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Hi, everyone. Um We'll just wait for a couple more people to uh join and we'll just start in the next few minutes. Ok, so yeah, hello everyone. Um welcome to this teaching things. Um everything you need to know about the pediatric abdomen. So if you're new to this series, um then welcome and it's gonna be weekly tutorials. Um that's open to everyone, but it's gonna be catered towards UK MLA um and CPS A um content and yeah, and it's gonna be done by medical students for medical students and doctors will look over what we present before we present it to you to make sure it's accurate. Um And you're welcome. Ok. So let's get started. So, first off today, I was thinking we'll cover vomiting after feeds, abdominal pain, abdominal distension and jaundice as the main like presenting complaints. Um Obviously with a lot of abdominal issues, there's a big overlap between all of these. Um but this is the way I feel like it helps break down what's going on in the gi tract slash hepatobiliary system. Ok. So we're starting with vomiting, first of all. Um I just wanna check everyone can hear me. Ok. Yes. Gonna take that as the. Yes for now. So um, ok, let's start. So first off, I have a question. Um, so let me just start this pull. So we've got a 24 year old mom comes in with her seven week old baby boy to the GP, he frequently regurgitates slash vomits about three hours after feeds. He is exclusively bottle fed. He has also developed a rash on his trunk over the past week based on the likely diagnosis. How should this child be managed? Um So eight PPIs B just reassured that this is normal positive um C extensive hydrolyzed milk. DT mon to breastfeed exclusively or E amino acid based formula. So I'll start the pool if you can't see it, it might be because you need to just minimize and not be in full screen. Ok? And I'll just give you guys a couple of minutes for that. Oh, no, sorry, sorry, let's go back. Um Sorry, I clicked on a different pull back then. Ok. Stop pulling. Cool. So majority of you have gone for extensive hydrolyzed milk. Um A couple people said, tell mum to breastfeed exclusively. Ok. So, well, first of all, you, you're all right in the sense that this is not normal. Um And the biggest thing that points towards it's not being normal as is the fact that he has a rash. So the reason why we wouldn't tell mom to breastfeed exclusively is because this condition, which I'm assuming you will have guessed, um, can also occur with breastfed babies. Um Also, I guess it's the mom's prerogative. So we can't really go down that route of just saying you have to breastfeed exclusively. So you're right, it's extensive hydrolyzed milk. And um the reason this is happening is because the child has either cow's milk protein intolerance or allergy. So I guess I just wanted to check, does anybody know the difference between um intolerance versus allergy? You can just put it on the chart if you do so? Ok, I'll move on. So it usually presents within the first three months and it's usually seen more. So in former fed babies, but not exclusively can be in breastfed too. And the difference between intolerance and allergy is whether it's I GE mediated or not. So I ge mediated is called the cow's milk protein allergy. Non I GE mediated is cow's milk protein intolerance. So the difference in how these present essentially is the fact that um an allergy as the name suggests tends to have a more immediate and severe reaction and occurs up to two hours after ingestion. Whereas intolerance is more of a mild to moderate delayed reaction. So anything between 2 to 72 hours. Another big thing is you don't really get the more classic allergic presentations with cow's milk protein intolerance. So the fact that you're getting like a rash, um that is more of an allergic reaction. So you're thinking it's more I ge mediated so typical presentation um is gonna be regurgitation, vomiting, urticaria, eczema, cough, diarrhea, bloating, and rare cases, anaphylaxis. Um So, depending on how this child is presenting and if it's really severe, um or you're unsure, you really do wanna consider hospital admission in case it's anaphylaxis. Um There may be questions sometimes where they talk about in the future when you're reassessing and trying a milk challenge on the child to see if they've developed tolerance. One thing you really wanna remember about that is you always, always do a challenge in a hospital setting um because of the risk of anaphylaxis. Ok. Um OK. So in terms of examining and diagnosing, um does anyone know of any like would it be a clinical diagnosis or is there an investigation, someone can put it in the trap real quickly and if you don't know that's also completely