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ACID RELATED DISORDERS ADMITTING CONFERENCE AND TOPIC DISCUSSION

MENG MADDUMBA

THE PT.GENERAL DATA

This is the case of DZG, 13/F, born on May 23 2001 BP: LMC, San Fernando City, La Union, POR: Dontogan, Baguio City, Student Roman Catholic Filipino

HISTORYOF PRESENT ILLNESS

Admission

7 DAYS PTA(+) Epigastric pain

• after skipping meals, burning in nature • rated 5/10, localized, non-radiating• aggravated by an empty stomach, minimally relieved by food intake

(+) Dysuria and Increase in frequency of voiding(-) associated: N/V, Anorexia, diarrhea, febrile episodes, chest pains or DOB.


Admission

7 DAYS PTAConsult at a private clinic

Dx: ARD + UTIMeds Given:

• CEFIXIME BID (dosage unrecalled)• OMEPRAZOLE 20mg/tab OD


Admission

7 DAYS PTA(+) Epigastric pain(+) Dysuria(+) Consult

Dx: ARD + UTI

(-) associated S/Sx

6 DAYS – 2 DAYS PTA

(+) Dysuria and frequency of voiding decreasing up to two days PTA(+) Epigastric pain, same characteristics

• Decreasing pain rating from 6 to 2-3/10 • Decreasing in frequency from 3 to 1 episodes

(-) associated: N/V, Anorexia, diarrhea, febrile episodes, chest pains or DOB.


Admission


Dx: ARD + UTI

(-) associated S/Sx


(+) Epigastric pain(+) Dysuria(+) Consult

(-) associated S/Sx

Medications continued


Admission


Dx: ARD + UTI

(-) associated S/Sx


(+) Epigastric pain(+) Dysuria(+) Consult

(-) associated S/Sx


1 DAY PTA

(+) continuous epigastric pain after missing a meal.• Burning in nature, Rated 6-7/10,• Radiating to anterior chest area; left• Aggravated by intense training and minimally relieved by rest and

medications.

(+) Associated DOB and weakness(-) associated: N/V, Anorexia, diarrhea, febrile episodes, .


Admission


Dx: ARD + UTI

(-) associated S/Sx


(+) Epigastric pain

(-) associated S/Sx


(+) AssociatedDOB and weakness

1 DAY PTA FEW HRS PTA(+) Epigastric Pain

• Same characteristics• Rated 8-9/10

HISTORYFEEDING HISTORY

At present, the diet is slightly below the patient’s daily calorie requirement

Based on a 2,500 kcal RENI of 13 year old female adolescent.

HISTORYGROWTH AND DEVELOPMENTAL

Weight and Height:• Weight= 46 kg • Height= 1.57m• BMI: 18.66 = Normal

Physical growth:No reported delays in growthand Development.No observed impairments


Psychological and Cognitive Development (HEADS)HOME

good interaction with family members

with occasional fights with siblings.

Still respectful of authorities and non-rebellious.

More concerned about his looks, clothes and body image.


Psychological and Cognitive Development (HEADS)EDUCATION

More influenced by her peer groups in school though not rebellious towards authority.

Verbalized having hard time in more challenging academic requirement.

At present the patient’s developmental milestone is at par for age.


Psychological and Cognitive Development (HEADS)ACTIVITIES

Physically Active Member of the National

Wushu Team Competes at International

competitionDRUGS

No history of use or plans of using

SUICIDE No grave problems that

would warrant suicidal ideologies

HISTORYIMMUNIZATION STATUS

Claims to have complete immunization status

PAST MEDICAL

2001BETHANY HOSPITAL

LA UNION- Innocent Heart

Murmurs- Anemia

D/C WELL

2004SLU-HSH

- Pneumonia- Benign Febrile

Convulsions

D/C WELL

2007SLU-HSH

- Pneumonia

D/C WELL

Childhood illness: measles, mumps, UTI, and occasional cough and colds Allergies: No known allergies Medications: Omeprazole 20mg/tab OD

HISTORYFAMILY DISEASES

Diseases in the Family:Both parents are presently well. Patient has a family history of HPN, Diabetes Mellitus, Arthritis, Colon cancer, CVD, and CAD.

No reported history of other heredofamilial diseases and other communicable diseases. No other persons residing in their home was noted

to have illness.

