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Hi, everyone. The event will be starting soon. I'm just gonna put a feedback form into the chat. Um So that when we're going through it um or afterwards you can fill in the feedback. Um And then that would be really helpful. Um So we'll just make a quick start. So, hi, everyone. Um Thank you for joining today. Um Our talk is going to be on um pediatric gi and fever and here is I are joining us now. Hello, guys want to make it work. Um So I'm just saying to um I that we're doing a talk on our pediatric gi um so what we're hoping to cover is um common conditions that you'll see um in pediatric um gastrointestinal issues. Um Today, we're being supervised by um Doctor Banerjee who is um a consultant, gastroenterologist, um and allergy consultant at um Lincoln County Hospital. So welcome Doctor Banerjee and thank you for being here today. Thank you. Actually, I work in Pilgrim, but it's all right. The same trust. So no problem. 00, I actually didn't realize you were Pilgrim, not Lincoln, right? Ok. So if anyone wants to, to pick Doctor Banerjee's ear he's Pilgrim, not Lincoln. Um So thank you everyone for joining today. Um If anyone has got any questions as we're going through out, feel free to put them in the chat. Um And then myself and IA or um Doctor Banerjee is happy to answer questions at the end. Um So I if you happy to um share the slides, of course, oh, hang on a sec. See why is it not sharing, sorry guys, some technical difficulty difficulties. Ok. Um We've got it up Chloe. We can't uh we can't hear you. It would be good if I turn my microphone off. Thanks a that's ok. Um So if we're happy to make a start um and then we'll have questions at the end if that's ok. Um So if we are ready to make a start next slide, please, I, so what we're wanting to cover today is some common conditions that we might find in pediatric abdominal pain and fever. And then I is going to talk about some common conditions that you might find for abdominal pain and vomiting. And then we're going to try and cover some red flag um symptoms um that we might see in Peds cases. So, what we're gonna do is hopefully go through some cases and try and pick out key um symptoms or signs that might give us a clue as to what diagnosis we're going to be thinking of. So, first case for me, I please, so case one, we've got three year old Toby, um, has had a 12 hour history of severe diarrhea. He was admitted in the morning following vomiting and fever overnight. His mum has said that he came home from nursery not very well and that other Children at the nursery are also not very well. He's pointing and saying that his tummy hurts. So, if anyone wants to sort of put in the chart, what diagnosis we might be thinking, I'll give you guys a few seconds to have some thoughts about this. So what might we be thinking with this sort of presentation? It's all right. It doesn't have to be um, the right one. It can just be a guess. Ok. So next log, please. Eye. So Maddie's put gastroenteritis. So that is correct. Good job Maddie. So out of the history that we've um taken. So I've got here. So a key thing to point out would be that three year old Toby. So age is also a strong factor in gastroenteritis. It's very common in sort of young kids. 12 hour history of severe diarrhea and vomiting and fever from the other day is also another thing to pick out because gastroenteritis is quite an acute symptom. Other, the other thing is is that the other Children are also not well, so with viral and bacterial gastroenteritis, it's common for other people around you to also be ill. And also him saying that his tummy hurts. So the definition of gastroenteritis. It's an inflammation of your stomach and intestines. Um It can be viral or bacterial, as I said. Um So, viral causes are, for example, like rotavirus that it can go around nurseries really fast. Um And other things such as like E Coli and Campylobacter, which is also known as travelers diarrhea. Um So as I said, risk factors are if you've got any contaminated water or food, attending nursery contact with other people that have also got it poor hygiene and winter months. So some key clinical features that we would see would be diarrhea. So this can be bloody, um vomiting, abdominal sort of crampy pain in the epigastric region, fever. And as I said, it usually presents within 24 to 48 hours. XL P I. So what we're gonna do with Toby, that's just come in today, we probably want to do a quick stool sample. If we can to identify whether it's viral or bacterial, we're gonna want to do some basic abs to assess how severe we think it is. So we'll take heart rate, BP temperature. Um and we'll do an abdominal exam by palpating the areas of the um abdomen to see if we can exclude appendicitis. So, for gastroenteritis, it's mainly sort of symptom management. Um So what we want to do is if they're dehydrated, we're going to want to get some fluids in them. So if the child is well enough, then hopefully, we can get them to be drinking lots and also replace any of the electrolytes that they've lost if the child is what we call clinically dehydrated. So that's where if they've got dry oral mucosa and their blood tests are showing electrolyte abnormalities. So, changes in um sodium, then we're gonna want to give them IV fluids. What's a key thing to um sort of note is that we don't want to give