OK. Although unfortunately, I understand none of you can unmute. So sorry about that. Um OK, so it's a clinical diagnosis generally, but if you wanted to investigate to confirm, then you do skin prick or patch testing. Um But yeah, also while you that you'd wanna check things like um do you sorry, I just missed, do you ask the mom to stop with the formula, stop drinking dairy. If she does, then you reintroduce. Um Yeah, so I understand where you're coming from. I'll get on to that in a second actually. Um So yeah, so to investigate um uh check their weight height and BMI I, because you really wanna check that the child is still growing and is the correct weight um for their age. So, if there's failure to thrive or a really severe reaction, that's when you know there's red flags going off and you wanna consider having more senior involvement or specialist involvement. Ok. So in exclusively breastfed babies, um coming on to Amelia's question. So management um is mom can continue breastfeeding but ask her to cut out milk from her diet? Um and then obviously discuss support for mom in terms of calcium Vitamin D supplements, but she can eliminate it from her diet up to 9 to 12 months. Then you'd like to stop and reassess and see if the child's built up um uh tolerance. So it doesn't have a reaction anymore. Then next step of management would be extensive hydrolyzed milk. And then if that doesn't work, you go amino acid based formula, the next referred to pediatrics. Now, in exclusively bottle fed babies, the management is basically the exact same taking out the fact that mom doesn't need to cut anything out of her diet since she's not breastfeeding. Um Yeah. So I'm just wondering, does that all make sense right now? If anyone has any questions, please do ask? Ok, cool. Let's move on. So next is gourd in Children which can also present quite similarly in the sense of it, that general feeding and then regurgitating. Um, but the main difference you look out for is the fact that when feeding they're gonna be more irritable and crying. Um, and they'll present with a hoarse cough, which is um, a key thing to look out for and it usually presents between like um under two months of age. So again, this is also a clinical diagnosis. Um And yeah. So management, does anyone know management for Gordon Children? Uh Yes. OK. I'll put out a question. Do we give PPI S yes or no if you can just put in the chart? No, but not entirely sure. Yeah. So we, so we don't really want to give them PPIs but it can be considered later on much further down the steps of management. So, yeah, so first you're gonna wanna do breastfeeding assessment to see, you know how mom is positioning the baby if the baby's latching on properly. Um And also just make sure the baby's head is rotated. Yeah. After thickened solutions. Yup. Um So head rotation, they say about 30 degrees upright. Um And if after all of that, the baby is still irritable and it's not working. That's when you're, I'm gonna just also discuss, I guess kind of with step one, you're gonna discuss how to stop and avoid overfeeding, which could be contributing to this picture. So you can discuss, you know, decreasing the feed volume by increasing frequency. Um And trial a feed thickener. Um, and then third would be trial alginate therapy, which is known as Gaviscon infant. Um, so try that for 1 to 2 weeks and if that's working you'd want to stop and reassess. Um, so stop every two weeks and reassess to see, you know, if it's gotten better yet to, then slowly wean them off, then if that doesn't work, then we're gonna consider PPIs. So the main reasons we consider PPIs is, you know, if they're gagging, choking, refusing feeds, obviously very distressed and they're just, you know, failure to thrive. Of course. So that is when we'd consider PPIs, but it's definitely not the go to straight away. Yeah. Good. Um Let's see. Yeah. Ok. So that's good. And now I have a case that I wanted to present. So um the presenting complaint is four week old baby boy presenting with constant forceful vomiting after feeds. Ok. So what would you like to do next? Does anyone have any suggestions? You don't have to type out big answers? Just like little suggestion if you'd like to get involved? Yeah. Examined baby weight. Oops, et cetera. Y good. So yeah, history. Good. So full history you want gonna wanna do an abdominal exam, see what's going on and when you do um Yeah. And when you do an abdominal exam, you see an olive shaped mass in the right upper quadrant, you check the hydration as well. So that's one thing I really wanna emphasize on any child or any patient in general but especially in the elderly and young infants. Um, vomiting happens after feeds. Sorry to chazz you in the chats. So um