PHYSiOLOGY

Fluids and Electrolytes

SUGGESTED READING
Anderson S. Garcia DL, Brenner BM. Renal
Table 5. Normal Glomerular Filtration Rate (GFR) DurIng
and systemic manifestations of glomerular Infancy
disease. In: Brenner BM, Rector FC Jr, eds.
The Kidney, 4th ed, Vol II. Philadelphia, AVERAGE GFR RANGE
PA: WB Saunders Co; 1991;1831-1870 AGE ML/MINII.73 M ML/MIN/1.73 M
Briggs JP, Sawaya BE, Schnermann J.
Disorders of salt balance. In: Kokko JP, 2-8 days 39 17-60
Tannen RL, eds. Fluidc and Electro’ytes, 4-28 days 47 26-68
2nd ed. Philadelphia, PA: WB Saunders Co;
37-95 days 58 30-86
1990:70-138
Darrow DC. A Guide to Leanzing Fluid
1-6 months 77 39-114
Therapy. Springfield, IL: Charles C Thomas 6-12 months 103 49-157
Publishers; 1964 12-19 months 127 62-191
Finberg L, Kravath RE, Fleischman AR. 2-12 years 127 89-165
Water and ElectroIytes in Pediatrics.
Philadelphia, PA: WB Saunders Co; 1982 Reproduced with permLssion Heilbron DC, Holliday MA, al-Dahwi A, Kogan 84.
Fanestil DD. Compartmentation of body water. Expressing glomerularfihtration rate in children, Pedlati NephroL 1991; 5:5-11.
In: Maxwell MH, Kleeman CR, Narins RG,
eds. Clinical Disorders ofFluid and
Electrolyte Metabolism, 4th ed. New York,
NY: McGraw-Hill Book Co; 1987:1-13 PIR QUIZ
Guyton AC. The lymphatic system, interstitial
11. All of the following are correct D. Familial hypercholestemle-
fluid dynamics, edema, and pulmonary fluid
and partition of the body fluids: Osmotic
statements regarding normal and mia.
equilibria between extracellular and
abnormal body compositions E. Diabetes mellitus.
except:
intracellular fluids. In: Guyton AC. 14. True statements regarding effec-
A. Diarrhea represents an exam-
Textbook ofMedical Physiology, 7th ed. tive osmolality of body fluids
Philadelphia, PA: WB Saunders; 1986:361-
pie of excessive losses of and their controls include all of
371; 382-392
transcellular fluid. the foilowing except:
Holliday MA. Body composition, metabolism,
B. Current studies support the A. The osmoreceptors regulating
and growth. In: Holliday MA, Barratt TM,
concept of the hypoalbumi- release of ADH and those re-
Vernier RL, eds. Pediatric Nephrology, 2nd
nemia-hypovolemia- sponsible for thirst are set at
ed. Baltimore, MD: Williams & Wilkins;
edema sequence. different levels of plasma os-
1987:3-13
C. The size of the extracellular molality.
fluid compartment is deter-
Reineck Hi, Stein JH. Sodium metabolism. In: B. Total serum osmolality can
Maxwell MH, Kleeman CR, Narins RG, mined by the quantity of so-
be accurately estimated from
dium present because sodium
eds. Clinical Disorders of Fluid and measured serum concentra-
Electrolyte Metabolism, 4th ed. New York,
ions contribute effective cx- tions of sodium, urea-N, and
NY: McGraw-Hill Book Co; 1987:33-59
tracellular solute. glucose.
D. A person’s extracellular
Schwartz GJ, Haycock GB, Edelmann CM Jr, C. A normal serum osmolality
water contribution to total
Spitzer A. Late metabolic acidosis: A of about 280 mOsm/kg is
reassessment of the definition. J Pediatr.
weight attains 20% by 3 maintained by control of
years of age.
1979;95:102-107 water balance.
E. The intracellular fluid corn- D. Most infants by I month of
partment approximates 40%
age can vaiy urinary concen-
in both the infant and the
trations of solute from 50 to
adult. 1000 mOsm/L.
12. The most correct statement re- E. The serum proteins account
garding basal metabolic rate for the normal difference be-
(BMR) is: tween serum and intracellular
A. The higher BMR of infants osmolality.
results from the greater con-
15. Of the following, the most cor-
tribution of “central organs”
rect statement regarding Hf-ion
to body weight.
balance is:
B. The impact of fever on BMR
A. In the growing child, the
necessitates a 10% decrease
daily endogenous H-ion
of estimated fluid for insensi-
load approximates 8 to 10
ble loss for each degree cen-
rnEq/day.
tigrade above normal. B. The synthesis of “new”
C. The basal energy expenditure HCO3- normally matches
of the liver is the single larg-
that consumed in buffeting
est factor in determining the
endogeneous H-ion load.
BMR of infants.
C. Greater renal resorption of
D. In the adult, muscle mass ac- HCO3- results in higher
counts for approximately
serum HCO3- levels in
50% of the BMR.
infants versus adults.
13. Factitious hyponatremia may oc- D. A vegetarian diet adds to the
cur in each of the following daily H-ion load requiring
except: elimination to maintain
A. Hypothyroidism. homeostasis.
B. Hyperglycemia.
C. Addison disease.