antidiarrhea agents. So like loperamide, um because gastroenteritis, as we said before is a viral or bacterial infection. And what the body's trying to do is trying to get rid of that. So if we're stopping that, then we're just gonna prolong the, the infection and we don't want that. Um The key, one of the, another key thing is that if the child is on is sort of immunocompromised, then we may have to give antibiotics just so that we can help fight the infection with them. And some key advice on um contact and isolation is that, that don't take your child in, that's got gastroenteritis to nursery, keep them home. And once the diarrhea has resolved for two days, then they should be able to go back into school. Next slide, please. I am. So case two. So we've got 12 year old Lacey has come to A&E with generalized abdominal pain, which is worse on the right side. She's got a high heart rate and a temperature on the car ride over, she was complaining of when the vehicle hits bumps in the roads, um, that it's more painful and she's been constipated for the last week. So this is a bit of a, a tricky case. Does anyone get any thoughts as to what our differentials might be for this? I'll give you guys a minute or so if you want to put in the chart. So I very good. So, Maddie Maddie's Maddie's on one today. So appendicitis. So next lively's ire it is appendicitis. So that was a good spot there. That one was quite, I agree it could also be be fecal impaction. Um So one of the things, so some of the things that we want to pick out of this history that might point towards appendicitis is the age. So being between the ages of 10 to 30 appendicitis is quite common. I'm sure you guys know people that have had appendicitis, the abdominal pain that's worse on the right side as Maddie said, could be a fecal impaction. However, the high heart rate and temperature um may point towards the fact that this may be sort of an inflammatory or even infectious type. The bumping in the road is a bit of a, a bit of a sort of red herring, it can throw people off. So the reason why this might be happening is because in appendicitis, once the appendix has sort of burst, um you can get what's called peritoneal irritation. So therefore, when she's sort of going along in the car, um and then she's sort of hitting bumps in the road, this would then be sort of irritating her um, peritoneum further. So, definition of appendicitis is inflammation of the appendis appendix. Um, it can occur if the lumen has been obstructed, particularly by feces, um which can lead to sort of bacteria proliferating, causing necrosis, necrosis and then perforation. So, one of the other risk factors that she had was that she had constipation for the last week. So the clinical features that you'll see in appendicitis is in adults. It's very easy to pick up if you've got sort of dull central pain that then becomes sharp in the right iliac fossa. The difference sometimes with Children is that these clinical features may not be as present or specific into the regions of the abdomen. This can be and for a number of reasons. So for example, the child is sort of unable to point to where the pain is or the the anatomy of Children is slightly different. And therefore, it's not as sort of specific as to where the pain is. Some of the um s er signs that we may see nausea and vomiting fever and what's called rebound tenderness. And another examination finding is what's called Rosings sign. Next slide, please. AA, so I've just got some pictures here showing the physical examination signs that we may see with appendicitis. So, rebound tenderness is when you're palpating on the right iliac fossa, you press down and then when you lift up, the pain gets worse. This is also because of your peritoneal irritation. So when you're letting go of it, the appendix and the irritation is then pushing back and making the pain worse. Rovsing's sign is when you press down on the left iliac fossa, and then you get pain in the right. Also because of peritoneal irritation, soas and obturator signs um is again stretching the sort of abdomen into positions where it's going to cause pain. So, management of appendicitis, we're gonna want to do a fluid wash out for Laci, give her IV Coamoxiclav and then send her straight to surgery to get a laparoscopic appendectomy. So we're gonna want to take that appendix out as soon as possible. Next slide for me. A so case three, we've got 10 year old Poppy who is complaining of severe sharp abdominal pain, nausea and vomiting. She's lying on her side with her knees and hips flexed. The pain has got worse after 24 hours and she is starting to look yellow. Has anyone got any ideas as to what might be a differential diagnosis? It's ok if it's not right. Ok. We've got some answers in the chat. Should we go to the next slide and, and reveal the, the answer? So we've got pancreatitis. So a few of the things that might point to this in the history. So we've got severe sharp abdominal pain, nausea and vomiting. So, um she's also got the knees and hips flexed and it's worsened after 24 hours, I think Andrew one of the, the, with the ascending cholangitis, you probably would also have sort of worse with like eating and other things that may distinguish. But I agree that they're very similar. Um and, and jaundice as a presentation. So, pancreatitis is your the acute inflammation of the pancreas. Um So one