, or viral infections.

4. Examination: Expiratory wheezing on auscultation.

5. Variability tests: Confirm with lung function tests and response to bronchodilators.

• Spirometry: FEV1 < 80% and FEV1/FVC < 75%.

• Bronchodilator test: FEV1 improvement > 12% and > 200 mL.

• Peak flow variability > 10% over 2 weeks.

• Positive bronchial challenge test (methacholine/exercise).

• Significant improvement in lung function after 4 weeks of ICS treatment.

• Testing for triggers: Skin prick tests, GERD evaluation.

1. Wheezing

2. Chest tightness

3. Cough

4. Dyspnea (shortness of breath)

5. Symptoms worse at night or early morning (e.g., "night asthma").

1. Phenotypes:

   • Allergic asthma

   • Late-onset asthma

   • Persistent airflow limitation asthma

   • Asthma with obesity

2. Control Levels:

   • Well-controlled: Symptoms < 4–5 days/week.

   • Partially controlled: Moderate symptoms most days.

   • Uncontrolled: Severe daily symptoms with poor lung function.

1. Mild: Symptoms < 4–5 days/week, controlled with Step 1 or 2 treatment (low-dose ICS + formoterol).

2. Moderate: Symptoms most days or nighttime awakenings, controlled with Step 3 (low-maintenance ICS + formoterol).

3. Severe: Daily symptoms, poor lung function, requires Step 4 or 5 (medium/high-dose ICS + formoterol or add-on therapies).

1. By acquisition:

   • CAP: Community-acquired pneumonia (Typical & Atypical).

   • HAP: Hospital-acquired pneumonia (early >48h, late 7–10 days after discharge).

   • VAP: Ventilator-associated pneumonia (>48h after intubation).

   • HCAP: Healthcare-associated pneumonia (from healthcare facilities/nursing homes).

2. By radiology:

   • Lobar: Dense alveolar infiltration in 1–2 lobes.

   • Interstitial: Bilateral diffuse reticular and micronodular changes.

   • Bronchopneumonia: Bilateral patchy infiltrates; may cause cavitation.

   • Thromboembolic: Due to emboli.

3. By etiology:

   • Viral: Influenza, COVID-19.

   • Bacterial: Typical (e.g., S. pneumoniae, H. influenzae), Atypical (e.g., Mycoplasma, Legionella).

   • Fungal: Pneumocystis jiroveci, Aspergillus.

Typical:

• Dyspnea, tachypnea, productive cough, fever (>4 days), crackles, pleuritic chest pain, dull percussion, fremitus pectoralis.

Atypical:

• Non-productive cough, sore throat, fatigue, myalgia, slow onset.

CURB-65 criteria:

• Confusion.

• Urea >7 mmol/L.

• Respiratory rate ≥30 breaths/min.

• Blood pressure <90 mmHg systolic or ≤60 mmHg diastolic.

• Age ≥65. Score Interpretation:

1. 0–1: Outpatient.

2. 2: Consider inpatient.

3. ≥3: Inpatient or ICU.

1. Clinical Symptoms: Dyspnea, tachypnea, cough, fever, crackles.

2. Laboratory:

   • CRP >100 mg/L, CBC, inflammatory markers, pulse oximetry, blood gases.

   • Urea, glucose, electrolytes, liver tests.

3. Imaging:

   • Chest X-ray (AP, LL views).

   • CT scan if X-ray is inconclusive.

4. Microbiological Tests:

   • Blood & sputum cultures.

   • Bronchoscopy (FBS with brushing).

   • Urine antigen tests (Legionella, S. pneumoniae).

   • PCR for bacterial/viral DNA from sputum or nasal swabs.

1. Antibiotics:

   • Amoxicillin 500 mg–1 g PO

   • ± macrolide(azithromycin) or doxycycline. (if allergic to penicillin)

   • Short course (5 days), follow guidelines.

2. Symptomatic Therapy:

   • Mucolytics, hydration, rest.

   • Paracetamol for pleuritic pain.

1. Empiric Antibiotics (moderate/severe):

   • Amoxicillin ± macrolide (azithromycin) or doxycycline.

   • Broad-spectrum beta-lactamase inhibitors for severe cases (e.g., co-amoxiclav).

2. Duration: 7–10 days (depending on pathogen and severity).

3. Supportive Care: Hydration, oxygen, nutrition, mucolytics.

Discharge Criteria (last 24h):

• Temp <37.5°C.

• RR <24,

• HR <100,

• SpO₂ >90%,

• stable BP, normal mental status, oral intake.

Pneumonia caused by hospital-acquired pathogens, developing ≥48h after admission.

Classification:

1. Early: >48h after admission.

2. Late: 7–10 days post-discharge.

3. VAP: >48h post-intubation.

All cases of pneumonia should have a repeat chest X-ray at 6 weeks after clinical resolution to ensure that the consolidation has resolved and there is no underlying secondary abnormalities (e.g. a lung tumour).