Pediatrics in Review VoL 14 No. 2 February 1993 79

 ‘\

American Academy
of Ped iat r ics d

Continuing Education
Programs

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Washington, DC Dallas, Texas

October 30-November 3, 1993 October 22-26, 1994

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May 28-30, 1993
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To those enrolled in PREP (Pediatrics Review and Education Pro-

gram), these programs feature subject matter coordinated with the
PREP curriculum. Credits earned in these courses may be applied
toward the PREP Education Award available to Fellows and Can-
didate Fellows of the Academy.

PREP: THE COURSE

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San Diego, California Pine Mountain, Georgia

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For further information contact:

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 The American Board of Pediatrics#{174}

PR” P rog ram fo r Renewal

‘#4/ of Certification in Pediatrics

Guides for Record Review

Chronic Abdominal Pain

Supplement to Pediatrics in Review

 The American Board of Pediatrics
111 Silver Cedar Court
Chapel Hill, North Carolina 27514-1651

@1993 by the American Board of Pediatrics

All Rights Reserved
 This guide has been prepared by the American Board of Pediatrics (AB?)
as an integral part of the record review required for renewal of certification in
general comprehensive pediatrics. Its purpose is to provide the pediatrician
with criteria for assessing patient records dealing with specific problems.
Important elements to be included in the record appear in bold-face type in the
margins; other elements to be considered are printed in italics.

Theguides focus on the elements of the history and physical examination

relevantto specific problems and are not meant to discourage a more thorough
history and physical examination as appropriate for the patient and the
particular circumstances.

The guides will be updated periodically. Because of rapid changes in

knowledge about drugs and their availability, drugs and dosages included in
these guides should be verified in current sources. A table of interna-
tional units is included in each guide.

The guides are planned, written, and reviewed by an ABP committee

composed primarily of practicing pediatricians. Appropriate subject experts
are consulted during the preparation of the guides.

. Please note that these guides do not purport to.

articulate standards of care They are 4esigned
solely to address record keepIng Issues

Distribution of this guide is made possible by the American Academy of

Pediatrics through a license agreement with the American Board of Pediatrics.
INTRODUCTION

Chronic or recurrent abdominal pain is one of the most common and

challenging complaints evaluated by pediatricians.1 Depending upon the
frequency and severity of the complaint and the child’s and family’s response
to it, considerable school can be missed, and considerable expense entailed as
a result of medical evaluation and therapy. The etiology has frequently been
divided into organic, functional, and psychologic causes,2 but these are not
mutually exclusive and all avenues should be explored in the evaluation of the
child with chronic or recurrent abdominal pain. Functional pain is considered
to be of probable organic origin (eg, hypermotility of the bowel) even though
no organic cause can be identified; this type of pain should not be ascribed to
psychologic causes if there is little or no evidence for psychopathology.

This unit considers children from 3 years of age to puberty whose pains
have been present for at least three months and have been characterized by
persistence or recurrence over that time period.