when yeah any patient with um uh God, sorry, I've lost my train of thought, vomiting. Any patient with vomiting but especially Children and the elderly, you're gonna be worried about dehydration. So you really wanna check if they're needing fluids or whatnot. So, dehydrated baby, you gonna wanna do some bloods and you're gonna wanna do some imaging. So and yes to Chazz as well. You wanna check what type of vomiting is it bilious or not? If there's bilious vomiting, that is that immediately requires hospital admission with a child um to see what's going on. Well, we'll get on to that later. Ok. So I've got a VBG here. Um have a look and can tell someone, tell me what it's showing and one cat in. Ok. So we've got hypochloremic hypochloremic hypokalemic alkalosis, metabolic alkalosis. Yes. Um That is right. So got hypochloremic hypokalemic alkalosis and this is a typical picture of which I feel you guys have already guessed and it has been said in the chart pyloric stenosis. So essentially the pyloric, the pylorus muscle, I should say has thickened and therefore causes forceful or what's typically described as projectile vomiting and obviously vomiting that much after feeds is gonna lead to loss of um hydrogen ions, loss of potassium and chloride leading to alkalosis and this p uh picture presenting. So that's a very typical finding you wanna be aware of. And imaging would be ultrasound of the abdomen and you can kind of see here that that is the pylori and it's thickened essentially. Um You wouldn't really be expected to identify this on an ultrasound for, you know, UK MLA level, but just so you're aware. Ok. So management is, does anybody know the name? So I'll give you this so far. So, nil by mouth, of course, uh, drip and suck. So you're gonna wanna give fluids to rehydrate and you're gonna wanna put in an NG tube to get rid of all the gastric contents before surgery. So you wanna correct the fluid and electrolyte levels before surgery. Does anybody know what the surgery is called? I think is kind of in the name of the diagnosis? Ok, we'll move on. So it's Ramstad. I might be pronouncing it wrong. Ramstad Pyloromyotomy. Please don't take what I say for granted. Just you can pronounce it correctly. Um, ok, so that's what I've covered for now for vomiting. Other things you'd wanna just consider and go over in your own time is, um, things like, you know, lactose intolerance or sometimes classically, Children can present with a lot of vomiting because they're coughing a lot and it's a very loud cough and there's a noise upon inspiration. So that's when you're thinking about whooping cough and that kind of picture. Um But I'm not gonna cover that right now cause abdominal, so before we move on to abdominal pain, just wanna check. How's everyone doing. Is that all? All right. So far happy for me to move on. Cool. OK, let's move on. So another question, um I'll let you guys have a read of it yourselves. Um Rather than hearing my voice go on and on and let me just start the poll, whatever it is. Oh, you just give everyone a minute for that. OK. So we have slightly more split picture here. OK? I'll stop the call now. OK. So 33% of people went for dilated loops of bowel and pneumatosis, intestinalis and 66 went for target like mass. So the answer is target like mass. So basically, the main things to look out for here is abdominal pain, drawing his knees up, classic presentation for what's causing the abdominal pain. So he's got a sausage shaped mass in his right upper quadrant and red currant jelly like stool, which is a key presentation for int sorry. So intussusception is just in the invagination or telescoping of the bowel into the lumen of the adjacent bowel. And I've just added this image here. So you can kind of visualize what's going on because I always struggled with um thinking through what's happening. So with intussusception, it's more common in between 6 to 18 months. Um and the exact cause is not fully understood. So, viral infections, um premature birth leading to, you know, um anatomical features or um embryological development not occurring correctly in that area can lead to that um interception as well. And also Children with HSP and cystic fibrosis have also been known to have an increased risk of getting into suction. So, um management is air insufflation. So literally an air enema um to unfold that invaginated um bowel under radiological control. But if you're seeing any signs of sepsis or any like perforation, peritonitis, then straight to surgery in emergency. Ok. Uh Good. Next is infantile colic. So I'm sure a lot of people may have heard of colicky babies and not really understood what that means. So it's quite common and it's essentially just excessive crying, drawing their