of the really great acronyms that we've been taught um in medical school as a risk factor of like why you might get pancreatitis is called I get smashed. So if you can remember, I get smashed, um it's idiopathic. So I think it's about 70% of causes of pancreatitis. Are they just happen? Um gallstones is the second biggest. So if we've got gallstones, it's going to be blocking um the ducts and therefore you're gonna get inflammation of the pancreatitis because you can't get um the um fluids to come out. Um alcohol, which is ethanol, which I'm hoping wouldn't be a risk factor in Children. Um trauma, the use of long term steroids, mumps, which is a childhood infection. But because of our mmr vaccine isn't as common autoimmune diseases. A fun fact is a scorpion sting. I know that that's probably not one of the most common causes at all, but it's a, it's a fun one to remember hypercalcemia. So, having high calcium can also be linked with, um, gallstones as well. E RCP. So that's a procedure that we do to look at gallstones. So it's a long flexible tube that comes, um, down your esophagus through your stomach around the duodenum. And then it's going through what's called the ampulla of ARTA where we're going to look in to see, um, gallstones. So, if that camera goes in and it damages where the, um, a where the pancreatic duct is that can then lead to similarly blockage, sort of like gallstones. Um and then drugs um as well can be a cause. So, clinical features of pancreatitis is um severe epigastric pain that radiates to the back. Um It can be relieved by sitting forward. And also as, as Poppy's got sort of bringing her knees and hips inwards, nausea and vomiting are very prominent because of the severe and sharp nature of the pain fever and jaundice is present in 30% of patients. So it's not the most common sign, but it can happen. Some clinical signs that you may see is Gray Turner and Collin sign, um and a rigid abdomen. So, on the next slide, I've got some pictures of what the um Collins and Gray Turner's sign is. So, if it's ok, next slide, please. I, so these signs, these are the signs that you may see. Um And I'm actually not too sure how common they are. I don't think they're the, they're the most common sign that you may see, but it's, it's an interesting one to know. So cunning sign is where you've got that sort of periumbilical bruising and then gray Turner sign is where you've got bruising on your flanks. Um And these, these point towards pancreatitis signs. Um And then this other picture shows um common signs of pancreatitis. So next slide for me, please. Ile. So what we're going to do for popping is we're going to want to do um some baseline bloods. So full blood count, CRP for inflammation, E LFT S glucose and calcium. So this is gonna be, this is gonna help us to assess the severity. And then what is one of the most important ones to do is lipase. So that this is one of our enzymes that is released from the pancreas. So in pancreatitis, this can be three times the normal range. So how we're going to diagnose pancreatitis is a clinical history. So all of the things that we've said, you know, the pain that's epigastric radiating to the back nausea, vomiting. Um and then a raised serum lipase. This is diagnostic of pancreatitis. So you don't need to do any scans. Um but if we weren't sure between um gallstones, then we can do an ultrasound. However, it's not always necessary. So I've just got some red flags along the side um as to how we know whether we've got a severe pancreatitis case. So this is assessed with the modified Glasgow criteria. So we're gonna be looking at um oxygen. So how we're going to assess her oxygen is by taking what's called an ABG. So that's an arterial blood gas, um which we're taking from the arterial system um to assess her oxygen levels age over 55 which isn't the case for poppy hair on the blood count. Um We're gonna look at her white blood cell count and if that's like really raised, that's a sign of it. A severe pancreatitis, low calcium, um high urea, which is a um toxic um thing that we can have in the blood enzymes such as ast albumin and glucose. And if we've got any of the 33 or more, then we're gonna want to transfer Poppy to the intensive care unit. So management of this, we're going to want to do what's called an A to E approach where we're gonna look at her airway breathing circulation. So for example, if she's got the low oxygen, her breathing might not be very well. Um And then we're gonna want to go in that order and manage it in the order of the airway breathing circulation. We wanna going to want to give her some IV fluids, analgesia and enteral nutrition. So by an NG tube, if she's still vomiting because we don't want them to become dehydrated um or anything like that. So, next slide, please. I so of the three cases that we've gone through there are some similarities between a lot of them. All of them have had abdominal pain, vomiting, fever. Um, but a few of the sort of key differentials in knowing which one it's, um, pointing to in gastroenteritis, we're gonna want to know if they've had a travel history. If it's viral, then there may be other people in the family or home that are ill if they've had a recent, um, meal that's been maybe sort of an uncooked chicken salads or contaminated water or maybe there's, they've gone to a wedding or somewhere and other people are ill as