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cool medicine. Amazing question, Bank. I think myself in a strange A can vouch for that. We just renewed our membership. Um, they have wonderful questions, and good explanations will also which actually direct you to the guidelines. Nice guidelines, the gold standard investigation, stuff like that with explanations below. So and it's really tough questions. So if you're interested, please use on skis 20 for 20% off the question bank, I'm not gonna like this isn't due at the moment. We are trying to find people to sort of carried on because there is a large group of you guys that that's that's, I think, 1100 people now in the community. But if you do have any questions, feel free to us and we'll report reply immediately. We just haven't been on it with the questions that's been on our instagram. So anything on skis, example for research interconnection as well related. We have, ah, wonderful issues, indicating so he'd be able to answer any questions on that aspect also, so it's just a few ground rules. Please keep your microphone in camera on mute asking inquire and so that that would be quite a few questions to engage on the polls engaging. Even getting it wrong with your learning helps with my learning also, even if I get it wrong. So that's why I engaged to please be respectful in the chat, the session is recorded. Anything that you do if if, um you know, uh, Cirrhotic Amra will be recorded. If you want us to remove that out of our session, please let us know and we'll be happy to. This is back from will be given about three put into this section itself on and slide everything accessible on a middle. 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And moving is doing your pediatric gastroenterology. And that's something that I've heard that he's really interested in in proceeding a career in as well. So it's gonna be wonderful. Please also tune into our Thursday session knishes doing pediatric respiratory conditions, and I'm doing pediatric infectious disease conditions we expected to do because it's a really huge topic. So without further ado, I will. That strange I take it away. Thank you very much. I just let me know whether my slides can be seen. Yeah, Bug. Okay, so I'm covering pediatric cardiology today as we want mentioned something I'm quite enthusiastic about. And I do find quite interesting how I want to give a disclaimer before I begin much of pediatric cardiology is way outside the scope of medical school students. It's something which does come up in progress test and what I'm covering today is actually the very basics off what we need to know for our final exams, their parts of pediatric cardiology. It can become immensely complex. And what might it would be is for medical school. Just knowing the key difference between cyanotic a sign Arctic on so the common cyanotic and acyanotic conditions. If you start reading into the depths of pediatric cardiology or find that they're millions of sign Arctic and millions of a sign Arctic conditions how they're treated wide because what the cause? Why the cost Sinuses? Why? Because a patient not to be signed cyanotic don't get in the middle of there is just stick to the basics and yeah, and if anyone's interested, obviously, then read for that. This lecture will just be covering the bare bones off the attic. Cardiology. So this is the face question. Just launched a pool throughout the session. If you have any questions, feel free to put it on a chat, and I don't mind trying to you ever go to the answers at the end of the session. Give you 20 more seconds. Yeah, And the pool that So the majority of if you have gone for a which is the brachial artery on the second was going on. So with the carotid artery. So the answer to this question is actually did break your artery. It's important to remember in in unit. So with this patient, this child is just born. They have very small necks to find their carotid and actually feel it will be immensely difficult. So you look for the two major big arteries. If you can feel the pulse off once again, the radio large will be quite difficult. It's gonna be very small, so it'll it'll be a lottery. So what you're going to do is you're going to use the femoral very commonly used or the brachial artery. This is something which is which can come up in your final exams. But it's also something important to keep in mind as you go into becoming and F one or in S h O. Because this is something that you might actually be asked to do by your consultants. You might be asked by the consultant. Check with this child has a bald. Is it regular is a tachycardia. Is it bradycardic on the best place to feel it in a new unit would be the break it or the family? Uh, Vermijl closest all the best places. So just quickly going over when you're assessing a newborn, you can quickly go over the Apidra. That's the score used to see how well the child is, And I remember using the the morning off abhorrent Selves. You look at the red appearance. Is a child blew into getting cyanosis? Or is a child being the pulse rate of the child? Usually the child is a bit tachycardia. We're not too worried. The problem comes with bratty cardiac. There's something wrong. Once a child is Bradycardic is a child, grimacing president or absent. The tones wasted the reflex irritability of the child on what the child has active respiratory effort or not important thing to remember. If a child scores between 0 to 3, that's a low Apcar score. You worried about that child? 4 to 6. Okay, it's not too good, but we can wait and watch and see what's going on. And 70 10 generally means the child is quite healthy once again. This is not exactly pediatric cardiology, but it's something very important as a practical skills for you to know, because this is what you actually going to be doing as an estate, you in pediatrics. So you gonna be called in to see ENT when the patients undergoing a cesarean section, or when a child when a woman's just delivered in unit, you need to keep the resuscitate warm. That's basically the small bed captured the end of all these labor rooms where the newborn child has moved on, assessed by the pediatric team's going to keep all the equipment ready on a soon as a child is handed over to you by the midwife, you want to rob and stimulate it, kind of rub it on his chest, warm it up to see where they could try on its own. It would cry spontaneously. Well, I'm good. Listen to it. Listen to the heart signs to ensure that there's no doc, it cardio bradycardia. And once again, the concern mainly is bradycardia at our stage. Where we need to know is bradycardia, and the child is worrying what's going on and if you see that the child is not responding, the heart's under abnormal. You follow the new needle life support guidelines based Place the head. So the key thing of this light is the child's head is placed in the neutral position. So remember, if it's a toddler on your it's you're doing the basic life support. You place the child's head in the sniffing off morning air position to slightly build it, but in a newborn because of their muscles being weak and you push it too far to get a reconstruction, you want to place the child's head in the neutral position. That means the nose should be in line in a straight line with their body to remember that the neutral person is the key thing to remember. So that was a quick, practical point moving on to the second question. Now some will be more into the cardiology aspects off it is the ports launched battery. Do you think you can launch the place? I don't have access. Give you 10 more seconds. It will stop the pool there. So the majority of you have gone for B, which is the correct onset cooptation of the aorta. So this child is presenting at a young age these symptoms the Web neck on the wide space nipples. Pretty classic, often a syndrome on a young age. Hypertension. You thinking about cooptation off the aorta? Can anyone tell me on the chat any other childhood syndrome, which can present with very similar findings of a Web neck and a white police nipples? Does anyone have any idea of any other childhood syndrome, which presented similar features Noon and syndrome? Absolutely yes, The Newman's and Room and Tennis and Rufina. Typically, this seemed quite similar few little cardio type analysis to rule I. Turner's or New lens. But on this, this Web neck, the whites place nipples, you. It's very similar, but the Newman's and 10 s, So those two are the ones which you need to Dingell's. But, he asked, This is cooptation of the or death. Can anyone tell? So why does this Caucasian of the aorta cause hypertension? That one of the first questions I had when I came across the condition, but it's actually quite interesting. What what is cooptation of the aorta? Does anyone know? Can anyone tell me in one sentence what cooptation of the air days stricturing Exactly so just a fancy terms of quotations. A fancy term for stricturing or narrowing of the aorta. And generally we replace this narrowing or we localizing, narrowing according to its position relative to the doctor's arteriosus. She could be the pre doctor or a post doctor narrowing exactly. Someone's giving it on the chat. So there's two types devil this narrowing cause an increase in the after load. It causes a decrease in the radius off the aorta and therefore hypertension. Simple, tough. But a question which can come up is if you're suspecting cooptation of the aorta on physical examination, What is it putting what it's quite important to do and which can help you see whether this patient actually has cooptation of New York or not. Does anyone know that? What can you do on physical examination to help rule out cooptation of the air trapped? Yes, ready radial delay is one of them. But I'm looking for something more, which you can see more definite femoral pulses. Yes, down those lines. Exactly. You look at radio femoral delay so I'll come to why radio it'll do. It could be that could not be. That depends on the weather narrowing Israeli. But yes, ideally, you do a four Lindblad pressure if the cooptation. If there's a significant BP difference between the arms and the legs, you're thinking, okay, this patient might have cooptation of the aorta. It's not wrong. You might get a really A femoral delay is well on pulses, which is quite which, which could be present in a patient who has coarctation of the aorta. But ideally, in pediatric ward, you'll find all the consultants asking for four limbered