Table 5. Normal Glomerular Filtration Rate (GFR) DurIngInfancy

AVERAGE GFR RANGEAGE ML/MINII.73 M� ML/MIN/1.73 M�

2-8 days 39 17-604-28 days 47 26-68

37-95 days 58 30-861-6 months 77 39-1146-12 months 103 49-157

12-19 months 127 62-1912-12 years 127 89-165

Reproduced with permLssion� Heilbron DC, Holliday MA, al-Dahwi A, Kogan 84.Expressing glomerularfihtration rate in children, Pedlati NephroL 1991; 5:5-11.

Pediatrics in Review VoL 14 No. 2 February 1993 79

PHYSiOLOGYFluids and Electrolytes

SUGGESTED READINGAnderson S. Garcia DL, Brenner BM. Renal

and systemic manifestations of glomerulardisease. In: Brenner BM, Rector FC Jr, eds.The Kidney, 4th ed, Vol II. Philadelphia,PA: WB Saunders Co; 1991;1831-1870

Briggs JP, Sawaya BE, Schnermann J.Disorders of salt balance. In: Kokko JP,Tannen RL, eds. Fluid�c and Electro’ytes,

2nd ed. Philadelphia, PA: WB Saunders Co;1990:70-138

Darrow DC. A Guide to Leanzing Fluid

Therapy. Springfield, IL: Charles C ThomasPublishers; 1964

Finberg L, Kravath RE, Fleischman AR.Water and ElectroIytes in Pediatrics.Philadelphia, PA: WB Saunders Co; 1982

Fanestil DD. Compartmentation of body water.In: Maxwell MH, Kleeman CR, Narins RG,eds. Clinical Disorders ofFluid andElectrolyte Metabolism, 4th ed. New York,NY: McGraw-Hill Book Co; 1987:1-13

Guyton AC. The lymphatic system, interstitialfluid dynamics, edema, and pulmonary fluidand partition of the body fluids: Osmoticequilibria between extracellular andintracellular fluids. In: Guyton AC.Textbook ofMedical Physiology, 7th ed.Philadelphia, PA: WB Saunders; 1986:361-371; 382-392

Holliday MA. Body composition, metabolism,and growth. In: Holliday MA, Barratt TM,Vernier RL, eds. Pediatric Nephrology, 2nded. Baltimore, MD: Williams & Wilkins;1987:3-13

Reineck Hi, Stein JH. Sodium metabolism. In:Maxwell MH, Kleeman CR, Narins RG,eds. Clinical Disorders of Fluid and

Electrolyte Metabolism, 4th ed. New York,NY: McGraw-Hill Book Co; 1987:33-59

Schwartz GJ, Haycock GB, Edelmann CM Jr,Spitzer A. Late metabolic acidosis: Areassessment of the definition. J Pediatr.1979;95:102-107

PIR QUIZ11. All of the following are correct

statements regarding normal andabnormal body compositionsexcept:A. Diarrhea represents an exam-

pie of excessive losses oftranscellular fluid.

B. Current studies support theconcept of the hypoalbumi-nemia-hypovolemia-edema sequence.

C. The size of the extracellularfluid compartment is deter-mined by the quantity of so-dium present because sodiumions contribute effective cx-tracellular solute.

D. A person’s extracellularwater contribution to totalweight attains 20% by 3years of age.

E. The intracellular fluid corn-partment approximates 40%in both the infant and theadult.

12. The most correct statement re-garding basal metabolic rate(BMR) is:A. The higher BMR of infants

results from the greater con-tribution of “central organs”to body weight.

B. The impact of fever on BMRnecessitates a 10% decreaseof estimated fluid for insensi-ble loss for each degree cen-tigrade above normal.

C. The basal energy expenditureof the liver is the single larg-est factor in determining theBMR of infants.

D. In the adult, muscle mass ac-counts for approximately50% of the BMR.

13. Factitious hyponatremia may oc-cur in each of the followingexcept:A. Hypothyroidism.B. Hyperglycemia.C. Addison disease.