well. That's a, a good um indication that this is gastroenteritis in appendicitis. We're going to want to see where the location of the pain is. So, as we said before, in the right iliac fossa and all of these other clinical examination signs that we can do with rebound tenderness. Um Rob Zings, the so obturator signs pancreatitis. Um We're looking at similarly location of pain and also an elevated lipase. So I hope that was uh useful in uh showing how to diagnose and show the differentiations of similar, similar conditions. Um And next slide, please. I, so I'm going to hand over to I now to cover some abdominal pain and vomiting conditions. So, um I'm gonna take you through a few, an overview of a few presentations of abdominal pain and vomiting um in a similar way and we'll go through the different differentials. So in the first case, uh dad brings in six week old male Khaled complaining of milky vomits after feeds and whilst feeding Khalid seems in distress. Dad states that it sometimes occurs after being laid flat. What could the differential diagnosis be? So once again, if you have any guesses, put them in the chart, any guess is as good as another. So, ok, we've got good, good, good. Ok. Call it. Ok. So moving on to the next slide, um, it is in fact good. So if you've put that, which has been a popular answer, um, that's been that, that's really good. Um Although I'll come to some of the other things put in the chat and why it may not be those things. So what really points it out that it is good is the fact that the dad brings in the six week old meal and says that it's milk, he vomits after feeds. Um, the fact that it is milky is quite key because essentially the milk hasn't been digested. It's just come right back out. Um, and then again, after being laid flat is a key point because in infants, the lower esophageal sphincter is quite uh low down. And so it's a lot easier for that reflux to occur. And then if they've been put down that again, just, um, increases that risk of that happening. Um, in terms of risk factors, the big one is prematurity and it can be like normal uh, for babies to have just regurgitation. But obviously, if it's constant, um, then it might be a concern. And then this instance points to uh, gastro gastroesophageal reflux disease. Um, in terms of the clinical features, it typically develops before eight weeks. Um, and some other signs that can be noticed is that they might have, um, an unusual posture, they might arc their back, they may have, um, some choking or, you know, like gagging, sitting up. Um, but yeah, that, that entails the presenting complaint. Now, moving on to some investigations that you might do, uh, we might do a hydration status and see if there's any signs of malnutrition. And then you might look at the growth charts to see if the infant is kind of like falling behind, um, in terms of growth. Um, and then a red flag to look out for would be a cow's milk protein allergy. Um, because potentially this could be uh a reaction to, to the, to the milk protein. And this is particularly something to watch out for if the, if the infants recently started drinking, um, drinking cow's milk. However, it can also be transferred from mother to, to baby. So it could be the mother who's breastfeeding. Um And then obviously, in terms of identifying that we're looking at vomiting, itching, angioedema, um, sometimes like the, the back arching as well looking in distress after feeds or during feeds. Um, so that's, uh, that's one to watch out for, in terms of managing uh gastroesophageal reflux disease. Um, you're advising parents on the position at which they're feeding the infant. So typically that's a 30 degree, um, head up and, um, that you want to encourage them to sleep, uh to lay them on their, on their backs as well. And this just helps so that, that reflex doesn't occur. Um And then also obviously ensure that they're not being overfed. Um And perhaps uh a trial of thickened formulas. So for example, aptamil or any thickened formula, really, there's lots that can be purchased over the counter. Um And yeah, it's quite popular among, among um infants at this age because like I said, sometimes it can just happen. Uh and it may be idiopathic, moving on to the second case. Um We've got five week old male infant Hamid, he presents to the A&E with his mother, um stating that he has been vomiting for the past four days. And according to mum, the vomit seems to shoot out of his mouth and it usually happens after feeding Hamid is still hungry after feeds and he's less active than usual and having fewer wet diapers and less so than usual, what is the most likely differential? And I can already see everyone in the chart just saying pyloric stenosis. Um And that, and that's very, that's very good because it is, in fact, pyloric stenosis, I'm just gonna ask in the chat if anyone wants to put their, there aren't, I'm gonna go back. Um, there aren't or their reasoning as to why they've put pyloric stenosis. So, just give a few seconds or a couple of minutes since it's been, like, you know, quite a ok of answer. I'll just give you a few moments. Ok. Yeah. Yeah, exactly. That it is the, the, the shooting out the projectile element of it. Um, so, yeah. So in essentially the fact that the mum reports that it shoots I's mouth, that's what you're thinking. Pyloric stenosis, that's what the characteristic feature