Abdominal

Question 1

Diagnostic criteria for constipation

Answer 1

Delay or difficulty in defecation present for 2+ week

• Normal stooling _~1-2x/day
• Except first few weeks of lifeà 1-4x/day is normal

Question 2

clinical presentation of functional constipation

Answer 2

delay or defecation present for 2+ weeks

Peak occurence at:

6mo (with intro of solid food)

1-2years (with introduction of cow’s milk)

3-5years (with challenge of kids not wanting to stool at school)

Question 3

encopresis

Answer 3

follows untreated chronic constipation

child has 3-8 bowel movements in their underwear that they can’t control (leaking around impaction- can’t keep sphincter closed around distended rectum)

Question 4

inflammatory bowel disease

(Sx of both Chron’s and UC)

Answer 4

CBC indicative of anemia and you will see elevated ESR and CRP

abdominal pain, weight loss, diarrhea, growth failure and extraintestinal manifestations (like delayed puberty)

Question 5

clinical presentation of ulcerative colitis

Answer 5

fevers

bloody/ mucoussy diarrhea

nocturnal diarrhea

Question 6

Sx of Crohn’s

Answer 6

abdominal pain that wakes from sleep

hematochezia (bright red blood in stools)

Question 7

clinical presentation of irritable bowel syndrome:

Answer 7

episodic or continuos abdominal pain

NO evidence of an inflammatory, anatomic, metabolic or neoplastic process to explain the pt’s symptoms

some loss of daily functioning

additional somatic sx such as headache, limb pain, or difficulty sleeping

CANNOT have: persistent RUQ or RLQ pain; dysphagia; persistent vomiting’ GI blood loss; noctural diarrhea; FHx of IBD, celiac dz, or PUD; pain that wakes the child from sleep; arthritis; perirectal dz; involuntary weight loss; deceleration of linear growth; delayed puberty; unexplained fever

Question 8

Formulate a management plan for a child under 1yo with functional constipation

Answer 8

Education: explain the process of constipation (large/hard painful bowel, so child holds inside, colon is stretched and increasingly more full of stool, because the colon draws water out of the stool, the subsequent pooping is even more painful, which reinforces avoidance of pooping)

• *Diet**: can introduce 2-4 oz of sorbitol containing fruit juice into diet or feed pureed prunes
• *Medication**: If diet and education are not helpful, consider a trial of an osmotic laxative like Lactulose or Karo syrup (1-2 tablespoons QD-BID—titrating to achieve soft pudding consistency stools)

Can add in ½ dropper of Little Tummies laxative if necessary for 2 weeks if child is very retentive

Question 9

Design a managment plan for a child 1⁺yo with functional constipation

Answer 9

• *Education**: explain the process of constipation and that treatment will be a long term process (4-6 months minimum)
• *Diet: decrease milk intake; increase fiber (5g + age**); increase clear fluids
• *Behavioral changes**: toilet time 15-20 min after meals for 5-10 minutes
• *Medication**: If diet and education are not helpful, consider a trial of Lactulose or Miralax (1/2 capful/1TBS-1 capful/2TBS dissolved in 4-10 oz of clear fluid) QD to BID

Can add in 1 dropper of Little Tummies laxative or ½-1 square of Chocolate Ex-lax QD to BID if necessary for 2 weeks-2 months to help with frequency

*As long as child has been constipated is about how long will take to get better

• Goal of treatment is 1-2 pudding-consistency stools/day
• Administer enema (1-2) in clinic and that clear impaction before leave office as parents may not do enema correctly at home.

Question 10

types of laxitives used to treat kids

Answer 10

Miralax is used to achieve softer consistency

Ex-lax to achieve greater frequency

Question 11

DDx for patient with suspected functional constipation

Answer 11

• Infant dyschezia
• Hirschsprung disease
• Cow’s milk intolerance
• Cystic fibrosis
• Anorectal anomalies
• Celiac disease

Question 12

Predict the need for referral to a pediatric gastroenterologist in a patient with constipation

Answer 12

Treat aggressively and play with different medicine and behavioral changes. If patient isn’t improving or parents are very frustrated, refer to GI.

Question 13

clinical presentation of an infant with milk protein intolerance:

In infants (1-2 weeks of age to about 9-10 months of age)

Answer 13

-Typically it occurs in breastfed infants who present with fussiness anytime throughout the day and not just in the evenings. Occasionally the infants may even have bright red blood or mucous in their stools. The important thing about these kids is that they are growing well. They are eating and gaining weight appropriately for their age.

Question 14

differential diagnosis for recurrent abdominal pain

Answer 14

DDx:

Constipation
Encopresis
Celiac Disease (IBD)
Chron’s Disease (IBD)
Ulcerative Colitis
IBS (Functional Abdominal Pain)

Question 15

“red flags” in the assessment of a child with recurrent abdominal pain

Answer 15

failure to pass meconium in the first 48 hours or likely dealing with a condition other than chronic constipation

Other red flags you want to watch out for are: fever, vomiting, failure to thrive, anal stenosis, tight empty rectum on physical exam, and abdominal distention—these would make you more suspicious for another underlying cause

Question 16

primary care laboratory evaluation of a child with suspected celiac disease

Answer 16

Suspect Celiac Disease–> order a Tissue Transglutaminase Antibody blood test and a serum IgA level (to check IgA levels in general)

TTG levels suggestive of Celiac Disease (may take up to 2yrs after beginning Tx to see drop in TTG levels)

Confirm diagnosis with an upper endoscopy bc untreated or poorly treated Celiac Disease leads to osteoporosis, intestinal lymphoma, infertility