PATIENT IDENTIFICATION

The age of the patient or birth date should be recorded because the Birth date
common causes of abdominal pain tend to differ with age; for example, peptic
ulcer disease and inflammatoryboweldisease are more common after lOyears Race
ofage. Raceshould alsobe noted, for sickleceildisease isa causeofpaininblack
persons, and lactose intolerance is a frequent cause of symptoms in black, Gender
Mediterranean, Indian, and Asiatic children older than 4 years ofage.3 Gender Immunizations
may be significant, for urinary tract infections and pelvic abnormalities are
more common in girls. An up-to-date record of all immunizations should be Drug allergies
a part of each child’s medical record. Finally, any drug allergies should be
recorded prominently on the chart so that a drug to which the patient is
sensitive is not prescribed inadvertently.

PATiENT HISTORY

A detailed description of the abdominal pain is essential to the interpre- Description of pain,
tation of its likely cause. The location and any tendency to radiate should be including location,
noted, as well as the character, duration, and severity of the pain. Radiation of 5verftY,f1uency,
pain to the back occurs in posterior duodenal ulcer and pancreatitis, whereas character
pain from gallbladder disease radiates to an area between the scapulae.
Epigastric pain isassociated withdistalesophagitis, gastritis,orulcer, and with om ng
pancreatitis. Leftupperquadrantpain may representgastritis,gas trapping,or Description of stools
lesions in the jejunum or splenic flexure of the colon. Pain in the nght upper (eg constipation)
quadrant is likely due to hepatobiliary disease, perihepatic inflammation, or
duodenal ulcer. Right lower quadrant pain suggests appendiceal, ovarian, or
inflammatory bowel disease. Left lower quadrant pain is usually caused by
colitis or constipation. Periumbilical pain is less specific for an organic abnor-
mality but it may represent small bowel disease.

I
Weight Loss Characteristics of the pain and its duration are important; esophagitis,
gastritis, or ulcer pain is described as burning or gnawing, and small bowel or
Fever colomc pain as cramping. The pain of esophagitis, ulcer disease, or inflamma-
, tory bowel disease may awaken the patient from sleep; esophageal pain is
Family history of il particularly prominent upon awakening, in contrast to functional abdominal
sease pain, which rarely disturbs a child’s sleep. Peptic ulcer pain is most typically

Family history of present an hour or two after meals. The pain of esophagitis, gastritis, biliary
depression tract disease, or inflammatory bowel disease is aggravated by eating. Perito-
neal pain is dull, aching, and worsened by bumping or jumping motions.
Social history (eg,
environmental or The effect of time ofday, physicalactivity, schoolattendance, and the like
chronic stress) may provide clues to etiology. If the child is receiving any medication, a
relationship between the drug and the pain should be explored. If the child has
had previous studies or treatment for the complaint, the results should be
recorded. Finally, the degree of incapacity (that is, the response of the child to
the pain) should be noted; pain that interferes with school attendance, play
activities, or sleep is of concern.4

The history should also include the presence of any weight loss or recent
failure to gain weight, which would favor an organic cause. The child’s
appetite and diet should be evaluated, particularly any unusual intake, such
aslarge amounts offoods ormedicines containingsorbitol,6excessive amounts
of fruit juice, or frequent ingestion of chocolate or popcorn. The history of
vomiting and whether vomitus was bile stained or bloody should be noted in
the chart. The presence of low-grade or recurrent fever may be a clue to
inflammatory bowel disease or infection. Urinary tract disease is a common
cause of abdominal pain, and its presence may be indicated by the complaints
of dysuria, frequency, flank or suprapubic pain, and hematuria. The character
ofstoolsshouldbeascertainedbecausethepresenceofblood ormucussuggests
colitis, whereas fatty and foul-smelling stools indicate the possibility of mal-
absorption. Constipation may be one of the most common causes of persistent
abdominal pain, so the frequency and hardness of the stools should be
determined.’ Distention and flatus are clues to disorders such as lactose
intolerance8 or giardiasis.