knees up to their chest and it usually occurs in the evenings and it usually resolves around three months. Um, again, not completely understood why it's happening. Maybe some form of irritability, some mild form of, um, cow's milk protein intolerance. We don't really know, but essentially you wanna reassure the parents, um, and give them advice on how to manage and how to soothe their child. Um And also just make sure you safeguard them for any red flags, um, like projectile, vomiting or bilious, vomiting blood in stool, um, abdominal distension. That's when it's not just colic, there's something pathological going on. Um Another big thing that nice guy nice actually mentioned is you wanna just make sure parents have support because it can really drain them and have an effect on their mental health. So just know what support groups they can have to um deal with that period of time. Ok. So, Mesenteric adenitis is another form of abdominal pain. Can anyone tell me quickly in the chart? What it is or what causes it? So. Ok. Yeah, that's right. So, Amelia said viral infection in a child lymph node swelling as a result. Exactly. So, um yeah, so often the child will present with a recent illness, usually a viral upper respiratory tract infection and that will cause inflamed lymph nodes in the body, specifically in the mesentery causing pain in the abdomen. Now, the abdominal pain can mimic acute appendicitis. So you wanna know how to differentiate it. So you've got the history to help you as well. But other things in investigations would be your low grade fever. So if they have a fever, it's usually quite low grade. Whereas with appendicitis, it's quite high grade, they're really uncomfortable. So they have a decreased appetite. Whereas in mesenteric adenitis, the appetite is fine and their FP CS will also be fine. Whereas in appendicitis, it's an acute infection, right? So you're gonna have ele elevated white blood cells and if you do an ultrasound, you're gonna see enlarged mesenteric lymph nodes. So, um again, management is just conservative. Um give advice and reassurance and um safeguard for any red flags or progression. Ok. And abdominal migraine. So this is as the name's address, it's a typical migraine in terms of the features of migraine, but it occurs as central abdominal pain lasting for about an hour with other migraine associations. So, photophobia, um sensitivity to sound um feeling nauseous. Um Yeah. So it usually occurs in young Children and then in adulthood, they go on to develop more traditional migraines and there may be a family history of migraines as well that will point you towards this. Um So in terms of management, um so for an acute attack, you'd wanna, you know, similar thing as with adults. So quiet, dark room, so low stimulus environment and analgesia um question for the chart. You can just put yes or no. Can we give um uh sumatriptan like tablets for Children like we would with adults? Ok. Um So if you're feeling dry or confused, don't worry. So you can't give oral triptans to anyone under the age of 18 according to nice guidelines, but you can give a nasal spray of triptans if they require it. So you'd wanna kind of go off the analgesic ladder in a way. Um Yeah, so nasal triptans are good, but after they're 18, they can have oral triptans and in terms of prophylaxis, um you're gonna have two main medications you'd wanna remember. So, Propranolol like with adults and so um Pizotifen which is a Serotonin antagonist. Um Now with Pizotifen, you have to be quite aware when starting the child on that because it has quite a few side effects such as, um, feeling nauseous, really sleepy, um, increased appetite. So, parents really should be aware of, um, what to expect. Um, if their child starts on that and because they get so drowsy and sleepy, you'd wanna give that dose at nighttime. Um, another thing to be aware with Pi Pizotifen is if you're going to take them off, Pizotifen, you don't wanna abruptly stop the drug at all. You wanna withdraw it slowly, otherwise they're gonna have withdrawal symptoms. So, tremor, anxiety, nausea, vomiting. Um So that's just something to be aware of with that drug. Ok. So next one has a bit more weight to it. So Meckel's diverticulum, um Does anybody know what Meckel's diverticulum is? Ok. So it is the incomplete obliteration of the vitellointestinal duct. So essentially around the ileocecal area of your bowel, there is a little pouch called Meckel's diverticulum that should have gone once you were born, but it's still there. Um To put it in really layman's simple terms. So I don't know if you can see it on this out pouching, this remnant part of the gut. Yeah, exactly. So I don't know if you can see it on this diagram, but pointing