mesentric lymphadenotis.pptx

Importance of Mesenteric lymphadenitis

1. MESENTRIC LYMPHADENITIS Dr.ANJANA.K.S

2. INTRODUCTION Mesenteric lymphadenitis refers to inflammation of the mesenteric lymph nodes It is considered if a cluster of three or more lymph nodes, each measuring 5 mm or greater, is detected in the right lower quadrant mesentery.   Clinically often difficult to differentiate from acute appendicitis,    particularly in children Can be divided into two distinct groups: Primary and Secondary.

3. Primary mesenteric adenitis -defined as right-sided mesenteric lymphadenopathy without an identifiable acute inflammatory process or with only mild (<5 mm) wall thickening of the terminal ileum. Secondary mesenteric adenitis - defined as lymphadenopathy associated with a detectable intraabdominal inflammatory process.

4. PATHOPHYSIOLOGY Frequent association with upper respiratory tract infection- the theory of swallowing pathogen-laden sputum. Microbial agents gain access to lymph nodes via the intestinal lymphatics . Organisms multiply & depending on the virulence of the invading pathogen, varying degrees of inflammation and suppuration may be seen. Feco -oral transmission occurs in yersenia infection and can act as a common source of infection.

5. Grossly, nodes are enlarged and often soft. The adjourning mesentery may be edematous, with or without exudates Microscopically, the nodes show nonspecific hyperplasia and, in suppurative infection, necrosis with numerous pus cells. Swelling of the lymphoid tissue of Peyers patches can act as etiological factor for mesenteric adenitis induced intussusception in children.

6. ETIOLOGY Chronic (or Subacute ) Presentation ( i ) Inflammatory bowel diseases (ii) Systemic inflammatory diseases (SLE and sarcoidosis ) (iii) Malignancy (iv) HIV infection (v) Tuberculosis Acute Presentation ( i ) Appendicitis (ii) Secondary lymphadenitis of infectious origin (iii) Zoonotic infections: yersiniosis & nontyphoidal Salmonella infection (iv) Enteric fever (v) Infectious mononucleosis

7. CLINICAL PRESENTATION More common in males than females, with a peak incidence of 5 to 10 yrs. It commonly presents as pain abdomen of chronic duration Seen in 20% of patients undergoing appendicectomy . Reduced risk of ulcerative colitis in adulthood. It often follows or occurs in association with an upper respiratory illness.

8. SYMPTOMS Abdominal pain- -usually severe,but the patient does not appear to be severely prostrated. -The character varies from a discomfort to a severe colic. -The distribution is like that of appendicitis, is felt both in the periumbilical region and in the right iliac fossa . Fever Malaise and anorexia Nausea and Vomiting Shift in stool frequency and consistency.

9. SIGNS Flushed appearance Fever –mild to moderate degree RIF tenderness- with or without rebound tenderness Voluntary guarding rather than rigidity. Rectal tenderness Signs of upper respiratory tract infection.

10. DIFFERENTIAL DIAGNOSIS The presentation may clinically mimic Acute appendicitis, Tubercular lymphadenitis Intussusception Constipation, Inflammatory bowel diseases, Meckel’s diverticulum , Ovarian torsion, Basal pneumonia Henoch-Sch¨onlein syndrome,and Urinary tract infection Malignancies-lymphoma

11. WORK UP Complete blood count ESR Serology Urinalysis may be useful to exclude urinary tract infection. Blood culture Stool culture Abdominal ultrasonography is the main stay of diagnosis. CT/MRI

12. Sonography findings- -multiple, enlarged, hypoechoic mesenteric lymph nodes - absence of a thickened blind ending tubular structure in the right lower quadrant. - The radiological definition for mesenteric lymphadenitis suggested is a cluster of 3 or more lymph nodes with short-axis diameter of 5mm or more in the right lower quadrant and in the para -aortic region without an identifiable acute inflammatory process. -slight thickening of the terminal ileum wall and caecum in a minority of cases

13. Lymphnode enlargement is also found in some cases of appendicitis(especially if perforated)but generally the nodes are not as numerous nor as large Malignancies, most frequently non-Hodgkin lymphomas, have abdominal masses and may result in right lower quadrant tenderness. -Concurrent involvement of mesenteric, retroperitoneal and pelvic lymph nodes is common in these cases. Mesenteric lymph nodes were detected in 14% of symptomatic children, but enlarged mesenteric lymph nodes in children with acute pain represents a non-specific finding .

14. Histopathology In patients subjected to laparotomy –lymph node for inflammation & culture to be sent.

15. TREATMENT This is a benign, self limiting condition that does not require medical or surgical intervention but follow up is necessary in these patients. General supportive care- hydration and pain medication after excluding surgical causes of acute abdomen. Specific anti-microbial agents are indicated by microbiological tests, such as tuberculosis or typhoid fever. ????..Empirical broad spectrum antibiotics Reassure patients and families stating that affected patients recover completely without residuals within 2–4weeks.