pressure just to rule out cooptation. If there is cooptation, the opulence will have a higher BP than the lower limbs. You know why? Really radial delay? It really depends upon where the cooptation of the narrowing is. Really, really. It's basically when the balls are, let's see. The right hand side comes before the left and cycles. When you feeling both the radial pulse is, you find that one of the pulse is is before the other bowls. They're not in sync. They're not synchronous, you know. It depends upon whether narrowing is if the nerve doing is before the left subclavian artery. The artery supplies the left arm, then yes, there will be really, really, um, the liver. But if it's after the left subclavian, there'll be no radio radio. So yes, radio, it really is a possibility. But it's not always present. And therefore radio femoral delay or a radio femoral foreign and BP is much more prevalent and much more easily used to see what this patient has cooptation. So it all depends upon whether narrowing is, but in most cases, upper limb and loyal in blood pressure will be different. So you do a four Limbach pressure very important. So the interesting pressure just come up here And yes, this is something which, um, group good come up Israel. So the thing is that give it says most, most likely diagnosis of this question. Why shouldn't be bicuspid aortic valve and you're absolutely right because they're eating well. They're much more prevalent on is the most common condition to come up in tennis. In room, you have a clot clinically correlated this to this child. This child has hypertension at a young age with Dana syndrome. I know bicuspid aortic valves are more related to turn this syndrome, but this is where the questions congratulate you. Look at the clinical picture. Clinically, I'm not talking about a murmur. And my If there was a murmur present, then yes, bicuspid aortic valve will be much more prevalent. This is hypertension, one of the commonest cause of childhood hypertension resistant hypertension would be cooptation. So therefore, always think. Always look at the question and think about the clinical context off the question. It's very important. This is to bit about the cooptation. I've gone through most of it already, but symptoms in infancy of this patient has heart failure so hard feeling quit and see because it increase after Lord. Just treat the heart failure. Basically an adult representative factory and hypertension. So for cardiovascular exam, wanna do any CT chest X ray echo will prove it. A new magic balloon validation. Fill it and geography. You can put a balloon to put a catheter through and use a balloon to dilate up the artery or surgical fix station Are the usual medicines to fix it? I wouldn't worry too much to other treatment for Cooptation. It's more about recognizing this resistant hypertension at your stage on a bit about Dana syndrome. It's 45 6. To confirm the diagnosis, you need a cardio type analysis. You can do an E, C, G and echo cause once again as someone mentioned bicuspid aortic valve. Quite common into tennis. You want to steal, there's any cardiac anomaly is going on. They also get cystic. I'd rumors usually posterior triangle neck lumps, which transilluminated on when light showing through them. And once again it's usually treating the symptoms. These patients are a memory you need to give them home and replacement therapy and stuff like that. So that's briefly on tennis. Moving onto question number three. So I'll stop the pool there. So most you've gone to a ventricular septal defect and honestly, on reading this question again, I do see it could be very confusing. This is actually based upon a patient I saw in the Pediatric Assessment Unit. Okie concept for us to understand is when a child is unwell to this chalice, Pyrexia has wide spread across crackles and associated. We's nine month old for feeding this patient. If I remove everything else the first thought, which which would come to mind that there's some infection going on, given that it's nine months, probably a bronculitis type picture in patients were on well in. Children were on well. They can get murmurs known as flow murmurs or innocent murmurs, just because the heart is working very hard. So the answer to this question is, actually it's still the murmur, which is an innocent women. Once again, I appreciate it's quite difficult. And, yes, a ventricular septal defect would be something in your mind if you do hear a murmur and this child. But the key concept I want to drive home here is that when a child is through it with the federal illness by wreck, still not feeding well, looks generally unwell as well. Be in the case in this patient, you can't really say that this patient is a ridiculous apple defect because the murmur could well be. I still do my more innocent murmur. In most cases, what is done in these patients is that they have another review six weeks later. Once they're well, the GP checks their heart again. The murmurs disappeared. Confirm this is an innocent murmur, but forgetting about the question for a second, but just thinking about you as as an essential if you do hear a murmur important to document it document, whether it radiates or not, doesn't move with posture or not. And after that, always ensure that on discharge there's a safety getting advice given to go back to the general practitioner once the child is fine. So for them to auscultate once again to see what the murmur is still present or not Very often these moment members disappear. And once again, like I said, it's because in these femoral times the heart's working very hard. And when the heart works very hard, it creates a bit more of turbulence low, and that causes this flow murmur a very important, important concept in pediatric cardiology. Always remember, a diastolic murmur is pathological key. Take home message is anything you take home today in your risky. If you hear a murmur and it's diastolic, it's a pathological. Remember, no diastolic memory is ever a physiological murmur. Listen, murmurs are always systolic. They have no radiations will never need it to the corrupted or the axilla. There's not causing it. Okay, the symptoms so the child will not. The child will not be presenting with sometimes, for example, palpitations or anything of that sort or heart failure. They're asymptomatic. I mean, very good posture. I know there's some other signs of innocent murmurs, but these are the four main to remember always systolic. No radiation does not cause any symptoms on the may. Vary with posture Moving on the question number four just launched a poor Yeah, I'm unable to launch the pool for some reason. Walker, there's a questionnaire. How did this coming? Wish your VSD from when is d being the answer? I'm not an interesting question, actually. In atrial septal defects usually present you much later on in life. There is symptomatic initially and secondly, the murmur is also quite different. Secret is splitting off the second heart Stun initial septal defects. If you think you're invited, there's more flow coming from the left atrium into the right atrium. Blood always flows from region of higher pressure to lower pressure left atrium. The no blood coming into the right age. Right atrium. Therefore, in general physiology, the right heart, right valves close. Likely later than the left side of the valves. Would that be accentuated Causes more blood going through to get a fixed splitting off the S two with a mid astomic murmur. Do we? I remember it. It's very similar to a mitral mitral stenosis murmur, mid Astelin murmur with fixed splitting of the S, too. So that's what would be an ST and usually present much later on in life. And they can present with symptoms of heart failure, etcetera. But it's usually not seeing the pediatric population. It goes undiagnosed referral and the pulled up be That is the right answer. So I'm not in conditioner, Not in the immediate new needle. A period when the child is crying, getting more and more blue or sign. Ah, tick. Actually, a good question here to ask me. I'm talking about Sinuses. Does anyone know what exactly would be characteristic? What causes Sinuses? Okay, anyone Give me a particular value in the blood for you to be cyanotic. Any ideas? The auction? Your hemoglobin? Exactly 70%. So that's what That's the point I'm gonna come to. Actually, even I had the initial idea that it's Oh, just see about Jack, your pulse oximetry and see whether your blood option saturation is lower. Not, but that's not the case. Actually, for a patient to be sign Arctic they must have 50 g per liter of the option. It'd hemoglobin. So it's basically about how much D option and hemoglobin you have in your blood. It's not related to the auction saturation, so that's that's the key key key marker to remember. It's the amount of deoxygenated hemoglobin in comparison to the amount of oxygenated hemoglobin you have, which will determine your Sinuses. And therefore it's important to remember that the sign optic heart conditions will cause a lower amount of oxygenated hemoglobin on more deoxygenated hemoglobin in your blood as compared to the acyanotic conditions. So just moving. Once, quickly There was a murmur heard over the right sternal edge. Did anyone tell me what that movement is for? What's the murmur? You're here exactly. Bone restore Insulin injection. Systolic murmur heard best over the right sternal edge. So tetralogy of followed to be presented the floor symptoms Uh uh, septal defect on overriding aorta, right ventricular hypertrophy on right ventricular outflow tract obstruction. So I know many places mentioned published in assists, but the way I was started was always remember that the aorta is displaced towards the right hand side and that's why it's causing and right ventricular outfit. Active tract obstruction. It's not the typical stenotic valves you find. Inform restenosis. It's because of the pushing off the aorta towards the right hand side that you get this right ventricular out. So tract obstruction and I can actually link these through right ventricle out for tract obstruction. So that means an increased after Lord for the right ventricle. Therefore, you'll get hypertrophy. Does anyone know what time of hypertrophy you'll get? You get right, ventricular hypertrophy. Typically, you can get in a concentrically hide, right ventricular hypertrophy because you're pressing against or you're going against the higher pressure. Always remember concentrate. Hypertrophy is when