D. Familial hypercholestemle-mia.

E. Diabetes mellitus.

14. True statements regarding effec-tive osmolality of body fluidsand their controls include all ofthe foilowing except:

A. The osmoreceptors regulatingrelease of ADH and those re-sponsible for thirst are set atdifferent levels of plasma os-molality.

B. Total serum osmolality canbe accurately estimated frommeasured serum concentra-tions of sodium, urea-N, andglucose.

C. A normal serum osmolalityof about 280 mOsm/kg ismaintained by control ofwater balance.

D. Most infants by I month ofage can vaiy urinary concen-trations of solute from 50 to1000 mOsm/L.

E. The serum proteins accountfor the normal difference be-tween serum and intracellularosmolality.

15. Of the following, the most cor-rect statement regarding Hf-ionbalance is:A. In the growing child, the

daily endogenous H�-ionload approximates 8 to 10rnEq/day.

B. The synthesis of “new”HCO3- normally matchesthat consumed in buffetingendogeneous H�-ion load.

C. Greater renal resorption ofHCO3- results in higherserum HCO3- levels ininfants versus adults.

D. A vegetarian diet adds to thedaily H�-ion load requiringelimination to maintainhomeostasis.

‘�\

American Academy � �of Ped i at r ics d �

�

Continuing EducationPrograms

Annual Meetings

Washington, DC Dallas, Texas

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

Spring Sessions

Chicago, Illinois Denver, Colorado

March 20-24, 1993 April 23-27, 1994

Continuing Medical

Education Courses

Pediatrics 1993 Pediatric Trends

Maui, Hawaii Traverse City, MichiganMarch 5-7, 1993 September 3-5, 1993

Stateof-the-Art PediatricsNew York, New York .

State-of-the-Art PediatricsMay 14-16, 1993 .

Atlantic City, New Jersey. . September 29-October 1, 1993

Pediatric AdvancesHilton Head Island, South CarolinaMay 28-30, 1993

6th Annual PediatricsClinical Pediatrics in ProgressWashington, DC San Francisco, CaliforniaJune 18-20, 1993 October 8-10, 1993

To those enrolled in PREP (Pediatrics Review and Education Pro-gram), these programs feature subject matter coordinated with thePREP curriculum. Credits earned in these courses may be appliedtoward the PREP Education Award available to Fellows and Can-didate Fellows of the Academy.

PREP: THE COURSEAn Intensive Review of Pediatrics

San Diego, California Pine Mountain, GeorgiaMay 8-12, 1993 (one hour from Atlanta)

October 15-19, 1993

For further information contact:

CME RegistrationAmerican Academy of PediatricsP0 Box 927Elk Grove Village, IL 60009-0927800/433-9016Outside the US and Canada: 708/228-5005

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 pediatricianwith criteria for assessing patient records dealing with specific problems.Important elements to be included in the record appear in bold-face type in themargins; 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 thoroughhistory and physical examination as appropriate for the patient and theparticular 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 expertsare 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 thefrequency 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 beendivided into organic, functional, and psychologic causes,2 but these are notmutually exclusive and all avenues should be explored in the evaluation of thechild with chronic or recurrent abdominal pain. Functional pain is consideredto 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 painshave been present for at least three months and have been characterized bypersistence or recurrence over that time period.

PATIENT IDENTIFICATION

The age of the patient or birth date should be recorded because the Birth datecommon causes of abdominal pain tend to differ with age; for example, pepticulcer disease and inflammatoryboweldisease are more common after lOyears Race

ofage. Raceshould alsobe noted, for sickleceildisease isa causeofpaininblackpersons, and lactose intolerance is a frequent cause of symptoms in black, GenderMediterranean, Indian, and Asiatic children older than 4 years ofage.3 Gender Immunizationsmay be significant, for urinary tract infections and pelvic abnormalities aremore common in girls. An up-to-date record of all immunizations should be Drug allergiesa part of each child’s medical record. Finally, any drug allergies should berecorded prominently on the chart so that a drug to which the patient issensitive 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 5�verftY,f1��uency,pain to the back occurs in posterior duodenal ulcer and pancreatitis, whereas characterpain 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 stoolslesions 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, orinflammatory bowel disease. Left lower quadrant pain is usually caused bycolitis 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 orFever colomc pain as cramping. The pain of esophagitis, ulcer disease, or inflamma-

,� tory bowel disease may awaken the patient from sleep; esophageal pain isFamily 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, biliarydepression 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 likechronic 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 berecorded. 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’sappetite 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 ofvomiting 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 toinflammatory bowel disease or infection. Urinary tract disease is a common

cause of abdominal pain, and its presence may be indicated by the complaintsof 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 bedetermined.�’ Distention and flatus are clues to disorders such as lactoseintolerance8 or giardiasis.