16. SURGERY Indications -suppuration or abscess -signs of peritonitis -if acute appendicitis cant be excluded During laparotomy-appendicectomy is usually performed.

17. Write total parenteral nutrition order for a 3yr old boy with weight 10kg who gets all his drugs and infusions in 200ml of 5% dextrose..

18. Energy Guidelines from the American Society for Parenteral and Enteral Nutrition (ASPEN) outline the following age- and weight-based energy requirements. Preterm neonate – 90 to 120 kcal/kg/day <6 months – 85 to 105 kcal/kg/day ≥6 to 12 months – 80 to 100 kcal/kg/day ≥1 to 7 years – 75 to 90 kcal/kg/day ≥7 to 12 years – 50 to 75 kcal/kg/day ≥12 to 18 years – 30 to 50 kcal/kg/day

19. Protein  Targets for protein intake for pediatric patients with normal organ function for age are as follows:   Preterm neonate – 3 to 4 g/kg/day Infants (1 to 12 months) – 2 to 3 g/kg/day Children (>10 kg, or age 1 to 10 years) – 1 to 2 g/kg/day Adolescents (11 to 17 years) – 0.8 to 1.5 g/kg/day

20. Fat Between 20 and 50 percent of energy needs For most patients, start to provide fat at 1 g/kg per day. If tolerated, the fat dose can be advanced to 3 g/kg per day (or 2 g/kg/day for older children) if needed to provide adequate energy intake.

21. Electrolytes Daily electrolyte and mineral requirements for parenteral nutrition in pediatric patients Electrolyte Preterm neonates Infants/children Adolescent Sodium 2 to 5 mEq /kg 2 to 5 mEq/kg 1 to 2 mEq/kg Potassium 2 to 4 mEq /kg 2 to 4 mEq/kg 1 to 2 mEq/kg Calcium 2 to 4 mEq/kg (= 1 to 2 mmol/kg)* ¶ 0.5 to 4 mEq/kg (= 0.25 to 2 mmol/kg)* ¶ 10 to 20 mEq total daily dose (= 5 to 10 mmol)* ¶ Phosphorus 1 to 2 mmol /kg 0.5 to 2 mmol /kg 10 to 40 mmol Magnesium 0.3 to 0.5 mEq/kg 0.3 to 0.5 mEq/kg 10 to 30 mEq

22. 3yr old boy with weight 10kg who gets all his drugs and infusions in 200ml of 5% dextrose. Fluids: 100ml/kg x 10kg = 1000mL Energy: 10Kg x 100Kcal/Kg = 1000Kcal/day Protein: 10Kg x 2gm = 20gm/day (Energy= 20 x 4= 80 Kcal) = 100mL Lipid: 10Kg x 3gm = 30gm/day (Energy= 30 x 10=300 Kcal) = 150mL over 24 hours 200 ml 5% Dextrose –calorie= 10 x 3.4=34Kcal Fluid left after lipid & infusion = 1000 – (150ml +200ml) = 650ml

23. Carbohydrate Remaining energy = 1000 - (300+80 +34) = 590Kcal 45% of the energy = (45/100)X590= 265Kcal Carbohydrate = 265/3.4 = 78gm 25 %D = 300ml(each 100ml 25g) Sodium = 3mEqX10kg = 30mEq 100mL contains 51.3mEq (30X100)/51.3 = 60mL Potassium = 3mEq X 10Kg = 30mEq = 15mL (each ml contains 2mEq)

24. Calcium = 10Kg X 2mEq = 20mEq each mL of Calcium gluconate contains 0.45mEq (28 X 1)/0.45 = 44mL Magnesium = 10kg X 0.3mEq=3mEq=1 ml (1ml = 4mEq) MVI=5ml(max)

25. Calculation of GIR) for parenteral nutrition 1. Calculate grams of glucose in the parenteral nutrition (PN) prescription Energy ( kcals ) from carbohydrates ÷ 3.4 kcal/g = grams glucose 2. Convert to milligrams of glucose Grams glucose x 1000 = mg glucose 3. Calculate milligrams of glucose per kilogram Mg glucose ÷ body weight (kg) = mg glucose/kg 4. Calculate milligrams of glucose per kilogram per minute = glucose infusion rate (GIR) Mg glucose/kg ÷ minutes of infusion = mg glucose/kg/minute (where minutes of infusion = 1440 if infusion is continuous over 24 hours)