the after load is very high. He central hypertrophy is when your overloaded, when the fluid within this compartment is overloaded, when there's too much blood, you get any centric hypertrophy. Sometimes it typically will be dyspnea sinosis failure to thrive, systolic failure investigations, false oximetry. Just want to check the auction saturation levels. But the key thing is the echocardiogram. The easy can be normal. Initially, chest x three, you got the characteristics sign. Does anyone know what sign you get on a chest X three for a patient with translation. Absolutely. Boots sign plastic treatment symptomatic for heart failure. The death spells you can give them a need to chest position, which helps reduce some of the after load, helps increase some of the venous return. Pardon me and you can give them oxygen. Sorry, I've just been highlighted over here that I said It's the right sided injection. Systolic murmur. Best heard over the right sternal edge. I'm very sorry for that. Between the left sternal edge. Pardon me for making that mistake. So an illustration of what showed what happens in tetralogy of fallot. You can see the ventricular septal defect here. You can see that the air that's quite displaced, causing bone restenosis as well. And you can see this concentrically right ventricular hypertrophy East central would be run the hard dilates. But this way it becomes east entrance. Basically, when the myositis added in Siris, so you get a larger Sinemet. Rickel, rather than a concentric right ventricle, is really like puffing up type of thing. It's added in parallel is becoming bigger and bigger, important difference. Remember Question number five. You guys a lunchable and I think it's up. It's up now. Nothing on the pull that most if you have got this Uh huh. Correct. So most of your gone for transmission of the great arteries, which is absolutely correct. So I not take immediately in the post Natal period. You're thinking of transposition of the great arteries. So the way personally, I remember that my student level is, if a patient, if a child in the immediate new needle period is sign optic, I think of too many conditions. Transmission of the great arteries or tricusp between gentle tricuspid atresia track custard atresia basically means when the tricuspid valve has not formed or transposition of the great arteries. These are the two things that Sprinkle mind immediately moving onto the same patient. You know, it's transition of the great arteries. What is the immediate next best step in the management of this patient? That's a geek key sentence. That was the next best step just for time concerns. I think I called a pool there, but he asked us most if you've got this question right is well, so IV Prostate gland. It's. You need to keep the weight and doctors arteriosus open. A doctor's arteriosus is a connection between the aorta on the pulmonary artery, usually after breath. What happens is a number off the amount of prostaglandin within the body dips. That dip and prostaglandins is what causes closure off the doctors. Arteriosus, Do you want to keep it? Paid it in this case because what's happening in translation of great arteries is basically the aorta is coming out from the right ventricle on the pulmonary arteries coming out from the left ventricle. So instead of 22 barrel seconds you have you don't have to. You have to file a second set of one series second, basically to think about it, your arteries in your right ventricle. So the ivc and the S the superior vena a cave are draining blood into the right hand side of your blood off your heart, and then the it has taken the same the oxygen and blood back to the body. That's one second. The next circuit is when this side of the left side of the heart is pumping blood to the lungs on the floor over to the pulmonary artery. The problem remains and draining it back into the left side of the heart. So it effectively means what's circulating is completely deoxygenated blood, so you need some way to ensure the right and left side blood are mixing on. The way to do this is to ensure that the doctors arteriosus is open. If this child has a concurrent VSD, you want to keep it open. That's really helpful. Then he has a concurrent years. Did that help? It helps us. Well, you basically need to ensure that they some point in which the right and left side circulation are mixing, and in this case, to give IV prostaglandins. I've the indomethacin would be used to actually close down the doctors arteriosus so some Children actually have a doctor's arterio doesn't start on its own. In that case, you want to reduce the amount of frosted London's and clamping down you could give IV in your medicine on for those, if you're interested is actually really interesting study, which showed that I proceed to more can actually help close The doctor started your sister's well, but for the main thing is a common example ration of drilling this point room. If you see this question, always think okay, I need to keep the mixing open, and how can I do that in this case, prostaglandins will ensure you can keep the doctors arteriosus open training just to end on to that point. Sorry, actually, paracetamol issues nowadays also has he meant the pursuit of money is quite commonly use. So absolutely thanks for that. On finally district, those were interested anybody in pediatric cardiothoracic surgeons out there. Arterial switch surgeries. A very fascinating surgery. You literally removed the aorta along with the coronary arteries and push it on to the into the left ventricle and moved up on MRI are bothering artery into the right ventricle and reconnected. It's kind of like redesigning the heart. Just quite interesting for most of these conditions, and echo is diagnostic. Remember, because a very complicated always done that consultant pediatric cardiologists. So it's quite a skill based special thing. So investigation generally for most of these conditions, if you could put on the spot and echo would be the best, are the most of ideal investigation. Just a picture showing look. You can see the area a little on the right ventricle, the problem re artery leaving from the left ventricle. That's what transposition it's. It's literally what's what's in the name. So not just my last few slides. Like I said, it'll be a little starts to do it through cardiology. But some prominent things which come up in your exams, which you need to know, is if they ask you what's the most common cardiac manifestation of Down syndrome? It's atrioventricular septal defects, so it basically means the ventricular septum is affected, and so is the atrial septum. Because of malformations of the end of cardio cushions, however, the main thing is no AVS. Teas are the most common, followed by Vst common question. To come up as one of your kind of mentioned tennis syndrome is mostly associated with my custody or the girls. But as my question highlighted, always look at the clinical picture. Just don't think or turn is I'll go straight for the bicuspid aortic valve. That's the way my school's capture side. We need to see the clinical picture being described and answer accordingly. The George Syndrome. Once again, it presents a hypocalcemia and those type of conditions. The main thing is called a corner Trunkal, sometimes basically outflow tract problems. Taking cause an intra interrupted aortic arch or trunk is arteriosus basically means that the primary artery, the aorta, haven't septated. So there's no division between the two. That's the the Georgian drop of cardiac manifestation on SD, and I've already explained a quick teach eat. The blue ones are the sign Arctic conditions on the pink ones. Other whether babies will look pink so they're not. They're the acyanotic conditions. Important conceptual points, a concept it's important to grasp off would be large. VSD is will not have a murmur or a significant murmur could think about it in a large VSD. There's less stable and flow, but they will develop izing Megace syndrome much more faster. What's Eisenmenger's syndrome? Eisenmenger's syndrome is basically when I left to right shunt is reversed into a right to left shunt. I'll add that in my slides we'll go through it very quickly. What happens in a patient with a large ventricular septal defect is this constant truck transferred of blood from the left went to go to the right ventricle that causes fluid overload on the right ventricle. The dragon ventricle has to respond to this increased pressures and starts Khyber tripping. This increased blood flow to the problem revascular to this for memory hypertension as well, leading to concentrate hypertrophy of the right ventricle to the point where the right ventricle actually has higher pressures than the left ventricle to this controversy is. So now you're getting right side of blood going into the left hand side. What's gonna happen? That it means more deoxygenated blood will be going into systemic circulation. You'll turn blue. That's Eisenmenger's Eisenmenger's treat Treatment is usually a heart lung transplant, and that is basically it from my side. Thank you. So much of the images were taken from really comedian comments on moving has a wonderful pediatric gastrus a shin lightened up You if morning still moving You. Yes, I'm still that. Can you hear me? Yeah. Okay. Brilliant. Okay. I'm just gonna share my screen. So, guys that just have to warn you my exact connection is not very stable today. So please bear with me. And if you want me to repeat anything, just put it on the chat on. If someone can let me know as well from the team and I can repeat anything. All right. So thank you for that great run through pizza cardio. So today I'll be going through some main areas that will be really relevant for your finals in terms of pediatric gastro gastroenterology. Particularly focusing on emergencies on. But you need to be good at recognizing, and I'll take approximately about an hour. Okay, so this is the first question someone launched the pool, please. Mobile, You give him any cancer? Okay, that's fine. All right. Uh, sorry about that, guys. Um, so let me just go through it, then. Um, so this is a nine month old baby coming in with intermittent diarrhea and vomiting to be and be on this passing a flu stools, which are described as grave and loose. And there's also conducted problem double distention growth has also been affected. And the patient is a Pyrex. Oh, and another important thing to notice that this baby was not breast fed but was fed with