REVIEWOF SYSTEMS

General: (-) weight loss, (-) fever, (-) chills, (-) sweats, (-) irritability, (+) poor oral intake, (+) weakness

Head and Neck: (-) trauma, (-) lesions, (-) swelling, (+) headache, (-) pain, (-) stiffness

Respiratory: (-) productive cough, (-) pain, (+) DOB, (-) hemoptysis, (-) cyanosis, (-) TB/PPKI

Cardiovascular: (-) edema, (-) cyanosis, (-) palpitation, (+) chest pains (-) murmur, (-) known CHD

GIT: (+) good oral intake; (-) anorexia, (+) abdominal pain, (-) vomiting, (-) nausea, (-) diarrhea, (-) constipation, (-) flatulence, (-) melena, (-) hematochezia, (-) change in bowel habits, (-) hernia, (+) use of laxatives or antacids, (-) jaundice, (-) hepatitisGUT: (-) dysuria, (-) frequency

PHYS.EXPERTINENT FINDINGS

General Survey: Awake, conscious, coherent, afebrile, not in cardiorespiratory distress.

Vital Signs and Anthropometric MeasurementsCR= 98 bpm Weight= 46 kg RR= 24 cpm Height= 1.57mT= 36.6 C per axilla BMI: 18.66 = Normal

No signs of Dehydration

Chest/Lungs and Heart:SCWE (-)retractions, (-) lagging , clear breath sounds, adynamic precordium,(-) thrills, normal rate, regular rhythm, PMI located on the 5th LICS MCL, (-) murmur

PHYS.EXPERTINENT FINDINGS

Abdomen: Flat, non-distended(+) normoactive bowel sounds (+) tympanitic on all four quadrants Soft (+) tenderness on epigastric area upon deep palpation, (-) masses palpated (-) organomegaly

IMPRESSIONDIAGNOSIS OF THE PT

HISTORY (S)

Previous Dx:• Acid related

disorder• Under gastric

medications

History of:(+) Epig Pain (8-9/10)• Burning in nature• Radiating to chest• Precipitated by an

empty stomach• Aggravated by activity• Relieved by food

intake and medication(-) Febrile episode(-) N/V(-) Diarrhea

PHYS.EX (O)

Flat, non-distended Normoactive bowel sounds (-) Visible Mass and Pulsation (-) Palpated Mass Direct tenderness on

Epigastric area (-) pathologic gallbladder/

appendyceal signs

IMPRESSIONDIAGNOSIS OF THE PT

Initial Impression: ARD – Gastroesophageal Reflux Disease (GERD)

DAY10

PLANDIAGNOSTICS

URINALYSISUnremarkable Results

PLANDIAGNOSTICS

CBCPNormochromic, normocytic RBCsNormal: Hgb, Hct, Platelets, WBC (neutrophilic predominance)

*Essentially normal

PLANDIAGNOSTICS

Hook to D5NM 1li x 21 gtts/min computed at M%

Omeprazole 20 mg every 12 hoursAl + Mg Hydroxide (Maalox) 15 mL

every after meals

DISCUSSION

“'Acid-related disorders' is a term used to describe a whole range of conditions, where acid is entirely responsible for the problems. Careful evaluation of the patient's symptoms is required to establish the basis for the gastric problem”

Acid-related disorders: what are they? By: Colin-Jones DG

“Five Components of the Evaluation of Children with Abdominal Pain

1. History2. Physical Examination3. Laboratory Tests4. Imaging Studies5. Empiric Interventions”

Chronic Abdominal Pain in Childhood: Diagnosis and ManagementALAN M. LAKE, M.D., Johns Hopkins University School of Medicine, Baltimore, MarylandAm Fam Physician.

More than one third of children complain of abdominal pain lasting two weeks or longer. The diagnostic approach to abdominal pain in children relies heavily on the history provided by the parent and child to direct a step-wise approach to investigation.

Chronic Abdominal Pain in Childhood: Diagnosis and ManagementALAN M. LAKE, M.D., Johns Hopkins University School of Medicine, Baltimore, MarylandAm Fam Physician.

PHYSIOREVIEW

Two primary functional zones:A) oxyntic gland area (80% of the organ)B) pyloric gland area (remaining 20%)

Parietal cells (oxyntic glands) = hydrochloric acid and intrinsic factorChief cells (oxyntic glands) = pepsinogen. Neuroendocrine cells = regulate the activity of the parietal cell.

D cells enterochromaffin-like (ECL) cells A-like cells enterochromaffin (EC) cells.