is. Um And yeah, also you're right as well. It's essentially in terms of pyloric stenosis, it's the hypertrophy of the pyloric sphincter. And then this leads to that uh narrowing of the pylori. Um and then obviously that can cause gastric outlet obstruction. Um And then as you can see in the image that's kind of um that's kind of detailed there and you can see that that ring around it. Um in terms of risk factors, it is, it's got a 4 to 1 ratio of male to female. So it's a lot more common in males. Um and about 15% of infants have a positive family history. So it tends to run in the family and unfortunately for firstborns, they are most commonly affected. Um And yeah, so in terms of the clinical features, again, straight after a feed for projectile vomiting, these are all some key features. Did also want to point out that, um, the, well, he was, it was mum, mum pointed out that he's been less active and he's been having fewer wet diapers with less stools. Um, again, why might that be the case? I'll point that out again to the audience. If anyone would like to put an answer in, why could that be characteristic? Ok. So we've got dehydration. Um, yeah, essentially if, if he's not, uh, getting these things down and he's just having that projectile vomit, he's not getting as much, he's not getting as much digestion happening. So he's not gonna have, he's gonna have less um wet diapers, less stool. There's not that much to be seen um in the, in the basically. So, um in terms of the investigations, we've got two different types. Um we can on, on examination, the key finding um is a palpable olive shaped, um upper abdominal mass which you, which you can see on the abdomen. Um And yeah, it, it can be felt in the right upper quadrant, um or the fifth epigastric region in terms of blood, the blood gasses will show that they're hyperkalemic, um hyperchloremic and metabolic alkalosis because obviously the acid is coming out and it's making them uh making the child. Uh We've got a question asking if the, if the olive, if the olive mass is a common finding, um, it can be and especially if uh I'll come to it in the management but when doing the management, that's like the key place to make the incision and um remove the muscle of the pylori. However, if I'm not entirely sure, because obviously I haven't first hand experience, I'm not sure if doctor uh fan, if you know, if it's a, it's a common finding or this is quite rare to find. So I'll put that question out there. Right. The olive mass. Uh It is very difficult to find. That's one thing. This is quite an interesting finding. But if you find it, that it's diagnostic, right? And this is the only one condition where you have to be on the left side of the patient, not right, use your left hand, left other arm and uh should be really, really warm and the baby's temperature and then you just put your arm on the belly while the mom is feeding. And at that time, what you will feel the olive coming in a direction. So if this is your stomach, then it is uh basically from right to left and then it will just pucker the exit point of the stomach and then you, it will come and hit your finger. If you press it hard or if you roll your hand, you won't be able to find it. So that is the tricky thing. And if the babies are small and stronger, then if it is sitting under the muscle, then again, you are not going to feel it. That's why it is a very rare finding. So you can't feel it all the time. So that is the only thing. But if you find it, then it is a good job. I have, I have found it in uh in my whole period, probably seven or eight times. So as you can imagine, it is quite, quite rare. Thank you. Thank you very much. So, there you go. Um It is actually quite rare. Um But yeah, so that, that is one of the things um like band you said that can be diagnostic of it. Um In terms of management for immediate management, you wanna think um fluid replacement and electrolytes. Um and then surgical intervention, it's uh pylos pylorostomy and the main surgical intervention would be Ramsay's pylorostomy incision, which is made into the smooth muscle of the pylori. Um So widen that canal and then hopefully allowing a more smooth passage from the stomach to the duodenum. So now on to our third case, we've got Max who is a three year old boy. Um He's been brought in by mum and uh mum has said that he's been passing hard pellet like stools with pain during defecation for the past couple of months. Max strains a lot to open his bowels and even tries to stretch his legs to help it go down while sitting on the toilet. They also mentioned that max has episodes of loose stools leaking in his pants around three times a week. What are we thinking is the most likely differential? So this, OK, we've got constipation, overflow, diarrhea and constipation. OK. All right. There's some good guesses. A lot of constipation, fecal impaction. Yeah. So all of these answers are basically correct. It. It is constipation. Um And the constipation is characterized by a decrease in frequency of bowel movements and the passing of hard stools that may be large, um, and associated with pain or straining. So why in this case is it constipation? And what else is there? So essentially the fact that they're hard and they're pellet like um that's the key finding there. And then the fact that there's pain during defecation and the stretching of the legs, the