formula till six months of age. So since I did, um, accidentally reveal the answer are just you guys have kind of man it to kind of get your head around it. So if I were to go to a pregnancy again, this patient is not nine months old. Diarrhea and vomiting for the last couple of months And this is after, um, after stopping, you know, formula milk and presumably starting on some kind of food on also having grand loose stool. And there's also signs of anemia, such as conductor a palate, and his growth is affected and is currently a Parexel. So given all of this as I reviewed, the most common likely pathology is in this case, it's celiac disease. And this is because off the classic picture off anemia and the symptoms after starting some kind of solid food, presumably on the chronic diarrhea. Now let's look at why the other answers are not not a possibility. So partners Diarrhea is a good differential, but this would usually present after the age of one, and usually patients have very foul smelling stool with, you know, bits of undigested food in it. And this one I didn't mention anything like that. The cruise disease you don't really present in the noon. It'll state usually when you're on adolescent or, you know, early adulthood, you present it, the symptoms and then another good differential would be caused me of importance. But as you can see, he was fed with the formula milk, which you know which contains which is called milk, basically for six months, and they didn't have any problems. But the problems did start once they stopped Formula American, they started some kind of solid food, which is possibly some blood and containing food, you know, like some kind of cereal or so things like that. And finally, cystic fibrosis is also good differential because you get the kind of diarrhea picture as, well, a cystic fibrosis. But the main thing would be, you get scared area, which is, you know, fall smelling stools that are difficult to flush and things like that on also in the questions them they would give, like respiratory complications and recur and chest infections. So that's that's why a stage it's still a disease, and the presentation is around started on nine months, usually typically for the disease as well. It's important, you know, that kind of stuff as well. So let's talk about celiac disease. So, um, as I mentioned before, it's Xarelto immunity, um, condition, because your body amounts and inflammatory response to gluten, which is typically found in things like wheat rye. Um, and this is usually after they are introduced, the blood and flu. It's like cereals at, you know, 44 or five months on words. Usually they present before the age of three in the infants. And also they're various associations associated with other autoimmune conditions. Like, you know, type one diabetes. Um, Grave's disease. It's important to ask about a family history from, you know, from them parents to see if anyone has any autoimmune diseases and also with from several abnormalities like downs and turn us. And there's also associate with HLA D to two and the feet and classically a Z. This patient presented you specials clearly failing. Had failure to five is they weren't, you know, growing properly. And because of this malabsorption, you have produced absorption off nutrients and sometimes you get abdominal distention and pain and also diarrhea loose stool onstage area, Which is why cystic fibrosis is kind of a a differential for it. On also because of the anemia, you get the tiredness and less Sergeant patients usually sorry, parents usually say that that the Children are sleeping well. Then they should on playing around as much as they usually do and things like that. Okay, So in terms of diagnosis, the first kind of thing you would do after, you know, doing your basic bloods would be to do a total IgE and i g a r t tg. And that's very important because it's a port into both of them. Because if a patient S. O. R. Raised idea T TG would point towards the diagnosis and celiac would help the diagnosis, but can sometimes it can be low. And this is because the total IgE A is low for some, for some reason, and therefore, it's important to find out whether that total idea is with normal and if it's normal and the idea T TG is low, that suggest that this is not celiac, so it could be another condition. But if it is low, um, if both of them are low, which means ttg is also low because that's not enough idea being produced by the body. Sit on mounting that response, and therefore you can do if you think it is, see that you will do other screening tests like and the anti end of my stool antibodies and antigliadin antibodies to further because those can be used to so for the support as well and importantly, load is patients need to be on food containing gluten for at least six weeks before the test because you will only get these antibodies produced in reaction to gluten. So if they avoid gluten food because of symptoms and you know problems, then you wouldn't get the antibody response. And therefore, uh, you won't have a wrist ttg idea level. And then once you have done that, the mainstay the gold standard is an endoscopic duodenal biopsy. And these are the three things you look at. And I'll come on to talk about that in the next life. You can also do, Um uh, you know, other blood tests, like I am beat full it because it's classically, you get a mixed anemia, you get iron deficient sort of microcytic and a microcytic picture. So usually it may even be normal city. But I think in the clinical setting, it's usually I am. That's it does often look so any kind of iron and diarrhea on all these failure to thrive at this age range, you have to be thinking Celia, okay. And in terms of the treatment, the first step on the basically the only kind of confirmed confirmed treatment that is most effective is just to be on a gluten free diet. Just avoid the food. But you have to remember, these kids are still growing. So if you're removing blood and you have to supplement them with the high calorie diet just to ensure that they grow, okay, not in like adults. Just avoid gluten foods, but you need to supplement that as well. And if you have refractory disease that doesn't respond to this, you know, gluten free diet on the symptoms are still continuing. You'd have you could consider steroid, but patients with celiac often get, and we'll follow up just to see how the symptoms are managing. How they're managing with the symptoms have gotten better from a gluten free diet and things like that. And, um, usually alternative food that they can have his things like rice, potatoes, dairy products, milk, cheese, usually all right. And so in corn. All right, so Okay, so this first picture is a is a classic duodenal biopsy of a patient with celiac. So I remember I told you the threes, the three signs are we going through, which is I use the Acronym Week personally, so the for villus atrophy, as you can see. So if you compare this to a normal to order them without a patient in a patient without Celia, you would see that the will I will be taller. What? What happens in celiac is because of that autoimmune kind of destruction you would get the shrinking on. Do, um Well, I become smaller on then. The second one is interesting. Intraepithelial lymphocytes. You get increased movement off lymphocytes because of the autoimmune reaction. Um, and you get these increased density off lymphocytes within the within the bill, I and then finally see for crypto hyperplasia. So these are these are Crips. They If you compare them to a normal do a little biopsy, they they would be much smaller. But these have grown in response to that information and things like that. Okay. Can you guys put on the chat? What? This what? This picture on the right shoes. Yeah. Excellent. So this is demanded by dramatic Titus about it for ms, which is a rash that it's observed in celiac patients because of the reaction to gluten. And it's usually it's typically itchy. It's usually found on sepsis, such as elbows, shoulders, and it's usually symmetrical. So it's found on both sides and the Do you guys know what the what? The kind of means the treatment for this is And you won't know what how to treat this, uh, rash. Can you put it on the chair? Yeah, you could. Could you stop soon? Is there anything else? Uh, steroids a Zara's? I know. Probably. Yeah, exactly. There you go. Little free diet. So the mainstay treatment for these is to get on a gluten free diet because that because you're getting because of gluten in your diet and once you stop taking gluten little and that will go away. Um, okay. Brilliant. All right. Is the next question. I'll try not to, uh, um river. The answer. Can someone launch the pool, please? Yeah. And someone did ask how come it's not cause milk allergy? Because in the previous one usually cause milk's a protein intolerance or allergy usually presents in the first couple of months, especially in formula fed Children, so it could classically not present, um, so many months down the line. Um, yeah. If you guys are the Yep. That's for months. Rightly said absolutely could be indicated. Give you 10 more seconds. I will stop the pool there. Okay? Okay. Got a lot of close answers. Uh, most of you went for a, um e d c and A with ent being one of the most popular answers. Okay, So, um, can you guys first of all, tell me, Tell me what this patient's presenting with? I know it's a bit of a tricky question, but this is kind of a new fourth thing that can follow up, can put on the chapped what this patient is presenting with, exactly flock. So this patient is actually presenting with gastroesophageal reflux disease, not reflux on, and I'll talk about it more. But basically, once the reflux, all the symptoms start affecting your growth or it starts causing complications like pneumonia that then that's when it when you call it, Yes, stress for your reflux disease. If there's also guess for your reflux, which is just, you know, the kind of get the mild symptoms on. It's usually physiological in kids on our talk a bit about that later. So yes. So this patient is, uh, presented presenting the gastric reflux and the first mainstay treatment for that is to in the pediatric setting is to offer advice on feeding because usually it's because of poor feeding techniques, overfeeding and things like that. So you want to ask them to improve the feeding techniques like, you know, keeping a head drop upright, not lying the baby down on the bed after feeding, cause that can also cause