baby nelson tidbits Flashcards
Secretory Diarrhea vs Osmotic diarrhea
- Secretory diarrhea: intestinal mucosa directly secretes fluid and lutes into the stool; result of inflammation (i.e. IBD, chemical stimulus, from hormones - i.e. vasoactive intestinal peptide by neuroendocrine tumour). Holera - stimulated by enterotoxin of vibrio cholera, causes increased ccAMP in enterocytes, secretion into small bowel
- Osmotic diarrhea: malabsorption of a substance, pulls water into the bowel i.e.) lactose intolerance, maldigestion (i.e. pancreatic insufficiency, intestinal injury) , PEG, Milk of Mg; fermentation of the substances can lead to gas, cramps, acidic stools, toddler’s diarrhea
How to decide if diarrhea is osmotic or secretory
- calculate the osmotic gap
290- (2 x Na x K) Na and K are the measured stool Na and K
assume the stool is always isoosmotic (omsoles of 290) since will have free water exchange across intestine
Secretory diarrhea: osmotic gap 50 - malabsorbed substances other than electrolytes account for decal osmolarity - stop feedings and give IV only - if gets better when NPO, more likely osmotic, secretary will continue to poopp (not perfect, i.e. viral will cause some damages and inflammation of the bowel)
tests for pancreatic insufficiency
oily or fatty stools, should test decal fat content or decal elastase to test for pancreatic insufficient
Functional constipation, definition
2 or fewer stools per week, voluntary withholding of stool, infrequent passage of large-diameter, often painful stools, often have “retentive posturing” and have associated decal incontinence from leakage of retained stool (aka encopresis)
Constipation : defined as 2 or fewer stools per week or passage of hard pellet like soils for at least 2 weeks
Differential of constipation
- functional constipation very common when tolilet training onwards; key is large caliber stools, encopresis, voluntary retaining, age of onset at potty training; normal or reduced anal sphincter tone because the big poops may have stretched it ; often have fecal impaction, can also have a large-caliber empty rectum if they just pooped
- Hirschprung - (see below)
- Anorectal and Colonic Malformation - usually confirmation from birth - anal stenosis, anteriorly displaced anus (mainly in females), imperforate anus, colonic stricture
- Mulridystem disease: muscular dystrophy, CF, diabetes meliitus (?), Developmental delay, celiac, hypothyroidism -
- Spinal cord abnomalities - history of swelling/exposed neural tissue in the lower back , history of urinary incontinence; will have lax sphincter tone; i.e. meningomyelocele, tethered cord, sacral teratoma or lipoma
- Drugs - narcotics, psychotropics
Hirschprung disease - what part of the bowel is dilated
narrow distal bowel - no ganglions
dilated proximal bowel
(can look on barium enema), rectal suction biopsy is the confirmatory test - no ganglion cells in the rectal submucosal plexus, lack of internal anal sphincter relaxation by anorectal manometry
delayed passage of meconium, failure of ganglions to migrate **no associated with large caliber stools or encopresis; snug anal sphincter, empty contracted rectum, may have explosive poop after examiner’s finger is withdrawn
can present in the initial stages with enterocolitis
common drugs that cause giginval hypertrophy
cyclosporine
phenytoin
calcium channel blockers
causes of delayed teeth eruption
hypopituitarism, hypothyroidism, osteopetrosis, Gaucher disease, Down syndrome, cleidocranial dysplasia, rickets
eosinophilic esophagitis
non IgE mediated allergic reactions to foods or aeroallergens
may have some familial connection
diagnosis: biopsy will show >15 eosinophils/hpf
treatment with high dose PPI to exclude that it is simply from acidic injury from reflux
barium study - may show a food impaction or esophageal stricture
presentation: young kids - oral aversion, vomiting and failure to thrive
school age: vague abdo pain o vomting
teens/adults - dysphagia/food impactions
Treatment and prognosis of eosinophilic esophagitis
avoid the causative antigens - but can be hard to identify, since the typically allergy testing (skin prick, RAST and imunocap assay will only identify IgE mediated antigen)
atopic patch testing might be better
one approach: eliminate cow’s milk, soy, wheat, eggs, peanuts and fish/shellfish (since most common causes)
may need repeat endoscopy
elemental diet
steroids can help with symptoms but can’t do long term because of complications
endoscopy - can be used for food impactions and to dilate esophageal strictures
esophageal foreign body - when do you need to remove them
don’t need to remove if small and in the stomach already
need to remove if
1. - threaten the airway - (need to intubate and do GA)
2. symptoms
3. disc batter in esophagus or multiple magnets
what are pill ulcers
when certain meds (i.e. tetracycline, nSAIDS) are swallowed without sufficient liquids, allow prolonged direct contact of the pill with the esophageal mucosa
presents with odynophagia and dysphagia as well as chest pain
caustic injury (ie kid swallows a clearner) what to do?
CXR to rule out aspirations dn look for mediastinal air
hospital, keep NPO with fluids until endoscopy
can get subsequent strictures, also might not see the whole burn initially
NG tube can be placed over a guide wire at the time of the initial endoscopy - provides a route for feeding and to stent the esophagus
steroids don’t help reduce strictures
treatment of esophageal strictures: treat with endoscopic dilation; can have a risk of perforation during dilation
Peptic ulcer disease in kids, name some risk factors
- H pylori **plays a significant role, but not as much as in adults, RFs are lower SES and poor sanitation
- drugs - HSAIDS (including aspirin) tobacco use, bispohophonates, potassium supplements, family history, sepsis, head trauma, burn injury, hypotension
- family history
- sepsis
- head trauma
- burn injury
- hypotension
true or false - non ulcer dyspepsia is associated with H pylori
false - non ulcer dyspepsia - which are upper abdo symptoms 9pain, bloating, nausea, early satiety) in the absence of gastric or duodenal ulceration are not associate diwth H pylori
which ulcers have pain relieved by eating and which are worse with eating?
duodenal - better with eating
gastric - worse with eating - result in weigh gloss
diagnosis of ulcers
endoscopy
can do empiric therapy with H2 blockers or PPI
can test for H pylori with biopsy during scope or can do non invasive tests 13C urea breath test/H. pylori decal antigen
patients with ulcers and H. pylori (positive) how to treat
PPI
amoxicillin
clarithromycin
or PPI, amoxicillin, metronidazole or omeprazole/clarithromycin/flagyl
2x daily for 1-2 weeks
if no H pylori, then H2
most will heal in 3- 8 weeks in at least 80% of patients; esophagitis takes longer to heal 4-5 months
treatment of cyclic vomiting syndrome
acute episode - hydration, dark, quiet environment, and anti emetics such as ondansetron
abortive treatment - NSAIDS/triptans
if frequent - can try prophylactic (similar to migraine meds 0 cyproheptadine, TCAs, beta blockers or topiramate