Acute appendicitis is the inflammation of the appendix, typically presenting with

• right lower quadrant abdominal pain,

• fever

• leukocytosis.

It may progress to complications such as abscess, perforation, or peritonitis.

1. Keep NPO (nothing by mouth).

2. Start IV fluids, analgesia, and antiemetics.

3. Assess likelihood of appendicitis based on:

   • Patient demographics (age, sex).

   • Clinical features of appendicitis.

   • Initial lab studies (e.g., CBC, CRP).

     • will show neutrophilis leukocytosis

   • Appendicitis risk scores (e.g., Alvarado, AIR).

• Perform confirmatory imaging (e.g., abdominal ultrasound or CT abdomen).

• If imaging confirms appendicitis: Proceed with treatment.

• If imaging is inconclusive: Reassess clinical findings and likelihood.

What is the management for high likelihood of appendicitis? A:

• Urgent surgical consultation for admission and treatment.

• Start empiric antibiotic therapy. ( cefazolin + metrondiazole)

• Proceed with:

  • Laparoscopic appendectomy for uncomplicated cases (within 24 hours).

  • Emergency appendectomy for complicated cases with systemic manifestations (e.g., sepsis).

Lab studies:

• CBC: Leukocytosis with left shift.

• CRP: Elevated (>10 mg/L).

• Urinalysis: Mild pyuria/hematuria (if present).

• β-hCG: Rule out ectopic pregnancy in women.

Imaging:

• CT abdomen (nonpregnant adults): Most accurate initial imaging.

• Ultrasound (pregnant adults, children): First-line imaging.

• MRI (pregnancy/contraindication to CT): If ultrasound is inconclusive.

• Findings: Distended appendix (>6 mm), periappendiceal fat stranding, target sign, appendiceal fecalith.

• Recommended for complicated appendicitis with appendiceal phlegmon or abscess.

• Considered for early uncomplicated appendicitis in select cases after consultation with a surgeon.

• Parenteral antibiotics for 2–3 days, then oral antibiotics for 7 days (uncomplicated cases).

• 3–5 days for complicated cases.

  Cefazolin + Metronidazole.

gastroenteritis

ectopic pregnancy

diverticulitis

IBD

if <4cm broad spectrum antibiotics —> appendectomy

if >4cm:

• antibiotic therapy + image guided percutaneous drainage + cultures from aspirate

Clinical Features

1. Sudden, severe abdominal pain: Diffuse pain with rigidity (due to peritonitis).

2. Signs of systemic inflammation: Fever, tachycardia, tachypnea, hypotension (from fluid loss).

3. Pneumoperitoneum: Air under the diaphragm seen on imaging.

4. Referred shoulder pain: From phrenic nerve irritation.

1. Patient history: Look for history of ulcers and sudden onset of pain.

2. First-line imaging:

   • X-ray (abdomen & chest): Detects free air (extraluminal gas).

3. Most useful test: CT scan for detailed evaluation.

1. Open or laparoscopic surgery is standard.

2. Ulcer bed management:

   • Sewing over the ulcer.

   • Graham patch: Omentum is fixed over the ulcer if sewing is challenging.

     • 
       

   • Stomach ulcers: Ulcer resection preferred due to higher cancer risk.

3. Complicated cases:

   • Subtotal gastrectomy (75% stomach removal):

     • Reconstruction via Billroth II (preferred) or Roux-en-Y.

   • Damage control procedures for septic patients:

     • Pyloric exclusion + gastrojejunal anastomosis.

Clinical Features

1. Symptoms of blood loss:

   • Weakness, dizziness, sweating, palpitations, collapse.

2. Hematemesis: Vomiting blood (bright red or coffee-ground appearance).

3. Melena: Black, tarry stools (common with duodenal ulcers).

1. nitial evaluation:

   • History and clinical signs.

   • Lab tests: CBC, hemoglobin, CMP (for blood loss).

2. Definitive test:

   FGS (esophagogastroduodenoscopy) to visualize the bleed and treat.

Endoscopic Approach (Based on Forrest Classification)

1. Forrest 1a, 1b, 2a:

   1. 1a = active spurting, IB= active bleeding , 2a = non bleeding visible ulcer

      • Hemoclip + epinephrine injection or cauterization.

2. Forrest 2b ( adherent clot)

   • Remove the clot and cauterize any visible bleed.

3. Forrest 2c, 3:

   1. 2c = flast spot in ulcer base, III = clean base ulcer

      • Conservative management, rarely requiring surgery.

urgical Options

1. Gastric ulcers:

   • Partial gastrectomy + Billroth I/II reconstruction (due to cancer risk).

2. Duodenal ulcers:

   • Suturing over the bleed (or pyloroduodenotomy if proximal).