loose stools are leaking. These are all highlighted in bold, the, the reasons why and I'm gonna go into them a little bit more when we go through the clinical features. Um So he, so, so one of the clinical features is going um having less than three stools a week. So a decrease in frequency. Um And yeah, this can, this can be for all types of reasons which I'll get on to in a second. Um And hard stools that are difficult to pass. Uh rabbit dropping stools is another kind of de description of them, abdominal pain, straining or holding an abnormal posture known as retens of posturing. And that's why I'd like to take it back to the case for a second Max is straining and he's even trying to stretch out his legs that there tells you that the, he's got some retens of po posturing. Um So not only obviously like the hard, the hard like stools and pain during defecation, your mind would immediately probably think conservation, but the fact that he's stretching his legs to help it go down tells you that there's, there's, um, there's some difficulty there. Um And then he also mentions that max has a episodes of loose stools leaking. Let's look at the last bullet point of the clinical features, fecal impaction causing overflow, soiling with incontinence of particularly loose smelly sores. So what has happened here is likely that there's been desensitization of the rectum uh of max and either for a number of reasons um over time because of this fecal impaction because of the constipation. He hasn't been able um to open his bowels and then this has affected the nerves around like in the rectum and he hasn't been able to now, like he's lost sensation of when he's passing the stool and that's why he's getting the leaking, um moving on to the risk factors. Um It could just be a low fiber diet. Could you could just be dehydrated, not getting enough water. Most cases are idiopathic. And whilst I've given a couple of examples here, like of why it might be constipation is so varied and there's so many different reasons why um, the child could be constipated. It's also very common in pediatrics to find constipation. Um, but yeah, that's just something to know. Um, but it also can have some other, can, can have some other red flags there. So I'm gonna move on to the next slide and the red flag here is hash browns. So potentially, um, if a, if a child is born and um, they haven't passed meconium within the 1st 48 hours, this is a huge, like red flag that might point towards Hirschprung's and shouldn't just be ruled out as constipation. Um, Hirsh BRS is a birth defect in which the, the either parts of the large bowel or maybe the, the whole of the large bowel, um, it isn't getting, uh, it's, it's not getting the nerve stimulation and this can cause the absence of that, that feeling and impaction in these areas. So it can cause fecal impaction. It's very serious. It's quite rare but it can happen. Um, so yeah, that's a red flag to watch out for, in terms of investigations that can be done. There's not really any specific investigations required because like I said, most cases are idiopathic, um, for constipation. Um, but yeah, routine bloods can be done including bone profiles and T FT S. Um, and then yeah, obviously if there is a red flag, um, like Hirsh Bs gonna have a referral to a specialist in terms of management. Um, I'm gonna reassure that any underlying causes have been excluded and then laxatives, Amoral as a first line um is usually given for idiopathic constipation may need a disinfection regimen and also some behavioral interventions. Um I thought to mention, so I'm just gonna flick back on one of the risk factors. So one of the reasons could just be that it's habitual not opening of the bowels. Um and this could be for several different reasons. Um But yeah, the child is holding it in, seen sometimes in autistic Children, for example. Um but other, other Children as well and then that over time not wanting to go to the toilet, holding it holding in can then um cause that fecal impaction. Um So behavioral interventions could be um quite helpful in those situations to try and encourage them to go to the toilet. Um Yeah, here we have some of the differentiating factors to help you kind of like figure out whether it's gourd, pyloric stenosis constipation. Um Hirsh PRS or cow milk allergy, which is the thing that I've gone through today. So like with the gourd is the spitting up immediately afterwards. Um The pyloric stenosis, the fact that it's projectile, potentially not so much the olive size pyloric mass because it's quite rare. But you know, as like you said, if, if it is present, then that's gonna be diagnostic um for constipation, anything that is hard or hard stools that are difficult to pass her BRS, you've got the red flag of not passing uh meconium within the 1st 48 hours and then for the cow's milk allergy. Um I don't, I feel like there's a, there's an error there but um if there's a new introduction of uh of, of milk or if the the infant is refluxing um every single time like after a feed, those are some key factors there. So that is it for our presentation. Thank you very much for listening and coming along. Um I'd like to open the floor to any questions that you guys have got, either for me and Chloe or Doctor Banerjee. And thank you very much, Doctor Banerjee as well for coming along. And yeah, so I'm just opening the floor for