PHYSIOREVIEW

The principal stimulants for acid secretion are:a) Histamine

major paracrine stimulator of acid secretionb) Gastrin

main stimulant of acid secretion during meal stimulationc) Acetylcholine

directly stimulates acid secretion by binding to muscarinic (M3)

receptors

**released from postganglionic enteric neurons

“Inflammation of the gastric and duodenal mucosa is the end result of an imbalance between mucosal defensive and aggressive factors. The degree of inflammation and imbalance between defensive and aggressive factors can then result in varying degrees of gastritis and/or mucosal ulceration.”

Pediatric gastritis and peptic ulcer disease.Blecker U1, Mehta DI, Gold BD.

Gastroesophageal reflux disease is the exposure of esophageal mucosa to

a) acidic gastric contentsb) Pepsinc) bile acids.

Can lead to: Esophageal mucosal injury: Erosive Esophagitis

GERDDISCUSSION

Gastroesophageal reflux disease is the exposure of esophageal mucosa to

a) Acidic gastric contentsb) Pepsinc) Bile acids.

Can lead to: Esophageal mucosal injury: Erosive Esophagitis

GERDDISCUSSION

Signs and symptoms (Infants – Younger Children): Typical or atypical crying and/or irritability Apnea and/or bradycardia Poor appetite; weight loss or poor growth (failure to thrive) Apparent life-threatening event Vomiting Wheezing, stridor Abdominal and/or chest pain Recurrent pneumonitis Sore throat, hoarseness and/or laryngitis Chronic cough Water brash

GERDDISCUSSION

CLINICAL PRESENTATION

Signs and symptoms (Older Children):Signs and symptoms in older children include all of the

mentioned plus: Heartburn and a history of vomiting Regurgitation Unhealthy teeth Halitosis

GERDDISCUSSION

CLINICAL PRESENTATION

DIAGNOSISGERDDISCUSSION

a)History and physical examinationb) Esophageal pH monitoringc) Combined multiple intraluminal impedance (MII) and pH

recordingd) Endoscopy and biopsye) Empiric trial of acid-suppressive as a diagnostic test

Pediatric gastroesophageal reflux clinical practice guidelines: joint recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN).


“In infants and toddlers, there is no symptom or group of symptoms that can reliably diagnose GERD or predict treatment response. (B)”



“In older children and adolescents a history and physical examination are generally sufficient to reliably diagnose GERD and initiate management.”


MANAGEMENTGERDDISCUSSION

TreatmentParental education, guidance, and supportLifestyle changesPharmacologic therapiesSurgical therapy



Conservative measures: Providing small, frequent feeds thickened with cereal Upright positioning after feeding Elevating the head of the bed Prone positioning (infants >6 months)


Older Children: Diet that avoids tomato and citrus products, fruit juices,

peppermint, chocolate, and caffeine-containing beverages

Smaller, more frequent feeds Relatively lower fat diet (lipids retards gastric emptying) Proper eating habits Weight loss Avoidance of alcohol and tobacco, when applicable


Older Children: Diet that avoids tomato and citrus products, fruit juices,

peppermint, chocolate, and caffeine-containing beverages (?)

Smaller, more frequent feeds Relatively lower fat diet (lipids retards gastric emptying) Proper eating habits Weight loss Avoidance of alcohol and tobacco, when applicable


“In older children and adolescents, there is no evidence to support specific dietary restrictions to decrease symptoms of GER. In adults, obesity and late-night eating are associated with GER. (A)”



“In adolescents with GERD, left-side sleeping positioning and elevation of the head of the bed may decrease symptoms and GER. (A)”



PHARMACOLOGYAntacids :

aluminum hydroxide, magnesium hydroxideHistamine H2 antagonists :

nizatidine, cimetidine, ranitidine, famotidineProton pump inhibitors:

lansoprazole, omeprazole, esomeprazole, dexlansoprazole, rabeprazole sodium, pantoprazole


“Histamine-2 receptor antagonists (H2RAs) produce relief of symptoms and mucosal healing. (A)

Proton pump inhibitors (PPIs) are superior to H2RAs in relieving symptoms and healing esophagitis. (A)”



SURGICAL INTERVENTIONgastrostomy or fundoplication is required in only a very small minority of patients with gastroesophageal reflux

The goal of surgical antireflux procedures is to "tighten" the region of the lower esophageal junction and, if possible, to reduce hiatal herniation of the stomach


“Antireflux surgery should be considered only in children with GERD and failure of optimized medical therapy, or long-term dependence on medical therapy where compliance or patient preference preclude ongoing use, or life-threatening complications.(C)”


THANK YOU FOR LISTENING ADMITTING CONFERENCE AND TOPIC DISCUSSION

MENG MADDUMBA

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