Clinical Features

1. Compensated stenosis: Feeling of tightness in the stomach region.

2. Decompensated stenosis:

   • Vomiting old food, weight loss, and dehydration.

   • Postprandial non-bilious vomiting.

3. Succussion splash: Splashing sound on auscultation (due to retained gastric contents).

1. Lab findings:

   • Increased HCO3 (from vomiting), decreased Cl and K.

2. Imaging:

   • X-ray with barium swallow or CT scan:

     • Enlarged stomach, no peristalsis, delayed barium passage, pyloric stricture.

   • EGD for confirmation.

Treatment

1. Symptomatic Management:

   • Nasogastric suction, electrolyte replacement, parenteral nutrition.

2. Definitive Treatment:

   • Endoscopic balloon dilation (first-line for mild stenosis).

   • Surgery (severe or refractory cases):

     • Gastrojejunostomy or pyloroplasty

• Increase in serum creatinine > 0.3 mg/dL within 48 hours.

• Increase in serum creatinine to > 1.5× baseline within 7 days.

• Decreased urine output to < 0.5 mL/kg/h for > 6 hours.

1. Prerenal (most common):

• Dehydration

• Sepsis

• Congestive heart failure (CHF)

• Liver failure

1. Renal:

• Hemolytic Uremic Syndrome (HUS) (most common renal cause):

  • Associated with EHEC infection

  • Classic triad: AKI, hemolytic anemia, thrombocytopenia

• Glomerulonephritis (e.g., post-streptococcal)

• Acute tubular necrosis

• Congenital abnormalities of the kidney and urinary tract

1. Postrenal (less common):

• Obstruction (e.g., stones, congenital anomalies).

1. Oliguria or anuria

2. Edema

3. Hypertension

4. Electrolyte imbalances:

   • Hyperkalemia

   • Hyponatremia

5. Uremic symptoms (nausea, lethargy)

6. Metabolic acidosis

1. Laboratory Tests:

   • Serum creatinine, BUN, CBC

   • Electrolytes

2. Urinalysis

3. Imaging:

   • Renal ultrasound (to check for obstruction or anomalies)

4. GFR assessment

1. Treat underlying cause.

2. Indications for renal replacement therapy (RRT):

   • Acidosis

   • Electrolyte imbalance (e.g., severe hyperkalemia)

   • Intoxications

   • Overload (fluid)

   • Uremia

A condition caused by thrombosis in small blood vessels, leading to:

• Hemolytic anemia

• Thrombocytopenia (low platelet count)

• Acute kidney injury (AKI)

Triggered by Shiga toxin from E. coli (EHEC) or Shigella.

1. Gastroenteritis symptoms: diarrhea, often bloody.

2. After 5 days:

   • ↓ Urine output (oliguria)

   • Hematuria

   • Abdominal pain

   • Lethargy or irritability

   • Confusion

   • Hypertension

1. Supportive treatment (self-limiting condition).

2. Avoid antibiotics! (can worsen toxin release).

3. Dialysis if indicated for severe cases.

1. Hemolytic anemia (schistocytes on blood smear).

2. Thrombocytopenia (low platelets).

3. AKI indicators:

   • Elevated creatinine

   • Proteinuria, hematuria

   • Decreased urine output.

4. Stool testing for Shiga toxin (culture or PCR).

A rare, life-threatening inflammation of the epiglottis and surrounding structures (supraglottic laryngitis), most common in children aged 2–5 years.

Haemophilus influenzae type B (Hib).

Q: Name other pathogens that cause acute epiglottitis. A:

• Streptococcus pneumoniae

• Group A Streptococcus (GAS)

• Staphylococcus aureus, including MRSA

1. Inspiratory stridor

2. Drooling

3. Tripod positioning

4. Dysphagia

5. Muffled (hot potato) voice

Fever, irritability, lethargy, and severe sore throat.

inflammation and swelling of the epiglottis and surrounding tissues.

Thumb sign on lateral neck X-ray.

• Clinical evaluation.

• X-ray (Thumb sign).

• Blood culture.

• CBC.

• Swab of the epiglottis (in a controlled environment).

1. Croup (subglottic laryngitis): Gradual onset, barking cough, steeple sign on X-ray.

2. Anaphylaxis: Rapid onset, associated with hives, wheezing, and hypotension.

3. Foreign body aspiration: Sudden onset, asymmetrical breath sounds.

Airway management to prevent obstruction ( can do intubation, if fails —> tracheostomy)

IV Ceftriaxone or Cefotaxime.

IV Prednisolone.

supportive:

1. Inhaled adrenaline to reduce airway swelling.

2. Humidified oxygen.

3. IV fluids for hydration.

4. Analgesics and antipyretics for pain and fever.

Hib vaccination as part of routine childhood immunization.