The review of systems should be complete, but should particularly seek

evidence of other potentially functional complaints, such as headache, vague
chest discomfort, anorexia without weight loss, or joint and extremity pain
withoutobjective manifestions.9”#{176}Thepreviousmedicalhistory maybe helpful
if there is evidence of milk intolerance, gastroesophageal reflux, or encopresis.

Children with functional recurrent abdominal pain usually are “high

strung” and excitable, and may be apprehensive, timid, or perfectionistic. A
pattern ofover-reaction to minor illnessor injury maybeuseful as evidence that
the parent(s) may be overly anxious.

The familyhistory should focusongastrointestinaldisease, such as peptic

ulcer, spastic colon, and lactose intolerance. Because migraine and seizure
disordersare causesofabdominal pain, though uncommon, a family history of
these complaints may be helpful.4 A strong relationship between maternal
depression and recurrent abdominal pain in her child has been reported, so
evidence of psychiatric illness in the family may be important.11”2

The social history may shed light on the degree of stress in the child’s
environment and on thecontribution ofchronic stress to the patient’s complaints.

2
PHYSICAL EXAMINATION

Abdominal pain can be a manifestation of disease in many other organ Temperature

systems, so a thorough, complete physical examination should be done. The
height and weight should be recorded, because an impairment in growth can Height/length
be an important clue to the presence of an organic cause of the pain. The
temperature may be useful for reasons noted above. Given the possible Weight
presence of a urinary tract abnormality, the blood pressure should also be
recorded. The resuitsofa detailed abdominalexamination should be available, Blood pressure
including the presence of masses or enlarged organs, any tenderness or Abdomen
distention, and the description of the peristaltic sounds. A rectal examination
may be useful to search for fecal or other masses, to ascertain the character of Rectal examination
the feces, and to provide a specimen for examination for occult blood.

LABORATORY AND RADIOLOGIC STUDIES

Because most chronic and recurrent abdominal pain has no identifiable Complete blood count
organic origin, no laboratory or radiologic study is absolutely indicated in
every patient.”4 Rather, studies should be selected on the basis of the results Erythrocyte
of a detailed history and physical examination, and the most likely cause for sedimentation rate
the complaints. However, it is commonly desirable to perform a noninvasive , , . I
and inexpensive series of screening examinations, negative results of which ‘ll YSiS
will reassure both the physician and parents that organic disease is less likely Urine culture
to be present. For example, a complete blood count may provide evidence of
anemia, lead poisoning, parasitic disease or allergy (eosinophilia), and other Stool for occult blood
causes of recurrent pain. An erythrocyte sedimentation rate may be helpful in
considering a disorder such as inflammatory bowel disease. Several stool
examinations for occultblood canbe helpful in identifying sources of bleeding,
such as peptic ulcer or a Meckel diverticulum. A complete urinalysis and, in
girls, a urine culture will be helpful in the elimination of urinary tract disease
as the cause of abdominal pain.

Depending upon the history, physical examination, and screening labo-

ratory findings, further studies are sometimes indicated, but should not be
done indiscriminately in the absence of adequate indication. These include
stool pH and examination for reducing substances which may identify carbo-
hydrate intolerance, and stool examinations for ova and parasites or bacterial
pathogens. Stool studies for fat may be helpful in documenting suspected
steatorrhea, and an excessive number of leukocytes in stool may be found in
patients with various forms of colitis. Where available, breath hydrogen
studiescan be usefulinconfirming the presence ofcarbohydrate intolerance.3”3

Ultrasonography is the least invasive method for evaluating renal or

pelvic abnormalities and diseases of the gallbladder or biliary tract, providing
that the radiologist is experienced with such examinations in children. X-ray
studies of the abdomen may identify evidence of unsuspected constipation,
abnormal gas patterns, calcifications, and some masses. Contrast studies such
as upper gastrointestinal series and barium enema examination should be
reserved for those situations in which there seems a reasonable likelihood that
an identifiable disease will be found, rather than as screening procedures.
Radioisotopic scans have been used in the identification of a Meckel diverticu-
lum, although both false-positive and false-negative results have been reported.

