Beruflich Dokumente
Kultur Dokumente
Paul Scavella
4th Year Medical Student
Lecturer: Dr. Carlos Thomas
University of the West Indies, SCMR
Outline
Definition
Epidemiology
Anatomy & Embyrology
Aetiology
Pathophysiology
Clinical Presentation
Differential Diagnosis
Evaluation
Definition
Congenital Heart defect
Ductus arteriosus fails to close after birth
> 3 months in full term infant = Persistent Patent
Ductus arteriosus
Epidemiology
Estimated incidence in US (term infants) = 0.006% - 0.02%
Incidence increases in preterm babies
Anatomy
Anatomy
Classified by the
Krichenko classification
anatomically
Type A (Conical)
Type B (Window)
Type C (Tubular)
Type D (Complex)
Type E (Elongated)
Aetiology
Sporadic
Multifactorial
Genetic + Environmental
Aetiology
Genetic Foactors
X-linked mutations
Familial cases
Teratogens
Prematurity/Immaturity
Aetiology contd
Factors that increase incidence
Prematurity
Inversely related to gestational age
~ 45% of infants < 1750 grams
~ 80% of infants < 1000 grams
Fluid overload
Asphyxia
Aetiology contd
Factors that decrease incidence
Pathophysiology
The patent ductus allows the shunting of blood from the high pressure aorta to the
low pressure pulmonary artery, increasing the volume of blood passing through
the lungs and returning to the left atrium.
This is similar to an increased preload and leads to left atrial dilation, increased LA
pressure, increased PV pressure and ultimately pulmonary congestion (left-sided
congestive heart failure).
Bulging of the aorta and pulmonary artery proximal to the PDA occurs as a result
of increased blood volume and turbulent flow.
There is always a pressure difference between the aorta and pulmonary artery
(greatest during systole), and consequently continuous flow through the PDA
producing the characteristic continuous murmur.
The increased flow through the pulmonary artery can result in pulmonary
hypertension. When the pressure in the pulmonary artery equals or even exceeds
that of the aorta, either the diastolic portion of the murmur or the complete
murmur may disappear due to flow reversal (reverse shunting PDA). Blood then
bypasses the lungs and the patient presents with cyanosis and a compensatory
polycythaemia.
Clinical Presentation
Small PDA
Moderate PDA
Large PDA
Incidental finding
Large PDAs =
Arterial pulse
Arterial pulse
Auscultation
Differential Diagnoses
Coronary arteriovenous fistula.
Systemic arteriovenous fistula.
Pulmonary arteriovenous fistula.
Venous hum.
Tetralogy of Fallot (with absent pulmonary valve)
Ruptured aneurysm of the sinus of Valsalva (seen in Marfan's
syndrome).
Aortopulmonary septal defect (aortopulmonary window).
Investigations
Chest X ray
Normal Cardiomegaly and increased pulmonary
vasculature
ECG
Left Atrial Enlargement
Right Ventricular Hypertrophy
Treatment
Clinical Presentation
Abdominal pain may present with varying characteristics:
Persistent or intermittent
Sharp or dull
Vomiting
Diarrhoea
Constipation
Fever
Weight loss
Headace
Anorexia
Differential Diagnosis
Life-Threatening
Other
Trauma
Constipation
Appendicitis
Intussusception
UTI
Streptococcal pharyngitis
PID
Intestinal obstruction
Mesenteric lymphadenitis
Necrotizing enterocolitis
Evaluation
History
Physical Examination
Investigations
Treatment
Evaluation: History
Evaluation: Physical
Examination
ABCs
Vitals
Growth Parameters (is there evidence of failure to thrive?)
Inspection
Auscultation
Palpation
Percussion
Contour, Symmetry
Vascular irregularities
Skin markings
Wall protrustions
Abdominal distension
Auscultation
Abdominal bruits
Hepatic Hum (Portal hypertension)
Splenic rub (Splenic infarction
Fluid thrills
Tone
Special circumstances
Evaluation: Investigations
In general laboratory tests include:
Serum chemistries
Evaluation: Investigations
contd
Imaging includes
Ultrasound
CT scans
Gallstones
CT with contrast
Treatment
Medical Conditions = Pharmacological agents
RAP: Treatment
3 tiered empiric trial
High fiber diet
Antacids, H2 blockers, Proton Pump Inhibitors
A trial of lactaid or lactase
MCQs
A 24 year old dress designer complains of a crampy periumbilical pain.
These symptoms have been present over the past 9 months since she
has began her first job after graduating art school. During that time,
she has had several episodes of constipation lasting 4-5 days typically
followed by 3-4 days of frequent loose bowel movements. She denies
any blood in her stools, fever, weight loss or change in appetite. Her
symptoms are generally milder on weekends. Her physical
examination is normal. Her WBC is 6700/mm 3, her hematocrit 38% and
her ESR 4mm/h Her serum albumin and liver function tests are normal.
Which of the following is the most likely diagnosis?
a. Crohns Disease
b. Diverticulosis
c. Giardia infection
d. Irritable Bowel Syndrome
e. Ulcerative colitis
MCQs
All of the following are correct except:
a. Urine Beta hCG is done routinely on females with
abdominal pain
b. CT is useful in diagnosing equivocal appendicitis
c. Chest X-ray is useful in evaluating abdominal pain
d. Ultrasound is the preferred modality for diagnosing
gallstones on imaging