1. Drooling, inspiratory stridor, tripod positioning.

2. Thumb sign on X-ray.

3. IV Ceftriaxone + Prednisolone.

4. Prevention with Hib vaccination.

1. Sudden onset of diarrhea (≥3 loose/watery stools in 24 hours) and/or vomiting, often with fever.

2. Usually self-limiting and resolves in 1 week.

3. Dehydration is the biggest concern.

Viral (most common, ~80%)

• Rotavirus (first sign is vomiting).

• Norovirus.

• Adenovirus.

• Enterovirus.

2. Bacterial (<20%)

• Salmonella, Shigella, Campylobacter, E. coli (bloody diarrhea).

3. Parasitic

• Giardia lamblia, Entamoeba histolytica.

Symptoms

• Diarrhea:

  • Watery, non-bloody (viral).

  • Bloody (bacterial).

• Vomiting:

  • Common in viral gastroenteritis, first sign in Rotavirus.

• Fever.

• Dehydration Signs:

  • Increased thirst.

  • Sunken eyes.

  • Dry mucosa.

  • Reduced urine output.

  • Lethargy, irritability.

• Severe dehydration:

  • Tachycardia, tachypnea, sunken fontanel (infants).

  • Severe lethargy or altered mental state.

1. Severe abdominal pain.

2. Persistent diarrhea (>7 days).

3. Blood in stool.

4. Vomiting without diarrhea.

Treatment

1. Rehydration (mainstay):

• Oral Rehydration Therapy (ORT) (preferred).

• IV fluids for moderate/severe dehydration or if oral fluids are not tolerated.

2. Antiemetics:

• Ondansetron for vomiting.

3. Probiotics:

• Lactobacillus can reduce duration of diarrhea.

4. Antibiotics:

• Usually not needed.

• Indicated only in bacterial infections with systemic involvement (e.g., Shigella, cholera, or sepsis).

1. Clinical diagnosis: Assess dehydration severity.

2. Stool analysis (if red flags):

   • Culture, PCR, or antigen test for pathogens.

3. Blood analysis (if severe dehydration):

   • Electrolytes, CRP, glucose.

1. Triggers: Viral infections are more common in children; allergens and smoking in adults.

2. Presentation: Episodic symptoms in children; persistent in adults.

3. Diagnosis: Spirometry is difficult in children <5 years.

4. Medication: Weight-based dosing in children.

5. Prognosis: Many children outgrow symptoms; asthma in adults is often lifelong.

1. Viral infections (most common).

2. Allergens (dust, pollen, mold, pets).

3. Exercise.

4. Environmental pollutants (smoke, air pollution).

1. Children >6 years: Spirometry with reversibility testing (FEV1 increase ≥12% and 200 mL after bronchodilator).

2. Children <5 years: Clinical history, signs of recurrent wheezing, and response to treatment.

1. Step 1: Low-dose ICS + SABA as needed.

2. Step 2: Daily low-dose ICS + SABA as needed.

3. Step 3: Moderate-dose ICS or low-dose ICS + Leukotrine receptor antagonist LTRA.

4. Step 4: Referral to a specialist.

1. Step 1: Low-dose ICS-formoterol as needed.

2. Step 2: Daily low-dose ICS + as-needed SABA.

3. Step 3: Low-dose ICS-LABA (MART).

4. Step 4: Medium-dose ICS-LABA ± LTRA or tiotropium.

5. Step 5: Referral to a specialist; consider biologics.

• Symptoms ≤2 days/week.

• No nighttime symptoms.

• No activity limitation.

• SABA use ≤2 times/week.

1. Trigger avoidance (allergens, smoke, viral infections).

2. Education (inhaler technique, asthma action plan).

3. Vaccination (influenza, pneumococcal).

4. Encourage physical activity with proper control.

Chronic inflammatory skin condition commonly seen in children, often associated with

allergic rhinitis and bronchial asthma (collectively referred to as atopy).

Infants (0-2 years):

• Common Areas Affected:

  • Face, scalp, extensor surfaces (arms/legs).

• Symptoms:

  • Cradle cap (yellowish, scaly plaques on the scalp).

  • Weeping, erythematous plaques with excoriation, possibly superinfected with S. aureus.

  • Sparing of the diaper area.

  • 
    

    

Childhood/Adolescence (2 years - adolescence):

• Common Areas Affected: Flexor surfaces (elbows, knees).

• Symptoms:

  • Dry, scaly, hyperpigmented plaques.

  • Lichenification (skin thickening from chronic scratching).

  • Excoriation marks from itching.

1. Anamnesis: Ask about symptoms, family history of atopic diseases (asthma, rhinitis, eczema).

2. Atopy Score: Used to assess the likelihood of an atopic condition.

3. IgE Levels: Often elevated in atopic dermatitis.

4. Prick Test: Identifies common environmental and food allergens.

5. Provocation Test: Controlled exposure to allerg

• Avoid Triggers: Identify and avoid allergens, irritants (e.g., soaps, fragrances).