and then also, you know, not keeping them with the tummy flat on on the bed, because that can get, you know, caught that and things like that on your trial. These before going on to things. Um, and you wouldn't want to give you antibiotics in this patient because the patient is well in our self now. So no signs of infection on fundoplications, which is essence fundoplications, which is in adults. It is option, but in the pediatric setting, if it is not done at all, So fundoplications is not an answer. Uh, PPI could be, But in the pediatric setting, it's usually one of the last line options. There are other things you can try, like the tick and formula on things like that, which is usually corn starch and stuff. You can mix it with food to make it thicker, but most likely the first thing. So the first step to manage the symptoms is to offer advice. Okay, all right. So, um, as I mentioned before, gastric severe reflux is physiological. In most kids, it can have a lot of kids on. This is because you know, the the still immature that it's a fragile. You know, the lower esophageal sphincter, which, you know it prevents reflux is usually it has a lot, or just it's still growing, especially in the first week, few weeks of life, so that it's it's very likely that it goes back up. But usually it's not, too. It's quite minimal, and it doesn't cause many symptoms. Um um, and it's physiological, a swell and usually parents over feed as well, which can cause it to your stomach to stand and things and and push it back up. But if it doesn't affect that growth on your they're relatively asymptomatic, then it's just reflux becomes reflux disease. When the patients start going, become symptomatic. Um, you know, they have, like new recurrent New aspiration pneumonia. They start telling their growth starts tailing off and things like that and This is pathological. Okay, this is what when you when doctors generally get concerned, Okay, just I don't even important important learning point. So this is one of the biggest cause of warm eating that are different. Starting there's a different starting point peaks, and time improves by So within a year, like 90% of them usually get better and their risk factors like prematurity. Um, you know, logical disorders like cerebral palsy can cause them to, uh, um, have reflux. And that's why they get things like aspiration, pneumonia and things. And also, like, I guess, anemia can be one of the risk factors. And as I mentioned, you know, there is the lowest surgery. Think that has a low tours from very strong enough to prevent backflow on been feeding. You know, the patient is the sort of babies usually flat against the mother s O against gravity, so that can easily cause it to back flow as well. And also feeding overfeeding too much can also cause it, and the clinical features would be on. This is one of the causes of non bilious vomiting, which I'll talk about later, but important. Remember on. Do you know when the group. It's a fact that they start to, you know, stop eating as well just because to avoid the regurgitation and also expiration pneumonia. And in some cases these are less less common. But can still happen. Is they can get acute otitis media on, especially in Children. It's terrible. Probably they can have things like then for erosion. Okay, on this diagnosis is clinical, so you wouldn't do any Usually do any investigations. Um, do because, um, you would actually have these kind of risk factors, clinical features that would help with the diagnosis. And as I mentioned you, start off with conservative treatment. So you give them advice, especially new first time. Others ask them to keep the baby's head's up when breastfeeding and Italy 30 degree angle. They should, uh, sleep on their back, not on their tummy, to avoid carpet, um, and also feeds. Very important. You ask them to freed small amounts, but very frequently okay, making sure that they're over not over fan, because that, as I mentioned, can cause them to be regarded it. And also other options would be you can try taking for were like corn starch of extensive with some of the food. Um, you know, Oh, in the milk. If they're giving formula, let me mix cornstarch in it to make it thicker. And that just makes it stay in the stomach on without going back on allergy A terribly. So you can try things like Gaviscon. But you should not use them together because what both essentially do is to be kind of taken the the gastric contents eso you do. You wouldn't wanna because that would increase. Sorry, that would cause further delay in gastric emptying because of pinkness on. But you don't want that. And they might even get the one thing that constipation, uh, and that finally pee pee I see on this is usually resorted, at least according to night skylines is when there's severe complications, like when their growth is effective, or after having distress recur and aspiration pneumonia. And if all the other interventions have failed, we'll try the PPI. Okay. All right. Next question. Can someone launched the poor, please? Right. All right. Give you 20 more second. So even that's a good question. Even if it's a red flag with weight and things like that, you'd still want the most common thing you can do it is just trial because it's most most commonly due to those poor techniques on the mothers are using. So if you, um, ask them to improve those and see if they're doing it properly. But if there were, like, more red flags, like recurrent pneumonias, uh, then you may consider a PPI. All right, so let me stop the poor there, Okay? Most of you have said, uh, he which is, in fact, the correct answer. So yeah. So this patient is presenting with, um, in the susceptive in. So, um and you know, the risk factors are that's a boy, um, bombing a p in, uh, and you get this colicky abdominal pain as well, which is one of the key determining factors. And it's billions for meeting on because of billions vomiting. Usually, uh, not all the time, but it's usually billions vomiting and bloody stools. Do you guys know what this What? The specific name for bloody stools in these kind of patient? Is anybody on the check? Uh, no. Melena. Yeah, Exactly, Fred. Or And jelly stool. That's exactly it. To get this mucusy jelly red colored stools and things classic feature off fetal position. So basically, we're in front of showing that is, this patient is trying to drawing their knees up to the abdomen because the pain is so bad, that's that's the best way they can tolerate it. And there's on the mass on the right side of the abdomen. Abdomen. Is that usually a write up? A quarter and mass that you get, and it's typically typically on the right. Okay, all right, So Intussusception. So this is the past physiology. I'm sure most of you know it won't spend too much time. Basically, one part of the power getting vaginal did in another. So it's like a telescope on. It's most commonly in the right hand side, where the Ileocecal region around the region. That would be, you know, right up according mask, usually on the small bowel. So the ileum is more likely to be affected than the cecum on a Z. I mentioned. Being being a male is also respect. I think there's a 3 to 1 ratio as well, um, of increased risk, um, and the classic features, as I mentioned, you get the colicky abdominal pain, drawing their knees drawing their knees up to the abdomen. Billy, it's warm. It's usually bread conjuring stool and abdominal mass on examination. Okay. And what you would classically see on the first line investigation would be an abdominal ultrasound. Interesting as you, as most of you said on you would see this target science. If you look at this second like a bullseye kind of appearance, it's also called letting bullseye Sinus. Well, but this is what you would see on the endoscope just for out of interest. And the first line you do is an animal animal, which is basically where you put a tube into the back passage and you pump in there under on a while and x ray, and you would cause the pole toe push the ball back out from from which it slid into on def. That feels, or if there's any sign of perforation, such a spirit in is, um um um Domino guarding and things like that you would go in for surgery because it's very likely that that part of the bowel is, you know, necroes. Oh, you know, it's very passionate dick, and you go in and resect it. Okay? All right. Next question. Someone launch the pool, please. Okay. Okay. So, in your secret region, I would say it's the safest thing to say is the right hand side. But usually, if you like, look online and things like that just says right upper quadrant. Uh, but yeah, I would say to say, if you see a mass on the right hand side of the abdomen, um, that is more indicated. Um, more likely to be in this exception with this other clinic. If he just right, you guys. 10, 15 more seconds. Interest of time. So this question is basically just on the understanding, the nice guidelines. Um, just having an idea of it. Honestly, Not really a lot of thumb. He's allergic to anything. I understand that case. All right, I will. In the poor that so most of you have said A which is the right answer. Yeah. So this patient is presenting with, um, presented a clinic again because their symptoms have failed to resolve with more be called pediatric plan. So that's the you know, Usually the first line you give in, um um, in constipation. Um, and the next option, even if it's been two weeks on day have no improvement with, the more we call, you'd add a stimulant laxative. Something like Senna. Um, okay, so let's talk about constipation. So the most common cause it's idiopathic. So basically, there's no underlying physiology off, um, anatomy or anything that can be understood. But it just happens on other other cases. Could be the hydration medications. No fiber night, especially these three are quite important, especially the hydration and diet. Um, usually, um, things like when Children start school and things like that that can really affect that diet and the amount of fluid they take. So usually when one of one of the important things to look out for is that I have they started school. They had noticed any change in behavior and things like that, and then, obviously the other a bit rare because I rarely causes like I pulled terrorism mushrooms and in official, her shrunk. It's very, very rare, but it can happen, Uh, but and how strong it is more not to miss. Okay, so he did. For the constipation, particularly is linked to things like cerebral palsy, office