3
 TREATMENT

Dietary counseling Treatment will be dependent upon the findings and the diagnosis.
Specific treatment for specific abnormalities such as peptic ulcer disease or
Drug therapy inflammatory bowel disease is beyond the scope of this discussion, which will
focuson thechild with “functionalabdominalpain” for which noorganic origin
is apparent or suspected. Both parents and the patient will need a careful
interpretation of these findings, and a clear explanation of why no further
studies are needed if that judgment has been made. Considerable reassurance
may be required (see Patient Education).

Many treatments have been used in the management of functional

abdominal pain, with varying levels of success. The treatment of constipation,
when present, may be helpful in reducing abdominal pain.1’ Dietary coun-
seling,emphasizinga nutritiousdietwith adequatefiberand bulk,’6and the use
of stool softeners may be helpful in children whose bowel patterns or physical
findings indicate significant constipation. The cessation of sorbitol ingestion
hasbeenassociated with reliefin a few patients,’and a trial ofa lactose-free diet
may be worthwhile in patients thought to have lactose intolerance.8

Sources of anxiety and stress should be identified and an effort made to

reduce pressure for performance in school, to reduce unnecessary stress, and
to reduce intrafamilial tensions.1#{176} Relaxation techniques may be helpful in
children old enough to cooperate, as for other types of chronic pain.’5 For the
child who is missing considerable school and has no evidence of significant
organic disease, regular attendance is mandatory. The prescription of
antispasmodic drugs, antacids, or other medications is discouraged because
they are seldom effective and tend to reinforce the idea that there is something
wrong with the child, even though no disease has been identified.

FOLLOWUP EVALUATION

Regular followup Children with recurrent abdominal pain should beevaluated regularly in
visits follow-up, with particular attention to growth and to any change in symptoms
or findings on physical examination that may warrant further investigation.
Continued support and reassurance must be given if there continues to be no
evidence of organic disease, and previous instructions may need periodic
reinforcement.1’ Continued efforts should be made to resolve family and
school issues which may be contributing to environmental stress. Each visit
should be documented in the patient’s record. The longer a child is observed
and hasnoevidenceoforganic disease, thelesslikely itis thata hidden problem
is being missed. When organic disease is suspected, consultation with a
pediatric gastroenterologistmaybe indicated before an extensiveevaluation is
initiated for suspected organic disease to direct the evaluation along appro-
priate lines (eg, upper or lower endoscopy to rule out esophagitis, gastritis,
peptic ulcer, colitis, or other lesions).’”8

4
PATIENT EDUCATiON

Education of the child and family is one of the most important aspects of Counseling about
management of this troublesome problem. Both need to be assured that the cause of pain
pain isreal, and thatthe child isnot malingering. The pediatrician should avoid
stating that “nothing is wrong” or implying this by saying, “I cannot find
anything wrong.” A physiologic explanation, including the possibilities that
gastrointestinal motility is disturbed,’9 that intraluminal tension is increased,
and that these may be particular responses to environmental stress (as occurs
inadults)isoften helpful.”2’4’ Techniquesmay beused toreduceany secondary
gain by the child, such as insistence on regular school attendance, continued
responsibility for choresaround the home, and thelike. Considerable counsel-
ing may be needed to discourage parents from seeking multiple medical and
surgical opinions for further diagnostic evaluations and treatment. If parental
illness such as depression is thought tobe contributing to the problem, parents
may be advised to seek help for themselves.” The recurrent nature of the
problem, and the importance of periodic re-evaluation, should be stressed.

The management of persistent or recurrent abdominal pain in childhood

can be time-consuming and frustrating for pediatricians, but with a compre-
hensive approach to the possibility of functional, psychologic, or organic
diagnoses; careful evaluation; and comprehensive counseling, considerable
relief can be provided to the patient and his or her family. The pediatrician
should keep in mind that no matter what the etiology of thecomplaint, thechild
does hurt.

