Get That Cow Milk Away From Me, Please...!!

Tutor: dr. Julius Chandra Y.

Kelompok 9

NamaNIMPosisiYuliana Starsia405070021KetuaSaskia Prathana405070088SekretarisRendy Christian M.405070159AnggotaAditya Nagatama405070064AnggotaFrans Welly405070059AnggotaDavid Santoso405070074AnggotaPuspita Permata Sari405070150AnggotaLusia Christina405070073AnggotaJessica Purnamasari405070165AnggotaFracella Putri405070160AnggotaRonald Yulianto405070110AnggotaShandy405070149Anggota

Case 1B

You receive a call from Mrs. Melati, mother of Rosa, a previously healthy 2-month-old girl. For the past 3 days, Rosa developed an occult bleeding and mucous in the stool accompanied by a moderate degree of emesis. However, her temperature hasnt increased, no abdominal cramping or colic, but today she seems a bit pale and more irritable.

Unfortunately Mrs. Melati didnt breastfeed Rosa about a week ago, and give her regular cow milk formula. While you are discussing her family history, Mrs. Melati reports that Rosas brother and sister are having food allergy, her 6-year-old brother is asthmatic as well as his father. The mother assumed that he has the same dairy product allergy like his 3-year-old sister.

You tell her to bring him for further diagnostic investigation and call the lactation clinic for a counseling appointment in order to return to exclusive breastfeeding.

Foreign Terminology

Occult blood in the stool:Small quantities of blood in the stool, that can only be detected with chemical testing or microscopical analysis (Dorland)Emesis:Forceful expulsion through the mouth of the contents of the stomach as a response to irritation

GI Tract Anatomy

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GI Tract Physiology

The six processes of digestion involve: (1) the movement of food and liquids(2) the lubrication of food with bodily secretions(3) the mechanical breakdown of carbohydrates , fats, and proteins(4) the reabsorption of nutrientsespecially water(5) the production of nutrients such as vitamin K and biotin by friendly bacteria(6) the excretion of waste products

Comparison of Breastmilk and Formula

-HUMANCOWFORMULAProtein1.13.31.6Whey0.70.60.9 0.96Casein0.42.70.6 0.64Carbohydrate6.94.77.0Fat4.43.31.1Water87.588.080Calories (kcal)706160

GI BLEEDING AND OCCULT BLOOD

Gastrointestinal Bleeding

UpperGI bleeding: esophagus, stomach, or duodenum (first part of the intestine).

Bleeding can come from ingestion of caustic poisons or stomach cancer.

Peptic ulcers Gastritis Esophageal varices

LowerGI bleeding:

the digestive system-the segment of the small intestine farther from the stomach, large intestine, rectum, and anus. Diverticular disease, angiodysplasia, polyps, hemorrhoids, and anal fissures most commonly cause the bleeding. Blood in the stool can result from cancers, inflammatory bowel disease, and infectious diarrhea.

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GI Bleeding Symptoms

Acute GI bleeding first will appear as vomiting of bloodFatigue Weakness Shortness of breath Abdominal pain Pale appearanceVomiting of blood usually originates from an upper GI source. Bright red or maroon stool can be from either a lower GI source or from brisk bleeding at an upper GI source. Long-term GI bleeding may go unnoticed or may cause fatigue, anemia, black stools, or a positive test for microscopic blood.

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Occult Bleeding

Definition

Occult gastrointestinal bleeding refers to a slow loss of blood into the upper or lower gastrointestinal tract that does not cause changes in the color of the stool or result in visible bright red blood.

Occult bleeding has many of the same causes as rectal bleeding and may result in the same symptoms as rectal bleeding.

It is often associated with anemia that is due to loss of iron along with the blood (iron deficiency anemia).

Occult Bleeding

Cause and site of rectal bleeding determined

History and physical examination Anoscopy Flexible sigmoidoscopy Colonoscopy Radionuclide scansVisceral angiogram Blood tests

Occult Bleeding

Rectal bleeding treated

Correcting low blood volume and anemia

Intravenous fluids or blood transfusions and oral iron supplements (tablets).

Determining the cause and site of bleeding

Colonoscopy is the most widely used procedure in the diagnosis and treatment of rectal bleeding

Stopping bleeding and preventing rebleeding

Colonoscopy also be used to stop bleeding by removing (snaring) bleeding polyps, by cauterizing (sealing with electrical current) bleeding angiodysplasias or postpolypectomy ulcers and, occasionally

EMESIS

Emesis

Definition

Vomiting is emitting stomach contents from the mouth. This is not the same as regurgitation, which refers to emitting already swallowed food, and must be distinguished correctly. Vomiting is often related to or preceded by nausea, but both nausea-without-vomiting and vomiting-without-nausea are possible. Any nausea or vomiting symptom needs prompt professional medical investigation.

Emesis

Patophysiology

Receptors are stimulated which contribute impulses to the vomiting center in the brain

Sensory impulse stream from receptors reach the vomiting center and initiate a number of motor responses.