um, and Down Syndrome. On the classic features was so the united really great document on it on. I just added a few of them in that there's more. But some of the features you typically see is less than three complete stools. Either Type two your time for the rest of stool shot and also look out for any factors that may be causing the trigger. The constipation, like, um, integrin illness or infection stays in the diet like I mentioned and starting. Okay, um and, um, insufficient fluid up or diet and generally constipation. Most of the time, they don't really affect the growth of maturation. If it is, it probably warrants, um, investigation. Okay. And other possible features is, um this is if you see on image on the right, there's something called retentive posture E. This is usually seen in patients who have had, um, you know, constipation for a while and especially constipation associated with pain. So if they have to strain a lot and there's a lot of pain associated with months passing stool and things like that, the typical not typically, but generally assume this position basically, that you have the legs are straight on the arch back. Um, and this is to kind of contractor perfect muscles and the public floor to kind of with toiled feces because just passing it can be very painful, and they want to avoid it as much as they can. Okay, so this is, Ah, this indicated reliever if, like poor, Like what? Science To be honest. And you also get over four or soiling just basically, when sometimes kids notice they've had a bit of a bit of stool or like feces or something on the clothes without them knowing. It's usually when they change their clothes and very smelly. And it's very, very liquidy on This is This's because little by little, some parts can soft in and caused them to pass out without patients knowing that's called overflow soiling. And this is important because that could indicate, um, high likelihood of fecal impaction. So when are Stool Issue stuck on to the balance on passing through Okay and also get rapid droppings. Pellets straining and bleeding associated with passage of hard stool would be another thing to look out for. Okay? And as I mentioned, if there's any sign of fecal impaction like overflow soiling or you can, um, actually palpate a Mass. You need Teo. If there is, I mean physical impaction. There's a different kind of treatment. We would give Mobic all but as an escalating regimen. So you basically give Mom call, and you slowly kind of increase the dose until they respond to it. And they're they're about have it start to become a bit more regular or normal. Okay, so in terms of management thing in the throat therapy, especially this vehicle infection is you give it more vehicle. It's also the actual name is polyethylene glycol and electrolytes. A combination of those on you. Slowly increase the doors until they respond, but if they don't respond it in two weeks. A smoker, you answered, you just give him something like sodium. Pick yourself. It just even a laxative. And if they are not tolerating the movie cool. Okay, you removed. Stop the movie call and give them a stimulant laxative like sodium biggest off it. Or would combine the stimulant laxatives with the asthmatic lasted like lactulose. So I just put on the right side as reference, because I I used to very much struggle with the laxatives because it's just so many types of accident and just under focus on two. So the two different types are still too focused on a stimulant antibiotic. So what stimulant laxatives do? Is they basically the encourage pristall assist by causing the smooth muscle to, uh, contract and relaxed to past hour. Okay. And it moves the stool along. And typical ones ascena. I'm sure most of your familiar with by code L and sodium, because off it, okay. And then you've awesome Arctic laxatives, like last you lows, which basically what they do is they're a stool softener. They are. They just increased the water content in the bowel. So either they reduced the absorption of water into into the blood from the balls that it remains longer or it could increase water. So they draw water in from other parts of the body and just basically causing the stools too soft. Okay, so that's why if if you know, if that impacted and if the movie call which which has more of a stool softening effect, if that doesn't work, you would give a student accident to force, try to force that hard and stool to move through, um, and yeah, and then important to also just to be aware of, especially the results of the learning point. The clinical learning point is that most doctors let families know that because of this infection that can lead to overflow, soiling as well, because you soft in the stool and then they get supported to you need to be aware of it. And it also, you know, if you especially if you give a stimulant laxative China encourage the movement off, um, store, which is, you know, kind of harder and stock on on because of the increased Paris talis is you get the abdominal pain associated with it and then maintenance therapy. So what, you do it even if he s it's similar to initial therapy. It's just the first movie called Would Give you would you would not escalate the dose. You'd use a constant to us until the symptoms have resolved. Okay, Um um, you give it if there are no signs of people impaction. Okay, so no, all for a soiling, no abdominal mass. Oh, once you've noticed, noticed that off the patient symptom result. You would remain on that dose. And then once you are your healthy bowel habits are restored. You would gradually reduce the dose of it slowly. We know, but he would not stop. Um, the taking the last If, okay, you need to carry on. But it's slowly reduce the doors until it's resolved. And this can take several weeks and other measures just to note, like conservative measures, encourage them to eat more high fiber on. Also encourage them to drink fluid. Okay. And also things like I learned in my pediatric placement was power training habits. So make sure they go at a regular time every day and you can encourage their behavior so that they keep doing it is that give them some form of rewards, something you know, good style, things like that. And also keep a bowel diary just to make sense of things. And this is based on nice guidelines. All right, next question. So I mentioned loose offensive student. So that was when they came into the, um the pediatric assessment you've earlier, and that is a sign off pique. A limp action is what I was going for. Um, so that's why um um yeah, What's more, Dick would be if you know, I don't We can't order it. Moving Colon, you'd give it a stimulant, but you will try a list. England, because movie called also has, like the osmotic laxative properties. Also, it just trying to soft and Mr But if that's not working, you try to, you know, kind of encourage you to be pushed out. Yeah, this question is a bit of a tricky one. Yes, as Inishmaan Shin the It's a bit different for pediatric management and about management. All right, let's stop it there. So most of you have said or two some abdomen. Okay. Uh, okay, I can I can see why you would say that, but when I put as the answer is abdominal X ray. So this patient is from, uh, from presenting with billions. Woman thing on science. Off. You know, some form of cookies about bowel obstruction because he's abdominally distended, and that's when the stress is well on has not yet fast meconium. So when you think of not dead prostate volume, things that could be especially in the newborn period would be things like Oh, it could be her strong could be recording Milosz. The different types of atresia on does also empty rectum, which is what you usually find in both Hirschprung's and meconium ileus, which is why I put down abdominal X ray because this patient is presenting with science off for him. I liest. Sorry off bowel obstruction. You would want to confirm that using an abdominal X ray and it's usually much better confirming than the artist and abdomen be outside and if it is a good choice as well. But it's the thing is you are to be especially trained for using it as well, so it may not be commonly available on, but the same time you have to kind of have an idea of where the pathology would be. Um, otherwise it will be. It will take a very long time. Detected on Doberman, X rays are quite rapid as well, and they are very, very good for looking at all obstruction on. Do you will necessary director boxes or sweat tests or Erector biopsies to confirm for her front disease and sweat test is to look for cystic fibrosis, which is associated with anemia. Is you would not do those first time. You would confirm the small bowel obstruction. Then, given the other signs on the presentation, you would go in either direction. And you wouldn't typically do serum bilirubin because I haven't indicated anything. Like I'm drawn this. Okay, I know this. This can be a bit of Ah, tricky question. Um, Okay. So, uh, next question, um, can someone on to the pool, please? You got two more questions and then Yeah. Okay. Yeah, a snitch. Mention you can't really differentiate because you can get empty. Uh um indirect. Um, um you can get feeling the past me corneum and things like that. Which is why I've purposely left in wigs, but given the signs of government Sorry. Abdominal obstruction, intestinal obstruction, you would want to do an abdominal X ray. Okay. I hope that is clear. Um, can't do sweat test in first two weeks. Okay. I'm not really aware of sweat test, to be honest, um, I think in her strong, you would You can get empty rectum as well, But after you do appear, there may be explosive stool after that. Um, from what, uh, phone. Yeah. Okay. Yes, because they don't produce it. Okay. I wasn't really aware of that, I guess. Yeah, I think you can do Ah, screaming for cystic fibrosis. anything. All right, So I'll give you guys 10 more seconds, and then we'll move on. Were it cool? Okay, let me end it there. So most of you went for C, which is the correct answer. And I did see someone put that it's politics. Tennis is so yeah, this patient is presenting with prior extremists. Is And there's many, many indications here. So, severe vomiting, this one, uh, patient's meal. Um um And this is Billy a non bilious vomiting as well. So it's yellow. Orange in color. No green, um, and a palpable mosque in the epigastrium. Can you guys tell me? Not like another word for that. Another way. You can. Um, someone asked me. Could it yet? Olive Man suspect that Could