Download Welcome Applicants!! - LSU School of Medicine

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Step 1: ABCs!! Assess hemodynamic
status of the patient
› Orthostatic changes- best indicator of
significant blood loss
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Step 2: Establish severity of bleeding
› Coffee ground emesis, melena: lower rate of
bleeding
› Bright red blood: ?higher rate of bleeding
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Step 3: Determine the location of the
bleeding
› UGI: bleeding above the ligament of Treitz
 Hematemesis
› LGI: bleeding distal to the ligament of Treitz
 Bloody diarrhea
 Bright red blood mixed with or coating stool
› Hematochezia, melena, or occult blood loss
can be due to both UGI or LGI bleeds
 Passing NGT can determine if the blood is
originating from the UGI tract or LGI tract
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Simulates bright red
blood
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Simulates melena
› Bismuth or iron
› Food coloring
› Colored gelatin or
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children’s drinks
Red candy
Beets
Tomato skins
Antibiotic syrups
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preparations
Spinach
Blueberries
Grapes
Licorice
Cytoprotective
factors:
1. Mucous layer
2. Local bicarb
secretion
3. Mucosal blood
flow
Cytotoxic factors:
1. Acid
2. Pepsin
3. Medications
4. Bile acids
5. Infection with
H.Pylori
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Epigastric abdominal pain
Recurrent vomiting (at least 3x/mo)
Symptoms associated with eating
(anorexia/ wt loss)
Pain awakening the child at night
Heartburn
Oral regurgitation
Chronic nausea
Excessive belching/ hiccuping
FHx of PUD, dyspepsia, or IBS
Symptoms?
 Dietary history?
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› Specific foods that worsen pain?
Medications?
 Alcohol or tobacco use?
 Doses of acid-suppressive meds?
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Height, weight and BMI PLOT!
HEENT
› Funduscopic exam
› OP: aphthous ulcers Crohn’s dz, dental enamel
erosion GER, Eating d/o
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Lungs
› Wheezing GER
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Abdomen
› Splenomegaly portal HTN
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Rectum
› Perianal disease Crohn’s dz
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Extremities
› Clubbing Crohn’s dz, Russell sign Eating d/o
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Screening labs
› CBC with diff
› ESR
› LFTs
› Electrolytes
› Stool for O&P
› UA
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Endoscopy
› Indications
 Evidence of GI
bleeding
 Abnormality on UGI
 Odynophagia
 Refusal to eat
 Persistant
unexplained vomiting
 Lack of response to
medications
Gram negative
bacillus
 Transmission fecal-oral, gastric-oral, or oraloral
 *Organism associated with a significant
proportion of duodenal ulcers & chronic
active gastritis
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› To a lesser extent, gastric ulcers
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Also linked to the development of gastric
adenocarcinoma and lymphoma
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50 % of the world’s population is infected
› Most are asymptomatic
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Infection most common in developing
countries
› Incidence 3-10% in developing countries
› Incidence 0.5% in industrialized countries
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Asian Americans, African Americans and
Hispanic individuals living in North America
have a prevalence of infection similar to
that of a developing country
› Ethnic or genetic predisposition?
Poor socioeconomic status
 Family overcrowding
 Child care attendance
 Poor hygiene
 Living with an infected family member
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The ideal test does not yet exist!
› Endoscopy with biopsies from the prepyloric
antrum= gold standard
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Histologic identification
Culture
Immunologic detection of H.Pylori urease
PCR
› Urease breath test
› Anti-H. Pylori IgG
› Stool antigen testing
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Stool antigen testing
› Sensitivity and specificity> 98%
› Sample easy to obtain
› Less expensive than the urease breath test
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The AAP says…don’t test for it if you are
not going to treat it!!
› Active peptic ulcer disease
› History of ulcers
› MALT lymphoma or gastric cancer
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Goals
› Eradicate the organism
› Heal the ulcer
› Prevent recurrence of infection and the
emergence of resistant organisms
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Two antimicrobials + PPI
› First line: clarithromycin+ Amoxicillin OR
metronidazole+ PPI
› Alternative (age>8): tetracycline+
metronidazole+ bismuth subsalicylate+ H2
blocker
Length of treatment: 14days
 Cure rates 75-90%
 To check for eradication,
wait 6 weeks-3 months after
the completion of therapy
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› Urease breath test
› Stool antigen test
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A 12 yo boy who has a h/o recurrent abdominal pain
presents to your office for an annual health supervision
visit. The boy complains of periumbilical pain, unrelated to
meals, occuring twice a month and lasting 15 minutes. PE
is normal. FOBT is negative. His father, who is a physician,
asks if the boy should undergo testing for H. Pylori. Of the
following, a TRUE statement about H. Pylori infection is:
› A. All children who have positive H. Pylori serologies should
undergo endoscopy
› B. Antibiotic therapy for H. Pylori is most effective when
combined with a PPI
› C. H. Pylori is difficult to detect on gastric histology without
special immunofluorescent staining
› D. H. Pylori infection is less prevalent in children from the
developing world
› E. H. Pylori organisms rarely develop antibiotic resistance
Noon Conference:
Pseudoasthma, Dr. Pepiak