• Emollients: Regular application of thick creams or ointments to maintain the skin barrier.

• Bathing: Short, lukewarm baths with mild, fragrance-free products.

Pharmacologic Treatment:

• Antihistamines: For pruritus (itching).

• Topical Corticosteroids:

  • First-line treatment during flare-ups.

  • Use mild steroids on the face (e.g., hydrocortisone).

• Topical Calcineurin Inhibitors (e.g., Tacrolimus, Pimecrolimus):

  • Used for sensitive areas (face, eyelids).

• Antibiotics: For secondary infections (e.g., Staphylococcus aureus), often with mupirocin or oral cephalexin.

Flashcard 8: Preventive Measures

• Skin Care: Regular use of emollients, avoid harsh soaps, and allergens.

• Vaccination: Ensure proper vaccination, especially influenza and pneumococcal vaccines, to reduce the risk of infections, as children with atopic dermatitis may have weakened skin barriers.

1. Acute viral infection of the lower respiratory tract, characterized by inflammation and obstruction of the small airways (bronchioles).

2. Most Common Age: Affects infants and young children,

Respiratory Syncytial Virus

• Initial Symptoms (Prodrome):

  • Runny nose (rhinorrhea).

  • Cough (typically dry, becoming more productive).

  • Mild fever.

  • Wheezing (often noticeable on expiration).

• Progressive Symptoms:

  • Dyspnea (difficulty breathing).

  • Tachypnea (rapid breathing, often > 60 breaths per minute).

  • Nasal flaring and intercostal retractions (signs of respiratory distress).

  • Grunting (in severe cases).

  • Cyanosis (in severe cases due to oxygen desaturation).

1. Wheezing: High-pitched sound during exhalation.

2. Crackles: Fine rales or crackling sounds may be heard.

3. Respiratory Distress:

   • Tachypnea.

   • Nasal flaring.

   • Intercostal and subcostal retractions.

   • Use of accessory muscles for breathing.

   • Grunting (especially in severe cases)

Clinical Diagnosis: Based primarily on history and physical examination (often no need for specific tests).

can do nasopharyngeal swab to check for RSV

1. Supportive Care:

   • Oxygen therapy if hypoxic (low oxygen levels).

   • Hydration (oral or intravenous).

   • Nasal suctioning to clear secretions, especially in infants.

2. Bronchodilators and corticosteroids not recommended in children <2 years

Obstructive bronchitis

Asthma

CKD is defined as persistent kidney damage or decreased kidney function (glomerular filtration rate [GFR] < 60 mL/min/1.73 m²) lasting 3 months or more.

• Congenital Causes:

  • Polycystic kidney disease (PKD). mainly autosomal recessive

  • Congenital anomalies of the urinary tract (e.g., posterior urethral valves, vesicoureteral reflux).

  • Congenital nephrotic syndrome (e.g., Finnish-type nephrotic syndrome).

  • Renal dysplasia.

• Acquired Causes:

  • Glomerulonephritis (e.g., post-streptococcal, IgA nephropathy).

  • Hemolytic uremic syndrome (HUS).

  • Systemic diseases (e.g., lupus nephritis).

  • Chronic pyelonephritis.

  • Hypertension (often secondary to other conditions).

1. Family history of kidney disease.

2. Congenital kidney abnormalities.

3. Low birth weight.

4. Urinary tract infections (UTIs) or recurrent UTIs.

5. Hypertension.

6. Diabetes (Type 1 or 2).

7. Immunologic diseases (e.g., lupus).

1. Growth failure (poor growth and failure to thrive).

2. Hypertension.

3. Edema (puffiness, especially around the eyes or legs).

4. Anemia (fatigue, pallor).

5. Proteinuria (frothy urine).

6. Uremic symptoms: nausea, vomiting, anorexia.

7. Bone pain (due to secondary hyperparathyroidism).

8. Polyuria or oliguria (in advanced stages).

9. Developmental delay in children.

1. Laboratory Tests:

   • Serum creatinine and estimated GFR (eGFR) for assessing kidney function.

   • Urinalysis: To check for proteinuria, hematuria, and casts.

   • Urine protein-to-creatinine ratio (important for diagnosing glomerular disease).

   • Electrolytes: To assess for abnormalities like hyperkalemia or metabolic acidosis.

   • CBC: To evaluate for anemia.

   • Albumin: To detect nephrotic syndrome (if applicable).

2. Imaging:

   • Ultrasound: To evaluate kidney size, structure, and signs of obstruction or cysts.

1. Medical Management:

   • Control blood pressure: Antihypertensive medications (e.g., ACE inhibitors, ARBs).

   • Manage proteinuria: ACE inhibitors or ARBs to reduce protein loss.

   • Erythropoiesis-stimulating agents: To treat anemia (e.g., epoetin alfa).

   • Vitamin D supplementation: To manage bone mineral disorders.

