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Pediatrics(2)

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-Abdominal cramps

-Peritonism urgency, fever and diarrhea with blood and mucus in the stool

-meningismus and convulsions may occur

-Exclude intussusceptions which includes:

pain or abdominal tenderness

bile-stained vomitus

red currant jelly-like mucus Complications

- dehydration - Convulsions - Shock

- Toxic megacolon - Acidosis

- Rectal prolapse - Renal failure

- Haemolytic uraemic syndrome Investigations

- Stool culture to confirm diagnosis of Shigellosis

- Stool microscopy reveals many polymorphs and blood - Immediate microscopy of warm stool to diagnose amoebic dysentery

Non-pharmacological

Ensure adequate nutrition and hydration Pharmacological

Fluid and electrolyte replacement (see Acute diarrhea)

ciprofloxacin, oral, 15 mg/kg/dose 12 hourly for 3 days Or

ceftriaxone, IV, 20–80 mg/kg as a single daily dose for 5 days (If hospitalised or if unable to take oral antimicrobial agents)

Metronidazole, oral, 15 mg/kg/dose 8 hourly for 7 – 10 days (If amoebic dysentery, seen on stool microscopy) Recommendation

- Refer patient to the specialist, if dysentery with complications, e.g. persistent shock, haemolytic uraemic syndrome and toxic megacolon

2.4. Constipation

Definition: Constipation is an acute or chronic condition in which bowel movement occurs less often than usual or consist of hard, dry stool that are painful or difficult to pass.

Causes

-Lack of exercise

-Certain medicines

-Metabolic, endocrine, neurogenic and lower bowel abnormalities

-Psychogenic disorders

-Chronic use of enemas

-Not drinking enough water

-diet that does not include an adequate amount of fiberrich foods

-Anal fissure (a tear or crack in the lining of the anus)

-Chronic kidney failure

-Hischprung disease

-Colon or rectal cancer

-depression

-Hypercalcemia (abnormally high levels of calcium in the blood)

-Hypothyroidism (underactive thyroid gland)

-Illness requiring complete bed rest

-Irritable Bowel Syndrome

-Stress

Signs and Symptoms

-Symptomatic bowel impaction

-Blood in the stool

-Changes in bowel patterns

-Abdominal pain, distension Complications

-Bowel obstruction

-Chronic constipation

-Hemorrhoids

-Hernia

-Spastic colitis

-Laxative dependency Investigations

-Abdominal X-ray

-Barium meal - reveals blockage inside the intestine in particular

cases

-Laboratory analysis of blood and stool samples for internal

bleeding

- Sigmoidoscopy (examination of the sigmoid area of the colon

with a flexible tube equipped with a magnifying lens), rarely

indicated. Management

Principles

• Treatment involves 3 steps: → Initial clearance of stool

Prevent reaccumulation of hardened retained stool (diet change with additional natural fibre from fruit, vegetables and bran)

Retraining of the gut to achieve regular toilet habits Management is long-term, and requires the active involvement of the parents

Pharmacological

• Enema twice daily for 3 days for faecal clearance if faecal loading

• Lactulose (Duphalac) for 1 week but if 3 stools are passed/day stop it

• Bowel re-training

• In refractory cases:

Lactulose, oral, twice daily

< 1 year 2.5 mL

1–6 years 5 mL

> 6 years 10 mL

• determine and treat the underlying cause Recommendations

-Refer patient to the specialist, if an organic cause e.g. constipation from birth in a breast-fed baby is suspected

-If faecal loading continues, maintenance therapy should be continued for months to years

2.5. Constipation and Encopresis

Definition: Constipation is the delay or difficulty in passage of stools during defaecation that has been present for 2 weeks or longer. Stoolis usually hard.

Encopresis also known as faecal soiling is the involuntary leakageof small amounts of soft or watery stool in a child with chronic constipation.

Causes

-Psycho social precipitants

-Functional (incorrect diet, lack of exercise, poor fluid intake)

-Metabolic or Neurological Abnormalities

-Endocrine abnormalities (Hypothyroidism)

-Chronic use of laxatives

-Obstructive lesions (acquired and congenital defects) Signs and Symptoms

-Abdominal pain often associated with encopresis

-Infrequent defecation

-Pain or strain on defecation

-Hard stool

-Feeling of incomplete evacuation (Tenesmus) Chapiter 2: Gastro-intestinal Disorders Complications

-Anal fissure, ulcers and prolapse

-Over flow incontinence (Encopresis)

-Stasis syndrome with bacterial overgrowth Investigations

-Barium Enema

-Abdominal x-ray in suspected obstructive lesions

-Thyroid function tests when indicated

-Stool analysis

-Investigate other functional lesions

Management

Non-pharmacological management

Rehydrate to increase fecal bulk and soften stool

Education of patients/parents on diet, exercise, etc.

diet change with additional natural fibre from fruit and vegetables

Treatment involves 3 steps:

Initial clearance of stools

Prevent re-accumulation of hardened retained stool

Retraining of the gut to achieve regular toilet habits Pharmacological management

• Glycerin Suppositories 1 suppo/dose according to occurrence of symptoms

Or

• Lactulose syrup <1 yr: 5-10ml/24 hr PO Od; 1-6 Yrs 10-20 ml/24 hours PO Od; 7-14 yrs 20-50ml/24 hrs PO Od

Or

• Bisacodyl (Dulcolax) 0.3mg/kg/day PO Od maximum dose 30mg/24 hours

Recommendations

- Refer to tertiary health facility in cases of inadequate response to therapy for further investigation

- If continued constipation therapy should be continued for months to years

2.6. Upper Gastro-Intestinal Tract Bleeding

Definition: Upper gastrointestinal bleeding (arising proximal to the ligament of Treits in the distal

duodenum) commonly manifested by hematemesis and/or melena.

Management

Main objectives

Relieve or treat hemorrhagic shock if present

Stop bleeding

Treat the causative agent

Emergency treatment

CAB (include Blood transfusion if necessary

Assess to causative agent and treat according if need of endoscopy then refer to centre where it’s available

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