right down by the U valve, you can see a little pouch hanging off. Um And the next picture, if you don't like pictures of organs, maybe look away. Um But this is a really large metal diverticulum just to gauge how bad it can actually get. Ok. So you need to, one thing to remember is the rule of twos. Has anyone heard of the rule of twos? If so you can type in as I go along if you'd like. Um So presents between before two years of age, 2% of the population get affected 2 ft away from the EOC valve, two inches long and there may be two types of ectopic tissue. So, gastric and pancreatic, not always, but there may be. So how it would present. Um Does anyone know? So, yeah, so it's going to be, it's usually asymptomatic and if you find out someone's got meckel diverticulum, either it's an incidental finding or they present with painless massive rectal bleeding, which is key for a question. So just look out for that. But if they do get abdominal pain, it mimics appendicitis once again. Yeah. So in terms of investigations, if they're presenting with painless um rectal bleeding, once again, you do a technetium techne scintigraphy. Um Essentially it's, if you don't know what that is, which I actually didn't last year, it is a radioactive tracer. Um That's given IV and it will just collect parts of your body. It's what's used for your thyroid as well. So essentially it will go and collect in the thy like little pouch and you'll see that crazy. It's there. So, yeah. And if they're presenting with bowel obstruction, then don't waste time waiting for investigations and diagnose and just go straight to surgery. And, yeah, I've just included an image, um, here. So you can kind of see it so you can kinda see towards the bottom where the arrows are. That's a little out pouching, um, collecting that radioactive tracer. What? So treatment is, if there's symptomatic laparoscopic resection, they're asymptomatic and it's just an incidental finding then only operate if there's certain things that are, you know, worrying you that there's gonna be high risk of complications. So those are, if there's suspected ectopic gastric tissue, if there's narrow necks, um cos one thing you'd be worried about with narrow necks, as you can imagine is like if you imagine the pouch then like turning and becoming quite, you know, um, ischemic and necrotic. Um if it's longer than two centimeters, if it's inflamed and thickened and if you're younger than 50 years old, I guess they might as well operate. Here's what the guidelines say. Ok. Now, necrotizing enterocolitis, can someone tell me if you're aware, what kind of babies does this usually occur in? I don't know if that's the right way of wording that question premature. Yeah, that's right. So, yeah. So, necrotizing enterocolitis is essentially infection and ischemia of the bowels leading to necrosis and it mainly occurs within the first three days, but in premature babies. Um So the main reasoning for this is that in premature babies because they have immature development of all their organs, including their gi tract on their intestines. Um That makes them more available, I should say to um bacterial invasion um leading to infection. Um So yeah, risk factors are premature birth, congenital heart defects and formula feeds. Um ok, so you're gonna get abdominal distention, feeding intolerance, bloody stool, systemic compromise, bile stained vomit, which is a very big thing as soon as you see that hospital admission, something really bad is going on. Um, ok, so a little thing for you guys, um I've marked out on this x-ray A B and C. If you'd like to have a go, please do, can you type out what you're seeing if I'm being too mean? Then that's fair enough, don't worry, but we can talk through it. I'll just give you guys a minute for that. Ok. No one wants to answer. That's fine. Um If you have answers that you just don't wanna share cause you're shy, then it's OK. If you've got it right, you can celebrate with yourself. So, so with a what we're seeing here in general, I'm just pointing to that area is thickened walls um, of bowel and dilated loops of bowel um B pneumonitis intestinalis. Nice. So, um, if you can zoom in, um if not, you can see, yeah, see his rigor sign. So if you, with the slides later on, you can zoom in to try and see it properly. You can see that the bowel is like wall is thickened and there's like a slight line in, in there, like a little dark line, which is essentially air within the bowel walls, which is pneumatosis, intestinalis. And then in c what you can see here is that there's, you can kind of see the bowel like shape and then underneath that, you can see another bit of bowel, so like two overlapping shapes like opaque over each other. So that's known as