   • Phosphate binders: To control hyperphosphatemia.

   • Electrolyte management: Correct imbalances like hyperkalemia and metabolic acidosis.

2. Dietary Management:

   • Low-protein diet may be recommended in advanced stages.

   • Sodium, potassium, and fluid restrictions in advanced disease.

3. Renal Replacement Therapy (RRT):

   • Dialysis (hemodialysis or peritoneal dialysis) is required in end-stage renal disease (ESRD).

   • Kidney transplantation: Considered for children with ESRD and appropriate donor availability.

caused by the SARS-CoV-2 virus, affects children differently than adults. Most children experience mild or asymptomatic infections,

1. COVID-19 is less common in children compared to adults, with the majority of cases being mild or asymptomatic.

2. Transmission: Primarily transmitted through respiratory droplets and aerosols, and can spread via contact with contaminated surfaces.

3. Risk Factors: Children with underlying chronic health conditions (e.g., asthma, obesity, immunocompromised states) are at higher risk of severe disease.

Multisystem Inflammatory Syndrome in Children (MIS-C)

1. Symptoms of MIS-C:

   • Fever.

   • Abdominal pain.

   • Rash (often non-specific).

   • Conjunctivitis (red eyes).

   • Swollen hands and feet.

   • Diarrhea and/or vomiting.

   • Cranial nerve involvement (e.g., facial weakness).

   • Shock (in severe cases).

2. Laboratory Findings:

   • Elevated inflammatory markers (e.g., CRP, ESR).

   • Elevated D-dimer.

   • Low lymphocyte count.

   • Positive or recent history of SARS-CoV-2 infection.

3. Treatment:

   • Intravenous immunoglobulin (IVIG).

   • Corticosteroids.

   • Aspirin (for anti-inflammatory and anticoagulation effects).

   • Supportive care (e.g., oxygen, fluids).

1. PCR (Polymerase Chain Reaction): The gold standard for diagnosing active COVID-19 infection.

2. Antigen tests: Less sensitive than PCR, but can provide rapid results.

3. Serology tests: To detect past infection by identifying antibodies (IgM, IgG).

• Mild Cases:

  • Home care with rest, hydration, and over-the-counter medications (e.g., acetaminophen) to manage symptoms.

  • Monitoring for worsening symptoms (e.g., difficulty breathing).

• Severe Cases:

  • Hospitalization for oxygen therapy, IV fluids, and other supportive measures.

  • Mechanical ventilation or intubation may be required for severe respiratory distress.

  • Antiviral treatment (e.g., Remdesivir) and monoclonal antibodies may be considered for high-risk cases.

• The Pfizer-BioNTech COVID-19 vaccine is recommended for all children in the US ≥ 5 years of age

1. Usually thin or normal weight.

2. Symptoms appear suddenly:

   • Weight loss without trying.

   • Polydipsia (excessive thirst), polyuria (frequent urination), polyphagia (excessive hunger).

   • Fatigue, irritability, blurred vision, frequent infections.

• Ketoacidosis: High glucose → Body breaks fat → Ketones → Acidosis.

• Positive urine/serum ketones, low pH.

1. Often overweight.

2. May be asymptomatic for years.

3. Common initial signs: Numbness, tingling, fatigue, infections.

4. Complications:

   • Atherosclerosis (e.g., CAD, stroke).

   • Long-term: Retinopathy, nephropathy, neuropathy.

Blood Sugar (Glycemia):

• Pre-meal (fasting): 3.9–7.2 mmol/L (70–130 mg/dL).

• Post-meal: <10 mmol/L (<180 mg/dL).

• HbA1c: 6.0–6.5% (higher if life expectancy is shorter).

• Before bed: 6.0–7.0 mmol/L.

Other Goals:

• Cholesterol: <5.2 mmol/L.

• Blood Pressure: <140/90 mmHg.

• Microalbuminuria: Monitor yearly for kidney function.

1. Monitoring:

   • Blood pressure, cholesterol, weight, and blood sugar.

   • Urine microalbumin yearly (Type 1 = 5 years after onset; Type 2 = at diagnosis).

   • Eye exams (Type 1 = 5 years after onset; Type 2 = at diagnosis).

2. Vaccination:

   • Pneumococcal every 5 years; flu annually.

3. Foot care:

   • Annual exams, self-care, and proper footwear.

4. Psychological care:

   • Screen for depression or cognitive issues.

Type 1 DM:

• Carb counting: 1 Bread Unit (BU) = 12g carbs = 1 unit of insulin.

  • Example: 1 potato or 2 tablespoons of rice = 1 BU.

• Glycemic index:

  • Low GI (<55) = Slow blood sugar rise.

  • High GI (>70) = Fast spikes.

Type 2 DM:

• Lifestyle changes:

  • Stop smoking.

  • Physical activity.

  • Balanced diet:

    • Carbs: 45-60%, Protein: 15-20%, Fats: <35%.