that. OK. No question. Oh, not a silly question at all. Yeah. So Gaviscon is mixed with milk. So uh that is something the g sachet are mixed with milk and uh thereafter we can give it or we can give it directly as well. Uh mixing that with the water. OK. So that's what gas is used. So what I have done on this uh uh chat chat chat box. So there are quite a few things out there. So you can have a look in those links. Now, why does pancreatic causes bruising? Right. OK. That's a very good question. So basically what happens in pancreatitis, pancreas produce lots of uh proteolytic called uh enzymes. Yeah. So these proteuric enzymes, they are basically kept under control. Because if they start digesting the protein, they will start digest the pancreas protein at the same time. So, it can cause a very significant and serious inflam inflammation and destruction of the tissue. So, when these uh uh during acute pancreatitis, what basically happens is these enzymes start leaking around and when they are looking around, they can destroy the wall of the small capillaries in the abdomen. So basically this is called hemorrhagic pancreatitis. So once hemorrhage happens in the belly, uh intraabdominal hemorrhage, it goes through the facial layer and then comes and stay under the skin. So that's why if you are, if the patient is lying down flat, it goes into the flank because of the pain. Most patients, what they prefer to do is to lie on their front because they want to uh keep this pancreas under pressure, which apparently gives a little bit of relief. It is a, it is one of the worst pain that people can endure. And that is the reason why the blood will come and stay in the front of the umbilical cord. That's, that's the two signs basically that you are looking at. So uh to make it uh more uh concise, it is bleeding from the capillaries secondary to pancreatic pancreatic proteolytic enzymes. R SV bronchiolitis. So, right. OK. So this is not a gastro question but uh normally for others with bronchiolitis, there is no treatment as such. Ok. So it is a symptomatic treatment. All you need to do is to feed the baby. If not by mouth, then by NG tube and if the respiratory rate is too high, you stop giving NG feed and start them on IV fluid, nasal saline drops are not treatment. But if the nose is blocked because of the secretions, it might help but it is not. There is no evidence base behind that ps we small we don't use uh in small babies, right? And proper position. Uh raising the head at night. Yes, it is a good thing to do because it will uh improve your vital capacity because your diaphragm is not going to press against the lung. So if you are in a proper position, diaphragm is lying there and it's easier for the patient child to breathe. So that's all your uh it's all right. You can ask questions. Any pediatric question is fine. It's pediatric Society, isn't it? Thank you everyone for all of your questions. Um In in response to the question about bronchiolitis as Karishma put, we've got a um pediatric respiratory talk happening this time again next week. Um So it would be amazing to see everyone there again next week. Um I'm going to put the um feedback form in the chat again. So if anyone is happy to fill out the feedback form, to help to give any feedback from me or I that would be really useful. And then once you've filled in the feedback form. It will then generate a certificate for you for your attendance at this. Um So thank you again um for everyone that's coming. If there's any more final questions, um we can wait a couple more minutes. Um And I'm sure Dr Banerjee would be happy to, to wait a couple more minutes if there's any more questions. But thank you as well, Doctor Baee for, for your help with the the questions as well. It's a pleasure. It's a pleasure. I'm really happy that you guys are doing a very good presentation. So that's very simple. But at the same time addressing all these common s common situation that you normally see in day to day practice. So that is very good. The constipation was very good as well. Uh GD gastroesophageal reflux disease. There's a couple of things that I would probably like to explain a little bit more so that you get a bit of a understanding. So there, there are two different things. One is gastroesophageal reflux and one is called gastroesophageal reflux disease. So the difference between the two, we all have gastroesophageal reflux at one point or other. But most babies do quite well. You will see babies are vomiting. They basically uh bring a little bit of milk out. We call it pot. They're not at all uncomfortable with that, but parents are because they saw their uh clothes. So that's what uh is called posing and that is gastroesophageal reflux with this reflux. If they are unwell, if they're crying, if they're arching their back and they are uncomfortable, then it becomes a gastroesophageal reflux disease. This is associated with the inflammation of the lower part of the esophagus because of persistent gastroesophageal reflux. So that is one thing that I uh saw there lie on your front. Yes. So, because yes, I can. So, pancreas is a retroperitoneal organ if you remember. So, if you from your anatomy. So retroperitoneal organ because it is retroperitoneal organ. This solid organ, what basically happens when you are lying on your front of you sitting up with your uh arm across your belly and pressing