wrigglers or football sign. So basically, you're seeing a double wall, right? And that's suggestive of pneumoperitoneum. So just free air in the peritoneum, peritoneal cavity. Yeah. Um So that's what you'd be looking out for. Ok. Good. So, investigations as I've kind of already kind of shown you. So, uh abdominal X ray, so thickened ball, uh bowel walls, dilated loops, pneumatosis, intestinalis, pneumoperitoneum good. And a VBG as well is always helpful. Does anyone know what you see on the VBG? Hi respiratory or a metabolic thing? Alkalosis, acidosis have a go alkalosis due to vomiting? Ok. Anyone else? Ok. So it may show metabolic acid dosis. Now, the reason why this happens and I initially was confused because I thought vomiting you're gonna get alkalosis, right? So, essentially, the bacteria that have invaded and are caused, causing that infection, um cause a lot of acid release enough to cause metabolic acidosis essentially. So that's what you're looking out for in necrotizing enterocolitis. Ok. Good. Um, ok. And then management again. So, no, by mouth dripping, suck. Um, TPN. So to, I don't even wanna say it total parenteral. Yeah. Nutrition. You know what I mean? Um, I have the antibiotics and immediate referral to neonatal, um, surgical team. Cool. Now, these are just some other causes of abdominal pain to go over in your own time. So, for UCL students this is kind of stuff you would have covered last year slash stuff you cover in general medicine slash gastroenterology for everyone else. Um So there are also big um, things to go over intestinal malrotation as well is something else. Um, typically in p that presents with bilious vomiting that you'd wanna be aware of. Ok. So we're moving on to abdominal distension and I'd just like to check. I know this is a lot. Um I just wanna check if this is all going. Ok? And if I'm ok to carry on, um, again, if you have any, uh, questions up until now, then please ask and I will do my best to answer. Ok, cool. Thank you. So another question, um, let me stop the pool and you guys can have a go. Ok? I'll give her another 10 seconds if you answer. Ok, we'll stop it then. So some people have gone for Crohn's, majority of people have gone for cystic fibrosis. So the answer is, in fact, cystic fibrosis. So the reasoning for this and this is gonna be an explanation that's not very medically spoken vocabulary. Sure. So with cystic fibrosis, you're thinking about how there's this issue with secretion of mucus and there's a lot of mucus everywhere causing problems, right. So that issue will also apply to the meconium. So for anyone who does know what meconium is, it is essentially the first poo that a child will have, but it's not necessarily just feces, it's like bile fats and other like waste products that a child just needs to get out. Um, once they've been born and it's quite thick, dark green already. So imagine with cystic fibrosis and all these issues with um the mucus in itself, there's gonna be excessive amount of mucus in the meconium making it really sticky and hard to get up. And I think that's the best way that helps me remember the association as well. So Meconium ileus, you're worried about cystic fibrosis. Um ok. So, yeah, meconium, it should pass within the 1st 24 hours. If it doesn't. That's when meconium ileus, you're worried um present with abdominal distension, reduced feeds. And once again, what we love, well, not what we love bilious vomiting. So to investigate, you'd wanna do an abdominal X ray with contrast enema and that's also useful because the enema should hopefully flush out the meconium. So you might see a bubbly appearance on the x-ray and hopefully the meconium will have passed. If it doesn't, then you wanna go to surgery. And one other thing you'd wanna consider doing is a sweat test for the baby just to check for cystic fibrosis. Ok. Um, so the other thing you might be worried about with meconium ileus is hirschsprungs disease. So it is the failure of development of the Auerbach Meisner's plexuses. Um, basically leading to a lack of a ganglionic segment of the bowel. So the nerves aren't really working down there. They're not really there to constrict and relax. Um and peristalsis of the bowel. So nothing's really moving. So we've got a really upset baby. But as you can see, it's a grainy picture. I'm really sorry. Um But in the Hirschprung's disease diagram, you can see the sigmoid rectum is really inflamed, then the rectum. So the sigmoid colon, sorry, then the rectum and the anus is really, really constricted and that's the a ganglion excitement. So the ganglionic segment will be constantly constricted and won't relax. So nothing can really pass through. So, risk factors for Hirschprung's disease is going to be