26. GIR 78 x 1000 =78000 78000/10=7800mg/kg 7800/1440= 5.41mg/kg/min

27. To Calculate for each 650 ml @ 27ml/hr 25D =300mL in 650mL 3%NaCl =60ml AMINOVEN =100mL in 650mL KCl = 15mL MVI = 5mL of adult MVI Calcium Gluconate = 44mL Magnesium = 1mL Sterile water = Remaining volume 150ml intralipid over 18 hours GIR = 5.41mg/kg/min

28. Osmolarity calculation 1mL AMINOVEN (10%) = 1mmol DEXTROSE = gm of glucose/198 X 1000 50%D = 2.52mmol/mL 30%D = 1.51mmol/mL 10%D = 0.505mmol/mL 5%D = 0.25mmol/mL 1mL 3% NaCl =1.05mmol 1mL KCl = 4mmol 1mL Calcium gluconate = 0.22mmol 1mL MVI(adult) =4.11 1mL Magnesium =4.06

29. Write diatery advice for a child with a)CKD b)Type 1 DM

30. CKD Dietary management: The goals are: a) to reduce nitrogen intake b) to maintain nitrogen balance c) to cover essential amino acid requirement d) to supply enough calories i ) Energy: Infant 100-120 kcal/kg/day Children 80-100 kcal/kg/day

31. ii) Protein: -High protein will aggravate acidosis, hyperkalaemia and hyperphosphataemia . - Low protein will reduce BUN, improve renal function and reduce symptoms like nausea, vomiting, muscle cramps, convulsion, neuropathy etc. -Milk is rich in phosphate and meat is rich in potassium. Protein intake is based upon the extent of CRF, mild/moderate or severe iii)Fluids: - Fluids should be given without producing water retention. If fluid retention occurs, give diuretic and restrict sodium

32. Sodium: Excess intake will lead to hypertension and fluid retention. -Restrict salt intake to 300-600 mg/day in infants and to 1-2 g/day in older children. Potassium: -Restrict potassium intake - Hypokalaemia can occur at any time. -Give small dose of potassium or fruit juice if serum K is low normal or low.

33. Model diet in mild-moderate CRF a) Fluid: According to thirst or insensible loss + last day’s output or up to two-third maintenance 800 ml b) Calories: RDA for height age c) Protein: 1.4 x 15 = 21 g. d) Sodium: Restrict to 500 mg/day (no added salt). e) Potassium: Fruit juice can be given if S. K+ is normal

34. DIET ADVICE IN A CHILD WITH TYPE 1 DM

35. Maintain adequate carbohydrate, fat and protein ratio: carbohydrate 50- 60%, protein 10-15% and fat 20-30%. Avoid fasting and feasting. High fibre , low fat diet with adequate carbohydrate and protein is ideal. Ensure appropriate timings to prevent ups and downs in blood sugar values. The calories will have to be spread over as breakfast 20%, lunch 20%, dinner 30% and midmorning, midafternoon and evening snacks 10% each. One snack may be omitted and 10% may be added to the lunch (e.g., midafternoon ) if three snacks cannot be taken

36. 1. Meal Planning The goal is to ensure normal growth and to keep FBS <115 mg/dl, PPBS < 126-140 mg/dl, S. cholesterol < 200 mg/dl, S. LDL cholesterol < 130 mg/dl, HDL > 50 mg/dl, S. triglyceride < 160 mg/dl and glycated Hb (6-8 g) within normal limits. There should not be wide fluctuations in blood sugar Timing of meals and composition of diet should be relatively fixed and at the same time without monotony. Sodium should be restricted to 3-5 g/ day if there is hypertension and cholesterol should be restricted to 300 mg/day.

37. BMR is roughly 22 kcal/kg ideal weight. Bitter things like bitter gourd may stimulate beta cells of the pancreas. a) Carbohydrate: - Avoid rapidly absorbed mono- and disaccharides and refined sugars like glucose, sugar, honey, sweets, sweet drinks etc., and encourage complex carbohydrates. -Tubers should be restricted. - Whole wheat is considered better than rice b) Fibre : - Fibre delays carbohydrate absorption and decreases hyperglycaemia .

38. The suggested intake is 20-35 g/ day. -It increases insulin receptors and decreases insulin requirement. - Fibre relieves constipation. -Whole wheat, coriander, carrot, brinjal , cauliflower, ladies finger, mango etc., contain 1-3% fibre ; - Ragi , pulses, ground nut, peas, guava etc., contain 3-5% fibre . Low fat: - Low fat increases insulin binding and reduces LDL and VLDL cholesterol. -Better to give vegetable fat that contains PUFA.

39. Avoid animal fat, hydrogenated oil ( Dalda ) etc. Fish and chicken are preferred than beef and egg. Turmeric, Bengal gram, onion and garlic reduce cholesterol. d) Fruits : -When the blood sugar is well controlled, half to one fruit can be allowed at the expense of a snack or after exercise. -The fruit can be selected based upon the carbohydrate content of the fruit.

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