it hard, then it fixes the pancreas with the spine. So with the movement, the pancre movement of the inflamed organ is less. So that is 11 of the reason why people like to uh feel like to spleen to the pancreas basically against the, against something so that the pancreas um mo movement of the inflamed pancreas is less and that can reduce the pain. But this is just a kind of a mm kind of a thing that make them feel better, but it's very severe pain. So most of the time, what we tend to do is to give them morphine. So opioid is very used right at the beginning when you would get, when your patient is getting a pan, getting pancreatitis. Yeah. Previously, we, we didn't use to uh use of uh because it was supposed to construct the sphincter of dye. But later on, we found that that is baseless. So we are freely using it. And I have also send you a link with the Pancreatic is guideline. It is a bit long, uh a little bit complex, but I think it might be useful for you guys to have a read through that. It was just a, it is a very same guideline and II also shared IMAP guideline, which you will see very frequently whether you do general practice or you do it with pediatrics. Uh You will see these patients almost every other day. So have a look through that. There is 11 e website which I'm writing here, which is again, very good for constipation. So this is called Eric, this is for constipation as well as uh incontinence. Now. Yes, in constipation. One thing that uh uh you guys said that it is what it is type one stool. So ty type of the stool is really important, but there could be diarrhea as well associated with constipation. Now, how do you differentiate between the two? So only one question that you need to ask them is if this liquid stool is like type six stool is mixed with type one stool, right? So this is one of the very common thing that we'll find in, find in poorly treated constipation. So if there is a mixture of type one and type six stool or type five stool, then it is almost always a bad constipation that suggest fecal infection. But if it is the only type six or type five stool or a, a diarrheal stool on its own without any evidence of presence of type one stool, then you are, you are probably dealing with the diarrhea uh after the good wash out. So this is this kind of question we always ask when we start this infection regime. So the stool changes a mixture then finally like water is too. And one take home message for everybody is uh vomiting. If this baby is a baby is vomiting below one year and vomit contain green, green, bile, green means purple, green. Yeah, it is a surgical abdomen. So immediately refer to the surgeons that is the obstruction. All right, intestinal obstruction do present like that. Rest of the vomiting are ok. So always have a look at the vomit, always have a look at the poop. So these two things are really, really important because that gives you all the information of what is happening in the body. So that's good. It's very good presentation. Congratulations to you both. You have done. We did a lot of work. Yeah, with uh acute and with green vomiting, will they be acutely unwell and crying baby? Yeah, they will be unwell. And 11 thing that you will see uh quite commonly in this group of patient is because they're small babies right, less than one year. So what you will find that they are, their abdomen is distended. And sometimes you can also see the peristaltic movement because in small babies, their abdomen is very thin wall. So if you observe them from a distance, uh from a height, you may find the peristaltic movement happening there. So if distension and peristaltic movement is there, then it is probably you are dealing with it, uh obstructed bowel. But it also depends which part of the bowel is obstructed. If the obstruction is high up, the, the vomiting will be there, green vomiting, but the distention will be less if it is lower down or to the large bowel, then you will see more distention. So that gives you a kind of a legal clue where, where exactly is obstruction. But it doesn't always true. It is not always true. It is, it is, it is possibly, uh you can make a differential diagnosis and get an idea uh where the obstruction is in pi or uh gastric outlet obstruction. Secondary to pi vomiting is never green because the obstruction there is before the opening of the bile duct. So don't make a diagnosis of uh uh pie. If you see bile stained or green vomit, it is almost always the milk. Either it is semi digested or not digested at all. So they vomit straight away and these babies are very thin. They lost their weight, they could be dehydrated. They lost a lot of acid from their stomach. So there blood gas will be alkaline. So alkalotic blood blood gas and if it is going on for a while, you may find these babies are not passing stool at all. So they're constipated. So if you see all these features together, then you straight away ask for a ultrasound scan. Now it is and a blood gas. So blood gas, ultrasound scan and IV fluid and N by mouth. This is a treatment, initial treatment for white. Thank you. Thank you very much, Doctor Banerjee. And uh thank you for coming. I'm conscious of um I don't know if it will end exactly at 7 p.m. So I just wanted to say um thank you for everyone um for coming in listening to our talk. Thank you very much and thanks for inviting. Thank you. Bye bye now.