things like. Um, unfortunately, male being a male has a risk factor down syndrome, mental and neurofibromatosis and symptoms are going to be abdominal distension and chronic constipation into childhood, um failure to thrive and potentially meconium ileus at birth as well. So, um investigations is going to be an abdominal X ray, but the gold standard um, investigation would be a rectal biopsy. Ok. And then management. So initially, you can manage the child with rectal washouts and bowel irrigation. But eventually the definitive management is going to be surgery. Ok? And what they do is they'd essentially res probably resect the bowel. That's a ganglionic. Um One thing you'd want, you'd be worried about in that kind of surgery in a child. And in other things I've mentioned is the child having short bowel syndrome. So that's essentially, as the name suggests, the bowel is shorter than what it was supposed to be. And therefore, in terms of absorbing the nutrients they require, um, it's less effective. Um Essentially, so they may have trouble with their growth and nutrition. Um ok. And one other thing to be aware of with Hirschprung's is you can get associated enterocolitis to look out for. Ok, good. Now, chronic constipation, can anyone tell me the definition of chronic constipation? Actually looking at time? I may not wait for the chart, sorry. Just so to make sure we finish on time. So it's defined as fewer than three complete stools per week. So type three or type four and I'm sure you're all aware of the Bristol um, stool scale. So type three is corn on the cob. Type four is a sausage and if they're over one year, then you might see overflow soiling as well. Now, overflow soiling is really important because that could suggest that there's fecal impaction present as well. So red flags is going to be things like meconium ileus at birth. Um and ribbon stools, faltering growth, undiagnosed weakness in legs on your considering. Is there a neurological issue going on abdominal distension and signs of mild treatment? Um Ribbon stools, I just wanna mention when if you get a child with ribbon stools, you're worried about anal stenosis um hence causing the ribbon stools. So, yeah, so I'm just gonna discuss some signs to look out for, for, you know, abuse, sexual abuse in Children. So if you don't feel comfortable, then please feel free to mute yourself, mute this and just not watch for the next couple of minutes. So yeah, it's just something to be aware of the signs of child abuse just to quickly touch upon it is things like anal fissures and bruising in a child reflex, anal dilatation when you go to examine um uresis and ankle persis. So, urinary incontinence and fecal incontinence and the general presentation of a child. Like if they're really fearful, frozen watchfulness, um quite style and distressed. It's gonna be a bit of a red flag to suggest something else is going on. So just make sure if you spot any of these things refer to local safeguarding boards for an for advice on assessment and referral. Ok. So moving on to management of chronic constipation um in a child. Um first things first, always remember, start off with conservative management when you're thinking about steps. So you're gonna discuss their lifestyle, their diet and food intake and make sure they're getting enough fiber and a balanced diet and they're not dehydrated, which can also contribute to constipation. The next, it depends on if there's fecal impaction present or not. So let's just go with, there is fecal impaction. So if fecal impaction is present, start them on the disinfection regimen, which is essentially macrogol. So, Movicol pediatric plan and trial that for two weeks with a escalating dose. If that doesn't work, then add a stimulant laxative like senna. Now, if that doesn't work or they just can't tolerate the macrogol, then keep the senna and instead add a stool softener such as lactulose or docusate. Ok? Um And if that doesn't work urgent referral once again, so if there's no fecal impaction present or there was, and it's been managed successfully from the above management, then you can start a maintenance drug treatment. So it's the same as above. But the only thing is um with the first step when you start giving them macrogol, you start with half the dose that you would have used for disinfection. Um And then if they're getting prolonged diarrhea, then you wanna reduce the dose of laxatives because you're going to be worried about hyperkalemia. Ok. Cool jaundice. Last little thing and we will be done. So um I guess one more um question, let's see. OK. I'll wait for a couple of responses. Uh OK, I will stop it and give it another five seconds. This one's got a bit of a mixed response. OK. Let's stop the pa for