5
REFERENCES

I . Coleman WL, Levine MD: Recurrentabdominalpain: the costof the aches

and the aches of the cost. Pediatr Rev 8:143, 1986

2. Olson A: Recurrent abdominal pain: an approach to diagnosis and

management. Pediatr Ann 16:834, 1987

3. Wald A, Chandra R, Fisher SE, et al: Lactose malabsorption in recurrent

abdominal pain of childhood. I Pediatr 100:65, 1982
4. Levine MD, Rappaport LA: Recurrentabdominalpain in schoolchildren:
thelonelinessofthelong-distance physician. PediatrClin North Am 31 :969,
1984

5. Barbero GJ: Recurrentabdominalpain inchildhood. PediatrRev4:29, 1982

6. Hyams JS: Chronic abdominal pain caused by sorbitol malabsorption. I

Pediatr 100:772, 1982

7. Dimson SB: Transit time related to clinical findings in children with

recurrent abdominal pain. Pediatrics 47:666, 1972

8. Liebman WM: Recurrent abdominal pain in children: lactoseand sucrose

intolerance, a prospective study. Pediatrics 64:43, 1979

9. OsterJ: Recurrent abdominal pain, headache, and limb pains in children

and adolescents. Pediatrics 50:429, 1972

10. Robinson DP, Greene JW, Walker LS: Functional somatic complaints in
adolescents: relationship to negative life events, self-concept, and family
characteristics. J Pediatr 1 13:588, 1988
Ii. Hodges K, Kline JJ, Barbero G, et al: Depressive symptoms in children
with recurrentabdominalpain and in their families.JPediatr 107:622,1987

12. Zuckerman B, Stevenson J, Bailey V: Stomachaches and headaches in a

community sample of preschool children. Pediatrics 79:677, 1982

13. Barr RG, WatkinsJB, PermanjA: Mucosal function and breath hydrogen
excretion: comparative studies in the clinical evaluation of children with
nonspecific abdominal complaints. Pediatrics 6&526, 1981

14. Feldman W, McGrath P, Hodgson C, et al: The use of dietary fiber in the
management of simple, childhood, idiopathic recurrent abdominal pain.
Am J Dis Child 139:1216, 1985

15. Olness K: Hypnotherapy: a cyberphysiologic strategy in pain manage-

ment. Pediatr Clin North Am 36:873, 1989

16. Czinn SJ, Speck WT: Campylobacter pylon: a new pathogen. J Pediatr
114:670, 1989

17. Caulfield M, Wyllie R, Sivak MV Jr. et al: Upper gastrointestinal tract

endoscopy in the pediatric patient. J Pediatr 115:507, 1989

6
18. Steffen RM, Wyllie R, Sivak MV Jr, et al: Colonoscopy in the pediatric
patient. J Pediatr 115:507, 1989
19. Pi#{241}eiro-Carrero VM, Andres JM, Davis RH, et al: Abnormal gastroduo-
denal motility in children and adolescents with recurrent functional
abdominal pain. J Pediatr 113:820, 1988

7
 CONVERSION TABLE TO STANDARD
INTERNATIONAL (SI) UNITS

I. Hematology
Hemoglobin g/dL x 0.155 = mmol/L
Platelets/mm3 = count/p.L = 10’ cells/L

Leukocytes/mm3 = count/jLL = 10’ cells/L

Erythrocytes/mm3 = count/j.LL = 10’ cells/L
Hematocrit % x 0.01 = vol RBC/vol whole blood
Reticulocytes % x 0.01 = (1)