it have been pyloric stenosis is, uh Do you mean the previous one? Is that what you're asking? Um, the previous one can't be part of sense if that is because you you get non bilious for meeting. The previous patient had billions for meeting, and i'll this test that earlier until you can have been Okay. So this patient is presenting with classic science off oxygen. It's it's and you can see there's a depressed want to know which indicates that this patient's dehydrated, Okay? And he has a metabolic alkalosis, which is one of the classical signs would see. So protect our vomiting, metabolic alkalosis signs of dehydration. And for another risk factor is that if you renew our first in first, your first urine off appearance and what you want to do is because of this, um, electrolyte on. And normally you get you would want to give them but fluids and potassium because you get a classic hyperkalemic hypochloremia. What about it? Are closest to get low? Um, Dassin loose. Sorry. Yeah, no potassium local, right? And, um, Hypia a church. Okay. And because of that, you need to give the potassium supplementation and saline, which has go right on also to rehydrate the patient. Okay. All right. So when it comes to pediatric omitting, um, this to to kind of categories, this bilious just typically, you know, green in color because of the presence of bio. So this is usually distal, um, or just away from the junction of the duodenum for the Botox case of the pathology is after the Botox, um, at the you know that in the second part of the blood in him anywhere after that, because you get the mixture of bile and that causes, you know, go back on. Then you get the green form, it least some of the causes which are going to briefly. And then you have non bilious, which is usually, you know, castrate contents can be the food you ate. It could be orange, yellow, but typically one most definitely won't be green. And this is usually a proximal or before the disjunction with the biologics. Okay, and the the important one to know of is our external is is non bilious because it's it's quite a margin c situation, Um, and yeah, and other things. Like God, as I talked about earlier on an annual a pancreas. Very important. Know Honestly, it's zumba kind of pancreatic tissue growth, which causes progression off the war dinner at certain point, which causes the belly. So it's above the, um, the water on also called milk protein intolerance as well. So it's all about pyloric. So are chosen to focus on fire extra no sense in terms of non bilious vomiting. On this is what's commonly due to hypertrophy of the pylorus so thickening of the muscle, causing off flow, obstruction, gastric off the obstruction. And usually the classic period is in the first, usually first two weeks to first month and risk factors. A Z I mentioned being male first born child and a positive family history. Okay, the classic features are projectile non bilious vomiting okay, particularly after feet. So that's very important as well. Um, so usually on an empty stomach, they wouldn't really protect our limiting. But after patients eaten, they have it. Almost immediately afterwards, they have because they can't the food can pass through because of the obstruction. And you also get this olive shape mass in the gastric area, apparent during feeding and after feeding as well. Okay. And the important thing is the these patients are usually very dehydrated. So, you know, some conform to now in, you know, in new needs, because the suitors I'm close to that's an important time to look out for. I know everyone's aware of about bulging front enough, but it also good to look at some confronted ounces well, and it's important. Also know that in in your in the fontanel is slightly sunken so it's not completely flat, slightly sunken, but that's natural. But if it's a very sunken, that would indicate one possibility could be severe dehydration and also constipation as well. Because you're not things really passing through that thick and bile or is, Uh, and then the diagnosis you can you can do Ah VBG, And you can also do some urine electrolyte, and you'd see this electrolyte abnormality. So if I briefly go through what exactly happens in terms of the physiology, So you get low chloride and low potassium and the race pH, presumably because off the low hydrogen ion concentration, if the if I break it down one by one. So see your patient is in a moment in a lot, and it's project us. It's a large amount, and basically that that that's the gastric contents. Okay, in, you know, gastric content, you have your chloride on your hydrogen ion is well, so you are injecting them from your body, and so I'm getting absorbed into the blood. As a result, it would have looked chloride, and you also have a low hygiene. I guess you could have a metabolic alkalosis because you have less hydrogen eyes and as a result of peach will be higher. Hence the closest on hyperkalemic. Because flu correct. Then how do you get the hypokalemia? So that's when because of your dehydrations your your blood flu. Blood boiling decreases if you're not absorbing enough water because not really passing to pass the stomach. Isn't it on because of that? You get kidney Serena hyperperfusion your blood flow doing kidneys decrease because it's less fluid volume, um, in the vasculature. And that, in turn, via the various methods, causes the induction of the on activation off the railing, androgens and aldosterone system, and the end productive. That system is to produce a hostile on what Aldosterone does is in the kidneys. It increases sodium reabsorption. Okay, and with sodium water follows and you try to get a sodium to reabsorb into the blood from the kidney to bills. And with that water comes and you're trying to expand the intervascular volume to get your blood volume up so you can maintain things like BP. Okay, and what happens is when you taking sodium, you're also excreting potassium because that's linked. You excrete potassium or blood protesting decreases, and you get hypokalemia and at the same time, without one other effect of our lost run is it increases each plus secretion. You're losing it from the blood is world which further aggravates the alkalosis, or it can be a cause of the apple juice is okay. I hope that made sense. Um, I'm I'm happy to repeat that later on. If anyone wants. And the classic, the the definitive diagnosis is using an ultrasound scan. Okay, so you would see that taken pylorus on. Do you see that? Delayed passage of gastric contents. Okay. On the treatment. As I mentioned, it's fluids. You know, typically saline replace the chloride on you. Give it extra alongside with that and put up. That's include ride. Um, you get, um, to supplement the hypokalemia. And then finally, the definitely management. Is this something called pyloromyotomy around? Stepfather, remind me which is basically you go in and he split the pyloric muscle on, and it relieves the obstruction and increases the space for gastric contents to empty. Okay. But important to know is when I would say is protect our vomiting of epigastric mass signs of dehydration, constipation and the hyperkalemic hypo or so hyperkalemic hypochloremia metabolic calculus is, you would most likely think part of it's nurses, and you would do an artist and scan to look for that thick and pylorus. Okay, all right. Next up, Billy. A swarm eating. So this is a very exhausting slide. I'll try to be as brief as possible, but I would recommend you guys really don't own time and also do some further reading for interested. But it's important. Know the different varieties, of course, is and it's usually you can differentiate them, according to um, the presentation most commonly on and also different associations as well. So if you take medication borderless, basically, if I'm if I briefly go through what it is, is you get malposition ing off the, um, usually the small bowel, particularly during fetal development. Because of these fibrotic band's called Glad Bands. Basically, and because if your this different position of your small bowel, typically you get, it's more likely for it to get twisted on itself. And when you twist me about Kristen itself is is a marvelous so the medication. If patient wanted man rotation, they have increased chance of presenting with the volvulus, which is when that Bauer twists on itself, and that can compromise. It's blood flow. Okay? Particularly the superior mesenteric artery on that can lead to obstruction because of the twisting. And it also can be the infection if the blood flow is compromised. And you did not getting enough blood in my defense, crosis. Okay, which is why it is very important to detect this early on. And this is usually present in around the first week. Okay, it's quite early on. Um, because because of the marrow patient, okay, and the diagnosis would be classically done using an upper GI I contrast So you'd see that corkscrew a spider ship appearance on because of, you know, that twisting of the bowel okay. And the treatment would be last procedure. So I'm not very particularly about the procedure. From what I understand is they go and cut these fibrotic band's called lads bands, which are causing the small position off the bowel. They kind of correct the position so that this is less likely to happen. Okay, then you're doing it on atresia. Okay? This is basically when the the duodenum is informed properly, so it's a similar to like it's a federal atresia. If you get like a stump s o a C, you go, you know, from the stomach to the the or dinner there's the duodenum is informed properly. So it's It's like a end end of the expect on the stump, and then you have after the stump the rest of the GI tract. But there's no connection between the first part of the door dinner or sorry wherever the tree Jerry's. But the stump is to the other part. So there's no flow off any Patrick. Any contents through that. Okay, on this is very much associated with down syndrome, okay? And because of this, and it's quite high up, so it's in the door dinner, right? So it's usually high up, which means, um, usually after their first feet, Um, and things like that they can present, um, after, but okay. And you would do a double bubbles. Sorry, an ultrasound or an abdominal X ray and in a bone extremity this double bubble sign because I got the two different parts. You have the end stamp area and the area after that, which is the rest of the GI tract. So the rest of the reward in. Um um, and you're getting a million mental