By X. Yespas. Eastern Mennonite University. 2018.

Previously jejunoileal and gastric bypass proce- Complications dures were performed order 10 mg zetia mastercard, which despite being effective Malnutrition greatly increases the susceptibility to infec- were associated with significant side effects generic 10mg zetia visa. In children it has been shown to affect brain growth banded gastroplasty either by laparoscopic surgery or and development generic zetia 10mg fast delivery. Often oral rehydration is safest, fol- and mortality from diabetic-related illness and cardio- lowed by nutritional replacement therapy. Nutritional replacement is gradually increased Malnutrition (including kwashiorkor until 200 kcal/kg/day. Aetiology Many countries in the developing world are on the verge Aetiology/pathophysiology of malnutrition. Drought, crop failure, severe illness and Lipids are found in dietary fat and are an important en- war often precipitate malnutrition in epidemics. The two main lipids are triglycerides and choles- Pathophysiology terol, which are found in dietary fat and may also be It is unclear why insufficient energy and protein in- synthesised in the liver and adipose tissue (see Fig. The oedema seen in kwashiorkor results from in- eride, cholesterol and apoproteins). These are then creased permeability of capillaries and low colloid on- transported to the liver where the triglyceride is re- cotic pressure (low serum albumin). Oncotic pressure moved and the remaining cholesterol-containing par- is produced by the large molecules within the blood ticle is also taken up by the liver. The end product, deplete r Adults and children with marasmus have loss of mus- of triglyceride, is termed an intermediate-density cleandsubcutaneousfatwithwrinkledoverlyingskin. Hyperlipidaemias are classified as primary and sec- Clinical features ondary (see Table 13. The clinical signs of hypercholesterolaemia are pre- Primary hyperlipidaemia is a group of inherited condi- mature corneal arcus, xanthelasmata and tendon xan- tions subdivided into those that cause hypertriglyceri- thomata. Acute pancreatitis and eruptive xanthomata daemia, hypercholesterolaemia and combined hyperlip- are features of hypertriglyceridaemia. Nutritional Obesity, anorexia nervosa, alcohol abuse disorders Drug induced High dose thiazides, corticosteroids, sex Investigations hormones Random, non-fasting plasma cholesterol is used as a Renal dysfunction Nephrotic syndrome, chronic renal failure screen in low-risk populations. Bitot’s spots, which are flecks caused by heaped up desquamated cells occur and progress to corneal xerosis, and eventually corneal clouding ul- Management ceration and scaring. Patients are at risk of secondary The management of hyperlipidaemia is based on an as- infection. Management r General measures include weight loss, lipid-lowering r Prevention of eye disease with adequate diet and diets, reduction of alcohol intake, stopping smoking supplementation in patients with disorders of fat and increasing exercise. In pregnant women, vitamin A but not r Control of hypertension is important preferably β carotene is teratogenic. Corneal transplant may be required 1 Cholesterol-lowering drugs include resins, which for irreversible corneal ulceration. Vitamin B1 (thiamine) deficiency Vitamin deficiencies See also Wernicke–Korsakoff syndrome in Chapter 7 (Nervous System; page 317) Vitamin A deficiency Definition Definition Deficiency of thiamine (vitamin B1). Deficiency of vitamin A, a fat-soluble vitamin, is a major cause of blindness in many areas of the world. Aetiology Insufficient intake of thiamine, which is present in for- Aetiology tified wheat flour (the natural thiamine is removed by Insufficient intake of carotenoids, especially β-carotene milling, so it is replaced in most countries), fortified found in carrots and dark green leafy vegetables and breakfast cereals, milk, eggs, yeast extract and fruit. Occasionally it can be seen in disorders of fat malabsorption, such as cystic fibrosis, cholestatic Pathophysiology liver disease and inflammatory bowel disease. Thiamine is an essential factor for the maintenance of the peripheral nervous system and the heart. It is also involved in glycolytic pathways, mediating carbohydrate Pathophysiology metabolism. Vitamin A is required for maintenance of mucosal sur- faces, the formation of epithelium and production of Clinical features mucus. Dry beriberi is an endemic form of polyneuritis re- Retinal function is dependent on retinol, a constituent sulting from a diet consisting of polished rice deficient of the retinal pigment rhodopsin. The neuropathy predominantly affects the 512 Chapter 13: Nutritional and metabolic disorders legs with weakness, parasthesia and loss of ankle jerks. Wet beriberi is the high output heart failure caused by thiamine deficiency resulting in Management oedema. Supplementation with nicotinic acid and treatment of other coexisting deficiencies. Erythrocyte transketolase activity and blood pyruvate Vitamin B6 (pyridoxine) deficiency are increased. Definition Deficiency of pyridoxine is rarely a primary disorder, but Management it does occur as a secondary disorder. The cardiac failure usually responds rapidly, but Aetiology neuropathies may only partially resolve if they are long- Important sources of Vitamin B6 are similar to those of standing. Deficiency may occur with malabsorp- Niacin deficiency (pellagra) tion such as coeliac disease, dietary lack in alcoholism and drug toxicity especially isoniazid.