Reduces liver glucose production, increases peripheral insulin sensitivity, and reduces intestinal glucose absorption.

Metformin should be used after meal

Metformin goes through urine in unchanged form

GFR < 30 mL/min/1.73 m²: Metformin is absolutely

o If iv contrast, should stop metformin one day before!

1. High efficacy in lowering blood sugar.

2. Minimal risk of hypoglycemia (when used alone).

3. May cause slight weight loss.

4. Low cost.

1. Gastrointestinal upset (nausea, diarrhea).

2. Vitamin B12 deficiency with long-term use.

3. Rare but serious: Lactic acidosis.

1. Severe kidney disease (eGFR <30 mL/min).

2. Use with caution if eGFR is 30–45 mL/min.

3. Severe liver disease, alcoholism, or history of lactic acidosis.

Stimulates insulin secretion from pancreatic beta cells by closing ATP-sensitive potassium channels.

1. Weight gain.

2. Hypoglycemia (especially with missed meals or overdose).

3. May lose efficacy over time (beta-cell burnout).

Severe kidney or liver dysfunction.

repaglinide, nateglinide

Similar to sulfonylureas, they stimulate insulin release but have a shorter duration of action.

1. Reduced risk of hypoglycemia.

2. Useful for controlling postprandial glucose.

1. Weight gain.

2. Hypoglycemia (less frequent than sulfonylureas).

pioglitazone, rosiglitazone

: Improves insulin sensitivity in muscle and fat tissue by binding to PPAR-γ receptors.

1. No hypoglycemia (when used alone).

2. Improves lipid profile (increases HDL).

3. Long-lasting glucose-lowering effect.

1. Fluid retention (risk of heart failure).

2. Weight gain.

3. Risk of bone fractures.

4. Bladder cance

1. Heart failure (NYHA Class III/IV).

2. Active bladder cancer or history of it.

   
   

Inhibit sodium-glucose co-transporter 2 in the kidneys, causing increased glucose excretion in urine.

1. Weight loss.

2. Blood pressure reduction.

3. Cardiovascular and renal protective effects.

1. Genital infections (e.g., yeast infections).

2. Increased risk of UTIs.

3. Dehydration (orthostatic hypotension).

4. Risk of diabetic ketoacidosis.

1. Severe kidney disease (eGFR <30 mL/min).

2. Frequent urinary tract infections.

exenatide

1. Enhances insulin secretion.

2. Suppresses glucagon secretion.

3. Slows gastric emptying (increases satiety).

1. Effective weight loss.

2. Low risk of hypoglycemia.

3. Cardiovascular benefits.

1. Nausea, vomiting, diarrhea.

2. Rare risk of pancreatitis.

3. Gallbladder issues.

sitagliptin, linagliptin

Inhibits DPP-4 enzyme, increasing levels of GLP-1 and GIP → Increases insulin secretion and suppresses glucagon after meals.

1. Oral, well-tolerated.

2. No weight gain.

3. Low hypoglycemia risk.

1. Metformin + SGLT2 inhibitors.

2. Metformin + GLP-1 receptor agonists.

1. Avoid combining sulfonylureas and meglitinides (same MOA → Hypoglycemia).

2. Caution with SGLT2 inhibitors + diuretics (dehydration risk).

1. Lack of insulin leads to glucose not being used by cells.

2. Lipids are broken down via beta-oxidation, increasing acetyl-CoA and ketone body production.

3. Ketones lower blood pH, causing metabolic acidosis (evident by Kussmaul breathing).

: Elevated ketone bodies, particularly acetone.

Acidosis stimulates peripheral chemoreceptors, causing deep, rapid breathing to expel CO2 and reduce acidity.

Hyperkalemia (potassium moves out of cells due to lack of insulin).

A reduced ability of insulin to stimulate glucose uptake and utilization in muscle, adipose tissue, and liver.

• Visceral fat releases inflammatory cytokines (e.g., TNF-α, IL-6) and free fatty acids, impairing insulin signaling.

• Central obesity increases cardiovascular risk via pro-inflammatory states.

Chronic low-grade inflammation disrupts insulin signaling pathways, mediated by cytokines like TNF-α.

: It releases more free fatty acids and inflammatory molecules, increasing insulin resistance.

Below 3.9 mmol/L.

1. Tremor, pallor, tachycardia, sweating.

2. Anxiety and hunger (sympathetic activity).

1. Confusion, agitation, drowsiness, or coma.

2. Seizures or focal neurological deficits in severe cases.

Oral glucose: 15-20g of fast-acting carbohydrates like candy or juice.

- In hospital: 25 g of 50% glucose IV (dextrose) and regular serum glucose monitoring.

- If oral and IV not avaliable: 0.5-1.0 mg glucagon IM or SC

Fat around the abdomen and organs, associated with:

• Higher inflammatory cytokines.