The diaphragm and the skeletal muscles of the abdominal wall contract

Increase the intra-abdominal pressure

The cardiac sphincter relaxes and soft palate rise to close off the nasal passage

The stomach (or intestinal) contents are then forced upward through the esophagus, pharynx and out the mouth

Emesis or Vomiting

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Emesis

The vomiting center has inputs mainly from:Stretch or irritant receptors in the stomach (responds to excessive gastric distention or ingestion irritants or emetics)Chemoreceptor trigger zones in the floor of the fourth cerebral ventricle (responds to increases in ICP)Mechanical receptors in the throatVestibular apparatus (responsible for the travel/motion sickness)

Emesis

Causes

These are possible causes of vomiting in infants (0 - 6 months):

Congenital pyloric stenosis, a constriction in the outlet from the stomach (the infant vomits forcefully after each feeding but otherwise appears to be healthy)

Food allergies or milk intolerance

Gastroenteritis (infection of the digestive tract that usually causes vomiting with diarrhea)

Gastroesophageal reflux

An inborn error of metabolism

Hole in the bottle nipple may be wrong size, leading to overfeeding

Infection, often accompanied by fever or runny nose

Intestinal obstruction, evidenced by recurring attacks of vomiting and crying or screaming as if in great pain

Accidentally ingesting a drug or poison

Diagnosing Causes of Emesis

The history and physical examination should include: duration of vomiting,the presence of blood in the vomitus, the presence of abdominal pain or distension, the character of the stool the presence of the fever.

Diagnosing Causes of Emesis

Blood and urine analysisPlain Abdominal X-rayUSGIntravenous PyelographyEndoscopyMonitoring oesophageal pH

Complications of Emesis

Excessive or repeated vomiting can cause dehydration and may lead to severe disturbances in the electrolyte and acid-base balance in the body.

Dehydration due to loss of water from the GI tract. Hypokalaemia due to loss of the potassium ions in GI secretionsHypochloremia due to loss of chloride ions in the vomitusAlkalosis - due to loss of H+ ions in the vomitusAspiration syndromeMalnutrition and failure to thrivePeptic oesophagitis

Therapy

Causal treatmentAntiemetic medication

ADVERSE REACTIONS TO MILK

Lactose Intolerance

Definiton

Lactose intolerance is the inability or insufficient ability to digest lactose, a sugar found in milk and milk productsLactose intolerance is caused by a deficiency of the enzyme lactase, produced by the cells lining the small intestineLactase breaks down lactose into two simpler forms of sugar called glucose and galactose, which are then absorbed into the bloodstreamPeople sometimes confuse lactose intolerance with cow milk allergyMilk allergy: by the bodys immune system to one or more milk proteins and can be life threatening when just a small amount of milk or milk product is consumedMilk allergy most commonly appears in the first year of life, while lactose intolerance occurs more often in adulthood

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Epidemiology

More than 50 million Americans are lactose intolerant. Nearly two-

thirds of the world's adult population has some degree of difficulty

with digestion of milk sugar because of a lactase deficiency:

97-100% of African Blacks90-100% of Asians70-75% of North American Blacks70-80% of Mexicans60-90% of Mediterraneans60-80% of Jewish descent10-12% of Middle Europeans7-15% of North American Caucasians1-5% of Northern Europeans.

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Etiology of lactose malabsorption

Primary lactose malabsorption

Developmental lactase deficiencyCongenital lactase deficiency

Secondary lactose malabsorption

Bacterial overgrowth/stasisMucosal injury of GIT that causes villus flattening

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Developmental lactase deficiency

Low lactase levels as a consequence of prematurityLactase activity in the fetus increases late in gestationPremature infants born at 28-32 weeks of gestation have a reduced lactase activity

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Congenital lactase deficiency

Characterized by the absence of lactase activity in the small intestine, with normal histologic findingsA gene located on the same chromosome of the lactase gene, is responsible for CLDAffected infants have diarrhea from birth, hypercalcemia and nephrocalcinosis

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Secondary lactose malabsorption

Mucosal injury

Villus flattening or damage to the intestinal epithelium

Celiac disease Crohns diseaseRadiation enteritis, chemotherapyHIV enteropathyWhipples disease

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Lactose Intolerance

Patophysiology

Lactose ingested into small intestine

Unabsorbed lactose into colon.

Normal bacterium split the lactose and use the resulting glucose and galactose for its own purposes

The bacteria also release hydrogen gas

the gas is absorbed from the colon and into the body

then expelled by the lungs in the breath

Most of the hydrogen is used up in the colon by other types of bacteria.

A small proportion of the hydrogen is responsible for the increased flatus (passing gas)

Bacteria changes the hydrogen gas into methane gas, and these people will excrete it in their breath and flatus.

Lactose Intolerance

Not all of the lactose that reaches the colon is split and used by colonic bacteria. The unsplit lactose in the colon draws water into the colon (by osmosis). This leads to loose, diarrheal stools.