Despite the normal vital signs cheap 10 mg zetia, his general presentation indicates the potential for multisystem injuries 10 mg zetia visa, and putting that together with the findings of mottled and cool skin indicate that this child is in hemorrhagic shock until proven otherwise cheap 10 mg zetia with amex. The vital signs of an injured child can be within normal ranges for an extended period of time secondary to an excellent ability to compensate physiologically for hypovolemia. The secondary concern regarding this child is the manner in which he presented suggesting potential abuse. Factors that raise these concerns include the delay in presentation, the extent of the injuries that appear much more severe than can be accounted for by the history, the age of the child, and the unwitnessed report of the injury. All 50 states have mandatory child abuse reporting laws for the treating physician. Regardless of the management plan, this child should be placed in a protected environment (admission to the hospital), and a report of suspected abuse should be submitted. However, the treating physician’s suspicions or emotions should not delay the child’s medical care (which is the first responsibility). Accurate and complete evaluations and documentation of your findings in an unbiased manner is the first important step. Confrontations with family members in the midst of a trauma room evaluation are rarely fruitful, and can hamper your efforts to care for the child. In those patients with multiple injuries identified, prioritizing the most life-threatening problem is of paramount importance. Even when intracranial hemorrhage may be suspected on the basis of physical presentation, the immediate threat to most children with multisystems injury is hypovolemic shock from abdominal injury and other hemorrhagic sources. Addressing blood loss source is critical not only for the correction of hemorrhagic shock but also for the prevention of secondary brain injury in these patients. The initial priorities are the assessment and maintenance of airway, oxygenation, and ventilation. Determination for immediate intubation is dependent on the initial evaluation of the child and the resources available. However, the initial signs of shock, includ- ing tachycardia, skin changes, and lethargy, represent a loss of approximately 25% of the child’s blood volume (Table 49–3). The likelihood of injury requiring opera- tive control of hemorrhage is much greater in these children, and careful atten- tion should be paid to the amount of fluid or blood that is required to maintain stable vital signs. If further fluids are required beyond this, then administration of packed red blood cells (10 mL/kg) should be considered. There is no doubt that the child presented in this case often presents a consider- able challenge. Not only does the possibility of abuse evoke strong emotions that are difficult to ignore during the evaluation, there is potential of multiple life-threatening injuries that must be prioritized. A systematic and efficient approach, with focus on the most immediate of concerns, cannot be emphasized enough (Table 49–4). However, to report a case of child abuse, the physician must first recognize that it is child abuse. The reporting and protection of the battered child is further confounded by the legal requirements for appropriate and complete documentation by the physician, which often is lacking if suspicions of abuse were not entertained upon initial presentation. Intentional injury accounts for approximately 10% of all trauma cases in children younger than 5 years old. While this figure may be alarming, it also suggests that the vast majority of trauma in children is actually accidental. There are several key aspects of the history, physical examination, and presentation of the child that should alert the practitioner to the possibility that the trauma was not accidental. Table 49–5 lists suggestive characteristics that should alert the practitioner to abuse. Skin and soft-tissue injuries are the most common injuries encountered in child abuse cases. Currently, there is no federal standard regarding the legal requirements for reporting of child abuse. However, all states have mandatory reporting legislation for suspected child abuse that includes healthcare workers, school personnel, social workers, and law enforcement officers. Very few states recognize the physician- patient communication privilege as exempt from these reporting requirements. Most states impose either a fine or imprisonment penalty to individuals that know- ingly or willfully fail to report abuse. When intentional injury is suspected in a pediatric trauma case, the appropriate child protective agency should be notified after the child’s medical condition is addressed. During the investigational process, it is often incumbent on the medical personnel to provide a high-visibility protected environment for the child. A complete, unbiased, and well-recorded history and physical examination can be vital in the protection of the child at a later date. Particularly important information includes detailed descriptions of the reported mechanism of the injury, the time of the injury and any delay in presentation, the presence of witnesses, conflicts, and inconsistencies.