II. Blood Pressure mm Hg (tori) x 1.333 = mbar

III. Blood Gases 1 mm Hg = 133.322 Pa PCO2 mm Hg x 0.1333 = kPa

Base excess mEq/L = mmoVL P02 mm Hg x 0.1333 = kPa
pH value = same

IV. Blood Chemistries

Acetone mg/dL x 0.1722 = mmolIL
Acetaminophen ig/mL x 6.62 = j.tmol/L
Albumin g/dL x 144.9 or gIL x 14.49 = j.tmol/L
Aldosterone ng/dL x 0.0277 = nmol/L
Ammonia mgN/dL x 0.714 = mmol/L
Bicarbonate mEjL = mmol/L
Bilirubin mg/dL x 17.10 = p.mol/L
Blood urea nitrogen mg/dL x 0.357 = mmol urea/L
Calcium mg/dL x 0.25 = mmol/L
Carotene IU x 0.6 = jig
or jig/dL x 0.01863 = jimol/L
Ceruloplasmin mg/dL x 0.0662 = j.unol/L
Chloride mEq/L = mmolfL
Cholesterol mg/dL x 0.0259 = mmol/L
Complement component (C3) mg/dL x 0.01 = g/L
Copper j.Lg/dL x 0.157 = j.unol/L
Cortisol j.tg/dL x 27.59 = nmol/L
Creatine mg/dL x 76.26 = p.mol/L
Creatinine mg/dL x 88.40 = jimol/L
Digoxin ng/mL x 1.28 = nmol/L
Enzymes
Alanine aminotransferase
(ALT, SGPT) U/L = U/L
Aldolase
Sibley-Lehninger units/mL = U/L
Amylase
Somogyi units/dL = U/L
Aspartate aminotransferase
(AST, SOOT) U/L = U/L
Creatine kinase (CK) U/L = U/L
Phosphatase
Bodansky units/dL = U/L
King-Armstrong units/dL = U/L
8
 Fatty acids mg/dL x 0.0354 = mmol/L
Ferritin ng/mL x 1 = p.gL
a,-Fetoprotein ng/mL x 1 =

Fibrinogen mg/dL x 0.01 = g/L

Folic acid jig/dL x 22.65 = nmol/L
Glucose mg/dL x 0.0555 = mmol/L

Glycerol mg/dL x 0.1086 = mmol/L

Haptoglobin mg/dL x 0.01 176 = jimol/L

17-Hydroxyconicosteroids mg/d x 2.759 = jimoVd

Insulin IU x 0.04167 = mg

or jiU/mL x 1.0 = mU/L

Iodine jig/dL x 78.8 = nmol/L

Iron p.g/dL x 0.1791 = j.tmol/L

Iron binding capacity j.tg/dL x 0.1791 = jmiol/L

17-Ketosteroids mg/d x 3.467 = .unol/d

Lead j.tg/dL x 0.0483 = jimol,t

Lipoprotein mg/dL x 0.01 = g/L

Magnesium mg/dL x 0.4114 = mmol/L

or mEq/L x 0.5 mmol/L

Phosphorus mg/dL x 0.3229 = mmol/L

Potassium mEqjL = mmol/L

Prednisone mg x 2.79 = j.tmol

Protein g/dL x 10 = giL

Salicylate mg/dL x 0.0724 = mmol/L

Sodium mEq/L = mmol/L

Theophylline jig/mL x 5.55 = jimol/’L

Thyroid-stimulating hormone p.U/mL x 1 = mU/L

Thyroxine jig/dL x 12.87 = nmol/L

Transferrin mg/dL x 0.01 = g/L

Triglycerides mg/dL x 0.01 = gIL

Triiodothyronine ng/dL x 0.0154 = nmol/L

Urea nitrogen mg/dL x 0.357 = mmol urea/L

Uric acid mg/dL x 59.48 = p.mol/L

Vitamin A j.tg/dL x 0.0349 = jimol/L

Vitamin B12 pg/dL x 0.738 = pmol/L

Vitamin C mg/dL x 56.78 = p.mol/L

Vitamin E jig/dL x 2.322 = j.unol/L

Xylose mg/dL x 0.0667 = mmolfL

Zinc j.tg/dL x 0.153 = jimol/L

V. Urine or Stool
Coproporphyrin jig x 1.53 = nmol
Epinephrine jig/d x 5.458 = nmol/d
Vanilmandelic acid mg/d x 5.046 = jimol/d
Homovanillic acid mg/d x 5.489 = jimol/d

VI. Energy
Kcal x 4.1868 = KJ (Kilojoule)
Rad x 0.01 = Gy (Gray) (joule/kg)

VII. Radionuclide Activity

Curie (Ci) x 37 = GGq (Gigabecquerel)