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Case presentation

Case presentation. 성균관대학교 의과대학 2007313075 손의영. Chief complaint. F / 1mo Regurgitation, Vomiting Onset 2012-01-06 ( 소아과에서 협진 의뢰 ) . Present Illness. 2011-12-12 39+3 weeks, 2.93kg, vaginal delivery 로 출생 출생 당시 initial crying 없었음 Apgar score 1m/5m : 1/1

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Case presentation

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  1. Case presentation 성균관대학교 의과대학 2007313075 손의영

  2. Chief complaint • F / 1mo • Regurgitation, Vomiting • Onset 2012-01-06 (소아과에서 협진 의뢰)

  3. Present Illness • 2011-12-12 • 39+3 weeks, 2.93kg, vaginal delivery 로 출생 • 출생 당시 initial crying 없었음 • Apgar score 1m/5m : 1/1 •  intubation  Epinephrine 1:10000 0.5cc E-tube 투여  ambu bagging 하면서 강동성심병원으로 전원

  4. Present Illness • 2011-12-12 • 강동 성심병원 전원 당시 Light reflex (-), pupil (fixed), movement (-), babinski reflex (-) 타원에서 시행한 Echo상 IAA type c PDA로 의심 되어 Evaluation 및 수술 위해 본원 전원 • 본원에서 시행한 Echo상 structure abnormality는 관찰되지 않았고, cord CBGA 6.85 – 86 – 14 – 23 , Apgar score 1/1 , mental : coma 로 미루어 perinatal asphyxia로 진단 후 현재 까지 manage 중

  5. Present Illness • 2012-01-06 • Regurgitation, Vomiting 발생. 하루에 2번 정도 • 지속적인 oral secretion 도 동반됨

  6. Family Hx • 아빠 -----엄마 • 오빠(5살)----환아 • GI disorder or cardiac disease in Family History (-) Personal History

  7. Review of system • General activity : Decreased • Oral intake : NPO state • Fever/chill (-/-) • Cough(-), Sputum(-), Rhinorrhea(-) • Sore throat/rhinorrhea/sneezing (-/-/-) • Cough/sputum/hemotpysis (-/-/-) • Dyspnea/orthopnea (-/-) • Nausea/vomiting (-/-) • Constipation/diarrhea (-/-) • Hematemesis/melena/hematochezia (-/-/-) • Pale (+)

  8. Physical examination • Vital sign • HR 65 /min – RR 20 /min – BT 36℃ • BP Rt arm 65/47 Lt arm 59/38 • Rt leg 61/42 Lt leg 73/34 • General appearance • Acute ill-looking appearance • Chest • Symmetric expansion • Regular heart beat without murmur • Supraclavicular node (-/-) • Axillary node (-/-) • Percussion resonance, symmetric • Vesicular breath sound without crackle, wheezing, rhonchi • Abdomen • Flat abdomen, soft on palpation • Normoactive bowel sound • Hepatomegaly/splenomegaly/shifting dullness (-/-/-) • Pain/tenderness/rebound tenderness (-/-/-) • Palpable abdominal mass (-/-) • External genitalia • Hyperpigmentation (-) • Pathologic reflex • Babinski sign – Rt(+), Lt(+) • Physiologic reflex • Sucking reflex (-) • Moro reflex (-)

  9. Diagnosticplan • 24h 하부식도 pH 검사 • 바륨 식도 조영술 • 위 신티그래피 • 내시경검사, 조직 생검 • 경험적 항역류 치료 (Proton pump inhibitor)

  10. Diagnosticplan • 24h 하부식도 pH 검사

  11. The fraction of time pH was below 4 : 1.5% DeMeester score : 17.7 (normal < 14.7) Symptoms index : none Impression : GERD

  12. Operation procedure (2012-02-06) • Fundoplication & Percutaneous endoscopic gastrostomy

  13. Post-operational plan • Position regulation엎드린 자세에서 역류가 덜 함  관찰 가능한 시간에 머리 높여 엎드린 자세영아 급사 증후군의 위험 때문에 잘 때는 바로 누운 자세를 취한다. • Feeding control소량씩 자주 먹인다.분유나 미음에 쌀가루를 넣어 걸쭉하게 먹이면 역류빈도가 감소 • Pharmatical위 내용물의 산도를 낮추고, 위의 정상운동을 촉진제산제, H2-blocker(cimetidine, ranitidine), PPI(omeprazole)

  14. Gastroesophageal Reflux • Definition • 하부 식도 괄약근의 이완에 의하여 위 내용물이 식도로 역류하는 질환 • Epidemiology • 대개 정상적인 영아도 미약한 역류를 보임 • 출생 4개월 째에 역류의 빈도가 가장 높고, 12개월이면 대부분 해소 • 고형식 먹는 2세가 되면 증상이 대부분 없어짐

  15. Gastroesophageal Reflux • Symptoms • Feeding resistance, recurrent vomiting, failure to thrive, fussiness/irritability, Apnea/choking episodes, Opisthotonic posturing • Diagnosis • 경험적 항역류 치료 • 바륨 식도 조영술 • Gastric scintigraphy • 내시경검사, 조직 생검 • 하부 식도 24시간 pH 검사 • 임피던스 검사 • 식도 압력 검사

  16. GERD – Treatments • Life Style Modification • Smaller, more frequent feeding • Antireflux positioning after feedings (누울 때 머리 올리기) • Avoid passive tobacco smoke exposure • Pharmacologic Agents Medication Dose Frequency Cimetidine 40 mg/kg/day Thrice daily or 4 times daily Famotidine 1 mg/kg/day Twice daily Ranitidine 5–10 mg/kg/day Twice daily or thrice daily Lansoprazole 0.4–2.8 mg/kg/day Once daily Omeprazole 0.7–3.3 mg/kg/day Once daily

  17. GERD – Treatments • Surgery – Laparoscopic Nissen Fundoplication • Fundus + Placation (접다)의 합성어 • Stomach의 fundus를 올려서 식도 주위를 360도둘러싸서 식도에 주름을 형성한다. • 식도 운동이 저하된 환자에서는 partial fundoplication을 시행하기도 한다. • Indications • Severe esophageal damage (such as ulcer, adhesion, Barrett’s mucosa) • failed response to medical therapy • recurrence of symptoms after weaning from medical therapy • respiratory symptoms associated with GERD (airway obstruction) GERD in the Pediatric Patient: Management Considerations, David A Gremse, MD MedGenMed. 2004; 6(2): 13. Published online 2004 May 6.

  18. GERD – Treatments • Surgical prognosis • Recurrent vomiting  수술이 효과적, 그러나 • Complete relief of GERD Sx in children  57 to 92 % • Mortality rates in children  0 to 4.7 % • postoperative Cx in children (such as dysphagia)  6% Fundoplication is not required for management of vomiting in the absence of other complications of GERD. GERD in the Pediatric Patient: Management Considerations, David A Gremse, MD MedGenMed. 2004; 6(2): 13. Published online 2004 May 6.

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