now. OK. So OK, so 11% said start immediate phototherapy. The other 11% said reassess after 24 hours. Um Yeah, 55% said measure serum bilirubin within two hours, which is the right answer. Oh, sorry. And 22%. So I measure bilirubin via transcutaneous bilirubin. No. OK. So um right, we'll come on to why? That's the right answer in a second. Um So I just wanna touch upon this. So jaundice in the newborn period, if someone is jaundiced within the 1st 24 hours, just remember. It's always, always pathological, which is why back on this question. Is there a feedback form? Hi. Yes. Um There should be ap feedback form when you leave and the recording and slides will be available. So, um you can just check in on that if you need to leave earlier. Don't worry. Um Yeah. So um you one more thing. So first we'll start immediate phototherapy. No, because you wanna see what's going on wrong first of all. Um And how to manage it. Uh reassess after 24 hours of age. No, because if they're jaundiced and this child is jaundiced at 16 hours, it's a pathological course. So do it straight away, reassure that it's likely due to bruising now because there's forceps and there's been bruising increased hemolysis. So it could be because of that. But again, before 24 hours you wanna investigate. Um And between these two, essentially, you just wanna measure it within two hours and transcutaneous bilirubin monitor, um you won't always just have at hand and you just want a quicker result. So um measure serum bilirubin within two hours. So always pathological if it's within the 1st 24 hours and the causes. So just split it up in this way. Ok. So if it's in 24 hours, just think there's some sort of extensive hemolytic procedure procedure, um reaction going on. So think hemolysis, so causes of jaundice in that period of time are gonna be things like rhesus or a b hemolytic disease here, hereditary hereditary spherocytosis and G six PD deficiency. If it's between 2 to 14 days, that is just normal physiology, you're not really worried. So that's just because um you know, baby is, has more red blood cells and the more fragile red blood cells. So there's increased hemolysis and cell turnover, but decreased clearance because the liver function isn't as developed as it would be once you're older. Obviously, um this is particularly true in premature babies. So, for premature babies up to 21 days as well, it's still normal physiology. So after 14 days or 21 in premature babies, once again, this is pathological, most likely. Um So it's prolonged ja uh jaundice and it can have a couple of causes. So, biliary atresia galactosemia, congenital infections and prematurity. Once again, breast milk and hypothyroidism. So the main one I wanna concentrate on is biliary arteria, so narrowed or absent bile ducts. As you can see here on the right side of this image, um The constriction is obviously going to decrease bile flow and how it's gonna be transported from liver to the bowel, so increased. Um Sorry, what am I saying? So this is gonna cause an increase in serum bilirubin specifically because the bilirubin has gone through the liver. And now, um it's passing through um, the bile ducts, it's going to be conjugated bilirubin. Ok. One thing to touch upon that actually, within the 1st 24 hours, if it's a hemolytic um, thing that's occurring then because it's hemolysis, it hasn't gone through the liver yet. So you're gonna have an increase in unconjugated bilirubin. So that's something to remember. Ok. So management of this um bilary arteria atresia, sorry, is Kasai Portoenterostomy and liver transplant? Now, the other causes. So with galactosemia, it's essentially an inability to convert galactose to glucose. So, high levels of glucose in your blood is going to damage the liver. Everything else essentially has a strain on the liver causing the jaundice to occur. Um, breast milk, there is um a mechanism that occurs. I'm forgetting in this moment, but you can just have a quick look. Um It's some sort of enzyme conversion that causes an increase in bilirubin. Um I'm sorry about that, but I'll double check that and if need be, I'll add it into the slides when I upload the slides later. Um Yeah, so that's it for today. Um Thank you for coming. Um And just at the end here, I've added if I just skipped through just a couple of key presentations as a summary for your revision of what to look out for. Um that may like glare out at you from, you know, questions or an ay of what it's hinting towards. Um So hopefully that will help to summarize it all. And um yeah, and we just finished. Does anyone have any questions last minute before we end? This, the slides I'm recording will be uploaded as well for you guys to look back on. Ok. Thank you everyone.