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

evidence of other potentially functional complaints, such as headache, vaguechest discomfort, anorexia without weight loss, or joint and extremity painwithoutobjective manifestions.9”#{176}Thepreviousmedicalhistory maybe helpfulif 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. Apattern ofover-reaction to minor illnessor injury maybeuseful as evidence thatthe parent(s) may be overly anxious.

The familyhistory should focusongastrointestinaldisease, such as pepticulcer, spastic colon, and lactose intolerance. Because migraine and seizure

disordersare causesofabdominal pain, though uncommon, a family history ofthese complaints may be helpful.4 A strong relationship between maternal

depression and recurrent abdominal pain in her child has been reported, soevidence 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’senvironment 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 Temperaturesystems, so a thorough, complete physical examination should be done. Theheight 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 Weightpresence of a urinary tract abnormality, the blood pressure should also berecorded. The resuitsofa detailed abdominalexamination should be available, Blood pressureincluding the presence of masses or enlarged organs, any tenderness or Abdomen

distention, and the description of the peristaltic sounds. A rectal examinationmay be useful to search for fecal or other masses, to ascertain the character of Rectal examinationthe 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 countorganic origin, no laboratory or radiologic study is absolutely indicated in

every patient.”�4 Rather, studies should be selected on the basis of the results Erythrocyteof a detailed history and physical examination, and the most likely cause for sedimentation ratethe complaints. However, it is commonly desirable to perform a noninvasive , , . Iand 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 cultureto be present. For example, a complete blood count may provide evidence ofanemia, lead poisoning, parasitic disease or allergy (eosinophilia), and other Stool for occult blood

causes of recurrent pain. An erythrocyte sedimentation rate may be helpful inconsidering a disorder such as inflammatory bowel disease. Several stoolexaminations for occultblood canbe helpful in identifying sources of bleeding,such as peptic ulcer or a Meckel diverticulum. A complete urinalysis and, ingirls, a urine culture will be helpful in the elimination of urinary tract diseaseas 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 suspectedsteatorrhea, and an excessive number of leukocytes in stool may be found inpatients with various forms of colitis. Where available, breath hydrogenstudiescan be usefulinconfirming the presence ofcarbohydrate intolerance.3”3

Ultrasonography is the least invasive method for evaluating renal orpelvic abnormalities and diseases of the gallbladder or biliary tract, providing

that the radiologist is experienced with such examinations in children. X-raystudies 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 bereserved 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 originis 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 physicalfindings indicate significant constipation. The cessation of sorbitol ingestionhasbeenassociated with reliefin a few patients,’and a trial ofa lactose-free dietmay 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, andto reduce intrafamilial tensions.1#{176} Relaxation techniques may be helpful inchildren old enough to cooperate, as for other types of chronic pain.’5 For thechild who is missing considerable school and has no evidence of significant

organic disease, regular attendance is mandatory. The prescription ofantispasmodic 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 follow�up Children with recurrent abdominal pain should beevaluated regularly invisits 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 periodicreinforcement.1’� Continued efforts should be made to resolve family andschool issues which may be contributing to environmental stress. Each visit

should be documented in the patient’s record. The longer a child is observedand hasnoevidenceoforganic disease, thelesslikely itis thata hidden problemis being missed. When organic disease is suspected, consultation with a

pediatric gastroenterologistmaybe indicated before an extensiveevaluation isinitiated 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 aboutmanagement of this troublesome problem. Both need to be assured that the cause of painpain isreal, and thatthe child isnot malingering. The pediatrician should avoid

stating that “nothing is wrong” or implying this by saying, “I cannot findanything 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 occursinadults)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 parentalillness 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, considerablerelief 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 achesand 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. IPediatr 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 sucroseintolerance, 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 childrenwith 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 withnonspecific 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 functionalabdominal pain. J Pediatr 113:820, 1988