• Increased free fatty acids → insulin resistance.

• Greater risk of cardiovascular disease.

Subcutaneous fat in areas like thighs and hips, releasing fewer free fatty acids and cytokines, with lower metabolic risk.

To prevent ulcers, infections, and amputations due to neuropathy and poor circulation.

• Daily inspection and cleaning.

• Wearing well-fitting shoes.

• Annual professional exams.

Associated with higher risk of obesity

risk of cardiovascular diseases

This means more free fatty acid and inflamatory moleculres into the bloodstream, increased insulin resistance, hypertension, high cholestrol and atherosclerosis. All these likelyhood of cardiovascular diseases.

Hypogonadism is common in men with central obesity and can contribute to further fat accumulation in the abdominal area.

Trigger: Gluten ingestion leads to an immune response that damages the intestinal mucosa.

These autoantibodies target the epithelial cells of the small intestine, leading to inflammation. These antibodies relate to disease activity and will rise with more active disease and may disappear with effective management.

Inflammation affects the small bowel, particularly the jejunum. The surface of the small intestine is covered in projections called villi, which increase the surface area and help with nutrient absorption. Coeliac disease causes atrophy of the intestinal villi, resulting in malabsorption.

• Anti-tissue transglutaminase antibodies (anti-TTG) 

• Anti-endomysial antibodies (anti-EMA)

1. Gluten peptides, especially gliadin, are deamidated by tissue transglutaminase (tTG).

2. These peptides bind to HLA-DQ2 or HLA-DQ8 molecules on antigen-presenting cells, activating T-cells.

3. Results in villous atrophy, crypt hyperplasia, and chronic inflammation of the sm

Presenting symptoms can include:

• Failure to thrive in young children (short stature)

• Diarrhoea

• Bloating

• Fatigue

• Weight loss

• Mouth ulcers

Dermatitis herpetiformis is an itchy, blistering skin rash, typically on the abdomen, caused by coeliac disease.

Anaemia occurs secondary to malabsorption and deficiency of iron, B12 or folate.

Rarely coeliac disease can present with neurological symptoms:

• Peripheral neuropathy 

• Cerebellar ataxia

• Epilepsy

The patient must continue eating gluten while being investigated. Antibodies and histology may be normal if the patient is gluten-free.

The first-line blood tests are:

• Total immunoglobulin A levels (to exclude IgA deficiency)

• Anti-tissue transglutaminase antibodies (anti-TTG) 

Anti-endomysial antibodies (anti-EMA) are a second-line option where there is doubt (e.g., a borderline result).

HLA testing: HLA- DQ2/ DQ8

Patients with a positive antibody test are referred to a gastroenterologist to confirm the diagnosis by endoscopy and jejunal biopsy. Typical biopsy findings are:

• Crypt hyperplasia

• Villous atrophy

A lifelong gluten-free diet should completely resolve the symptoms. Dietician input may be helpful. Relapse will occur upon consuming gluten. Coeliac antibodies may help monitor the disease.

• Nutritional deficiencies

• Anaemia

• Osteoporosis

• Hyposplenism (with immunodeficiency, particularly to encapsulated bacteria such as Streptococcus pneumoniae)

• Ulcerative jejunitis

• Enteropathy-associated T-cell lymphoma (EATL)

• Non-Hodgkin lymphoma

• Small bowel adenocarcinoma

Croup (Laryngotracheobronchitis)

1. A viral respiratory infection causing inflammation of the larynx, trachea, and bronchi, leading to airway narrowing and the classic barking cough.

   
   

children aged 6 months to 3 years (peak at 2 years).

Viral infection (most common):

• Parainfluenza virus (Type 1 & 3): Primary cause.

• Others:

  • Respiratory Syncytial Virus (RSV).

  • Influenza A & B.

  • Adenovirus.

• Rarer causes: Measles virus.

1. Viral infection → inflammation and edema of the subglottic region of the airway → narrowing.

2. Subglottic region is the narrowest part of the pediatric airway, making children more susceptible.

3. Results in stridor (due to turbulent airflow), barking cough, and respiratory distress.

1. Prodromal symptoms (early stage):

   • Non-barking cough.

   • Coryza (runny nose, congestion).

   • Low-grade fever.

2. Acute Symptoms:

   • Barking cough: Seal-like, worse at night.

   • Hoarse voice.

   • Inspiratory stridor (high-pitched sound on inspiration). (same found in acute laryngitis)

   • Respiratory distress:

     • Nasal flaring.

     • Chest retractions (intercostal, subcostal, and suprasternal).

     • Tachypnea.

   • Fever: May or may not be present.

   • Symptoms often worsen with agitation or crying, so calm the child.

Clinical Diagnosis:

• Based on symptoms: barking cough, stridor, and respiratory distress.

• (clinical diagnosis, same done for acute laryngitis, if needed Xray)