Onda treatment would be something called the door. They know. Do they know Stoney Mouthful? But basically, it's just to open up that stump and connected to the adjacent part. Okay, so the contents can float, then meconium ileus, which I just went through off. This is usually associated with cystic fibro. So secret cystic fibrosis to get taken, mucus started thinking, um, a cornea, um, and usually patient present with things like a failure to pass in Coney. Um, in the 1st 24 to 40 I was, um And, um, this is basically because, um, you get, um, Mom, I think on tents stuck in the small bowel typically typically in the illium on. Because of that, I get a ball obstruction, Okay. And it's usually that's why I said a common X ray would be the modality to do it. And the sweat test to look for, um, race chloride trained a kid which will confirm cystic fibrosis. And the treatment would be I can either do decompression or you would have to resect that part of the bowel. Okay. And then finally, sort of the last two which is necrotizing enterocolitis. I mean, the causes aren't really very much understood, but basically there's it doesn't insult which causes injury or information for the bowel, and this leads to If it's not detected early, it leads to necrosis, and if it's even across, it can lead to perforations. You can get peritonitis is well, it's important to protect these very promptly and their risk factors like prematurity. Okay, so and usually present second week off the butt on the mechanism of what actually causes this inflammation and things that is not very understood. And there are different kind of hypotheses as well. But the classic modality would be abdominal X ray to look for things like dilated bowel loops or pneumatosis intestine Lantus, which is basically a fancy way of saying this, um, AARP. But in the in the bottle of war, uh, not outside or inside ball, but within the bowel wall itself. Okay, And that means the kid that it's close to perforating and the treatment would be supportive. It gives things like fluid on mentioned obs if there's no signs of peritonitis or perforation. But if there is signs of perforation, you would definitely to go in and reset. Reset that. Follow the patient Very well. Be very unwell. And then I cannot get very much better if you need to go in there and resect okay and they finally heart's strong disease. Not very common, but this is because of, um, an absence off these ganglionic cells in the intestinal war called or backs. And my Sinus plaques is basically these are. These are. Then there are cells responsible for the contraction relaxation of smooth muscle, which caused the restlessness talker on these are often look at the most common locations are the distance sigmoid colon and the rectum. So usually these are the locations, which is why you classically do a rectal biopsy to confirm, and you would see the absence of these ganglionic cells okay, which would be the gold standard. But as I mentioned, it's It's associated with downs as well. On patient would be represented. Delay in passing your cornea or they can be fail as well, but usually it can be delayed to pass my colon so they pass it. It takes a bit longer on in order. Children, it could be construed station or a bone or distention as I mentioned earlier, and you could do abdominal X ray to look for any signs of all obstruction because it can call all of structure the director above is a quote standard. And then finally, the treatment would be ball irrigations or shock, and then surgical resection off the affected area because there's no no way to get that power to stop working against. It's basically doesn't doesn't have any place Dallas is going on. So you just remove that part of the bomb, okay? Final question, guys. Right. So can someone on stuff. Uh, thank you. All right, then. The interest of time. I will end the pole in about 10 seconds. You want to keep you guys here for longer than you need to? Um, all right, I understand it now. So this is, um so most of you for B, which is, in fact, the correct answer. So, um, the so this patient is presenting with tremendous on 13 hours ago, Donald distention and the percussion, or um, so it's very important, because in the 1st 20 hours, if you see jaundice, that is most likely or almost certainly pathological. Okay, there's some underlying process. Could be some hemolytic crisis or could be some underlying condition, but regardless, it's a pathological. So what you need to do is do a serum bilirubin? Well, ideally, within two hours. But urgently is the first step. So, um yeah, So I put in a dog out the cash in order in for kind of thing, so that I'm going with that is ah, splenomegaly. And I'm looking at things like the six PD deficiency is what I was going for, Which is why I put Measure Gees. Expedia's the answer, So you wouldn't you wouldn't start for the therapy. You know, you would have to confirm that is a Hyperbilirubin in here. Using syrah blooming and transcutaneous is not ideal way would have to check, um, cereal. And you were doing ultrasound abdomen. Um, because that will, if that's if you suspect things like ability, atresia and things like that, which I don't really present this early on. So this is a cheat sheet on your little John. They said, um, it what I would like to focus on is, um, the first one, which is in the 1st 24 hours. It's almost pathological. Okay, so you need to do a serum bilirubin urgently within two hours, ideally, on some of the various different causes Humanity, disease. So if they have a B o recent compatibility off had conditions like head three spirits I to assist, she's experience efficiency. Regardless of the cars, you have to do a serum bilirubin, Okay. And then the from two days to two weeks, this usually physiological okay on it's going to, you know, best feeding jaundice is well, and what you would most like a C is elevated. Unconscionable, Ruben. So that's that's, uh, that's most likely due to increase red blood cell breakdown. Okay, um and this is usually because in newborns, they have a very large red blood cell number on day. Usually very mature is well, so even though there's many of them, they break down here easily on they often have a short half life and high turnover. So they break down, and then your, um, your bilirubin levels increase as a result. And another thing is, um um, in this form, two days to 14 days, then liver is gonna be mature as well. Okay, so they won't be there, won't have the Contrave eating capacity which is why you get the race uncomplicated. Bilirubin. Okay, so your liver is not able to can't keep up with it, but it's still developing on as it is all your the elevator. I want to be a bilirubin. Um, and after 14 days, one important thing, I want you guys to take it from the slightest. If it's after 14 days and there's raised conjugated Billy Rubin, you have two highly suspect biliary atresia, okay? And this is very important because it requires urgent surgical intervention because it can lead to things like acute liver failure. Okay, so patient may need a liver transplants on do the surgery if it's not detected early enough. Okay, um, it will detect it promptly. If you see race conjugated bilirubin after two weeks, typically you need to do, Ah, a bilirubin again, check. And if it's congregated, you on. You'd have other clinical features about okay, but obviously there are the test you can do. Comes tends to look for any autoimmune hemolytic anemia. Um, tired function testing for hypothyroidism on other lefties. Watch to look for any other cause of John this on, um, using these, um as well. And then congenital infections like cytomegalovirus on box of plasmosis can also be associated with jaundice after for two weeks. Okay, so I won't go through the slide. This if you guys attended Are John this session? Is it just from that? And this is basically just kind of a summary of what I've said. And some additional stuff is off big later on breast feeding, uh, breastfeeding. John, this is Well, uh, but I just briefly go over the treatment, so you'd have to make sure that there's no kind of underlying section because that can cause, um, wrist Ruben as well. And also you do you usually get forgetting for the therapy and things like that that would be dependent on the craft. Uh, if you guys are just maybe having you're just taking a look, you don't really happen in my eyes, any any values or anything, but good to have an idea of what? What racial. You get treatment. Um, and you for therapy would be, uh, idea for if it's above threshold before the therapy on, there are other options, like exchange, transfusion. And now that I've come to this light, another important thing, I want to mention is, um if you have, um, fiber Ruben, especially in units with an immature blood being barrier, this could possibly mean that the bilirubin can possibly been very easily and get collected up in the brain, which can lead to, um, connector ist. And this is very, very much of a risk and something to be aware of because it can lead to deafness. Um, because of damage to the copy and of. And it can be, ah, Europe, toxic as well Get cause it's acceptable positives. Well, so it's important to recognize John this in kids just because of a metal liver on. But you know, they can't conjugated bilirubin. Okay, so the bilirubin stays in the blood and as a result that it's more likely to go into the brain and cause these complications that I mentioned. So therefore it's important recognized on this and also treated promptly and accordingly. Okay, and these are some of the causes of inherited ones. Okay. And then finally, just a bit on between treasure. This is from the jaundice. Um, um, electric deals work. There's just, um, congenital absence off part all of the bile ducts, which is why you get the kind of post hepatic picture off braced conjugated bilirubin on it. It's undetected. It can lead to liver failure in case it's important. Detected early on on other features would be pale stools, dark urine. Done this hepatosplenomegaly. But there's no risk of, um, can it just? And abdominal ultrasound would be the ideal investigation to confirm on. Then. These are the kinds of treatment that you give on Vitamin K should be given to reduce humor attic disease of the newborn, particularly because newborns have low levels of vitamin case. You to be aware of that. Okay, Brilliant. That is it from you guys. Um, unless you have any, uh, questions. Um, right. This one is the bilirubin done straight away to determine management.