Clinical manifestations

Abdominal pain crampy, localized to periumbilical area, or lower quadrantBloatingFlatulenceDiarrheaVomitingStools are usually bulky, frothy and watery

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Differential diagnosis

Irritable bowel diseaseInflammatory bowel diseaseCystic fibrosisDiverticulitisCeliac sprueAcute gastroenteritisGiardiasis

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Diagnosing Lactose Intolerance

Hydrogen Breath TestThe person drinks a lactose-loaded beverage and then the breath is analyzed at regular intervals to measure the amount of hydrogen. Normally, very little hydrogen is detectable in the breath, but undigested lactose produces high levels of hydrogen. Smoking and some foods and medications may affect the accuracy of the results. People should check with their doctor about foods and medications that may interfere with test results.Stool Acidity TestThe stool acidity test is used for infants and young children to measure the amount of acid in the stool. Undigested lactose creates lactic acid and other fatty acids that can be detected in a stool sample. Glucose may also be present in the stool as a result of undigested lactose.

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Lactose Intolerance Treated

Dietary changes

The most obvious means of treating lactose intolerance is by reducing the amount of lactose in the diet.

Food products that may contain lactose include:

Bread and other baked goodsProcessed breakfast cereals Instant potatoes, soups, and breakfast drinks Margarine Lunch meats (except those that are kosher) Salad dressings Candies and other snacks Mixes for pancakes, biscuits, and cookies

Lactose Intolerance

2.Lactase enzyme

Caplets or tablets of lactase are available to take with milk-containing foods.

3.Adaptation

Some people can slowly increasing the amount of milk or milk-containing products in their diets they are able to tolerate larger amounts of lactose without developing symptoms. This adaptation to increasing amounts of milk is not due to increases in lactase in the intestine. Adaptation probably results from alterations to the bacteria in the colon. Increasing amounts of lactose entering the colon change the colonic environment, for example, by increasing the acidity of the colon. These changes alter the way in which the colonic bacteria handle lactose. For example, the bacteria produce less gas. There also may be a reduction in the secretion of water and, therefore, less diarrhea.

Lactose Intolerance

4.Calcium and vitamin D supplements

Milk and milk-containing products are the best sources of dietary calcium and vitamin D .Its a good idea for lactose-intolerant persons to take supplemental calcium and vitamin D to prevent calcium and vitamin D deficiency.

MILK PROTEIN ALLERGY

Milk Protein Allergy

Definition

An abnormal response to a food triggered by the body's immune systemCan cause serious illness or deathProblem foods for children: eggs, milk (especially in infants and young children) and peanutsA reaction to food can also be food intolerance, which is not an allergic reaction, but may present like one.

Epidemiology

Cow's milk allergy (CMA) affects about 2-7.5% of infants. In CMA patients, 50% will develop an allergy to other food proteins (egg, soya, peanut) and 50-80% will develop an allergy against one or more inhalant allergens (grass pollens, house dust mite, cat) before puberty.There is also a higher risk of developing other allergic diseases such as asthma or eczema.

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Clinical Types of Milk Allergic Reactions

Type 1: Early Reaction

Appears 45 minutes after milk ingestionColic, diarrhea, vomiting, skin rash, eczema, occasionally wheezing or sneezing

Type 2: Intermediate Reaction

Appears 45 minutes to 20 hours after milk ingestionVomiting and diarrhea

Type 3: Late Reaction

Appears after 24 hours of milk ingestionDiarrhea, vomiting, wheezing and coughing

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Symptoms that could indicate a possible milk allergy

recurrent bronchitis recurrent "colds," sinusitisear infections fluid behind ears wet and wheezy chest coughing irritability failure to thrive excessive colic recurrent diarrhoea Vomitingabdominal pain excoriated buttocks rash, hives and eczema chronic runny nose nasal stuffiness

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Diagnosis

Only the immediate milk reactions that develop after a few minutes are most likely to give a positive blood or skin test, as these detect IgE that is involved in the immediate type reactionNearly 60% of milk reactions in the young child are the delayed type (intolerant) and therefore unlikely to give positive results with the blood and skin tests

Milk Protein Allergy

Milk Protein Allergy Treatment

Avoid allergens while maintaining a balanced, nutritious diet for infants and mothers.Breastfeeding can be continued if allergens are avoided.

Prognosis

Most children will outgrow their Cow Milk Allergy, +60% at 4 years and +80% at 6 yearsSome patients retain the allergy throughout lifeIf the milk is strictly excluded from the diet for + 2-3 years, the child then has an 80% chance of tolerating the milk in small amounts againCMA may be acquired later in life

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Conclusion and Recommendation

Based on Rosas symptoms (occult bleeding, mucous in stool, and emesis) and her given family history, it is possible that she suffers adverse reactions to foods, specifically milk, in the form of lactose intolerance or milk protein allergy.It recommended that she undergoes further diagnostic investigation to identify the underlying cause and also avoid dairy products for the time being

References

http://www.foodallergysolutions.com/lactose-intolerance.htmlhttp://www.medicinenet.com/lactose_intolerance/discussion-106.htmlhttp://digestive.niddk.nih.gov/ddiseases/pubs/lactoseintolerancehttp://pedsinreview.aappublications.org/cgi/content/full/29/2/39http://www.allergyadvisor.com/Educationalhttp://www.saanendoah.com/compare.html

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