7

CONVERSION TABLE TO STANDARDINTERNATIONAL (SI) UNITS

I. HematologyHemoglobin g/dL x 0.155 = mmol/LPlatelets/mm3 = count/p.L = 10’ cells/LLeukocytes/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 = kPapH value = same

IV. Blood ChemistriesAcetone mg/dL x 0.1722 = mmolILAcetaminophen �ig/mL x 6.62 = j.tmol/L

Albumin g/dL x 144.9 or gIL x 14.49 = j.tmol/LAldosterone ng/dL x 0.0277 = nmol/LAmmonia mgN/dL x 0.714 = mmol/LBicarbonate mE�jL = mmol/L

Bilirubin mg/dL x 17.10 = p.mol/LBlood urea nitrogen mg/dL x 0.357 = mmol urea/L

Calcium mg/dL x 0.25 = mmol/LCarotene IU x 0.6 = jig

or jig/dL x 0.01863 = jimol/L

Ceruloplasmin mg/dL x 0.0662 = j.unol/LChloride mEq/L = mmolfL

Cholesterol mg/dL x 0.0259 = mmol/L

Complement component (C3) mg/dL x 0.01 = g/LCopper j.Lg/dL x 0.157 = j.unol/LCortisol j.tg/dL x 27.59 = nmol/L

Creatine mg/dL x 76.26 = p.mol/LCreatinine mg/dL x 88.40 = jimol/LDigoxin ng/mL x 1.28 = nmol/L

EnzymesAlanine aminotransferase

(ALT, SGPT) U/L = U/LAldolase

Sibley-Lehninger units/mL = U/LAmylase

Somogyi units/dL = U/LAspartate aminotransferase

(AST, SOOT) U/L = U/L

Creatine kinase (CK) U/L = U/LPhosphatase

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/LGlycerol mg/dL x 0.1086 = mmol/LHaptoglobin mg/dL x 0.01 176 = jimol/L

17-Hydroxyconicosteroids mg/d x 2.759 = jimoVdInsulin IU x 0.04167 = mg

or jiU/mL x 1.0 = mU/L

Iodine jig/dL x 78.8 = nmol/LIron p.g/dL x 0.1791 = j.tmol/LIron binding capacity j.tg/dL x 0.1791 = jmiol/L

17-Ketosteroids mg/d x 3.467 = �.unol/dLead j.tg/dL x 0.0483 = jimol,t

Lipoprotein mg/dL x 0.01 = g/LMagnesium mg/dL x 0.4114 = mmol/L

or mEq/L x 0.5 � mmol/LPhosphorus mg/dL x 0.3229 = mmol/L

Potassium mEqjL = mmol/LPrednisone mg x 2.79 = j.tmol

Protein g/dL x 10 = giLSalicylate mg/dL x 0.0724 = mmol/L

Sodium mEq/L = mmol/LTheophylline jig/mL x 5.55 = jimol/’LThyroid-stimulating hormone p.U/mL x 1 = mU/L

Thyroxine jig/dL x 12.87 = nmol/LTransferrin mg/dL x 0.01 = g/LTriglycerides mg/dL x 0.01 = gIL

Triiodothyronine ng/dL x 0.0154 = nmol/L

Urea nitrogen mg/dL x 0.357 = mmol urea/LUric acid mg/dL x 59.48 = p.mol/LVitamin A j.tg/dL x 0.0349 = jimol/L

Vitamin B12 pg/dL x 0.738 = pmol/LVitamin C mg/dL x 56.78 = p.mol/LVitamin 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 StoolCoproporphyrin jig x 1.53 = nmolEpinephrine jig/d x 5.458 = nmol/dVanilmandelic acid mg/d x 5.046 = jimol/dHomovanillic acid mg/d x 5.489 = jimol/d

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

VII. Radionuclide Activity

Curie (Ci) x 37 = GGq (Gigabecquerel)

9