Child with emesis

Question 1

Pyloric stenosis

Answer 1

Hypertrophy of the pyloric sphincter causing a obstruction of the gastric outlet

Presentation:
First few weeks after birth - 3-6 weeks
Non-bilious projectile emesis, Poor weight gain
Palpable, epigastric olive sized mass

work up:
Hypochloremic, hypokalemic Metabolic alkalosis
Barium swallow - thin pyloric channel “string sign” or Complete stenosis
Ultrasound With increased pyloric muscle thickness

Tx: pyloromyotomy
- Most common surgery in the first two months of life

Question 2

Intussusception

Answer 2

MC bowel obstruction in under 2 yo

Risk factors:
Meckel's diverticulum
Henoch Schonlein purpura
Adenovirus infection - inflammed Peyer's patches
CF
Adult - cancer

Presentation:
6 mo - 36 mo
Sudden abdominal pain - Episodic, lasting less than one minute
Pallor
Sweating
Vomiting
Bloody mucus in stool - Currant jelly stools
Exam:
Abdominal tenderness With palpable sausage like mass

Dx:
Barium enema
CT or US

Tx:
Enema - barium, air, or saline
Surgery if refractory

Bowel ischemia worst complication

Question 3

Malrotation and volvulus

Answer 3

Classically before age 1, can occur up to 5 yo

Presentation:
Bilious emesis
Recurrent abdominal pain

Twisting of the small bowel often resulting in bowel obstruction
Can twist around SMA -> Ischemia

Dx:
Best exam: Upper G.I. series
barium enema
U/S - normal doesn’t r/o

Tx: sx

Question 4

Hirschsprung disease

Answer 4

Failure of neural crest cell migration

• > lack Auerbach and Meissner plexuses in colon
• > cannot produce normal peristaltic waves to expel feces

Presentation:
Meconium ileus
Early-onset chronic constipation and abdominal distention

Associated with:
Down syndrome
Duodenal atresia
annular pancreas
celiac disease

Question 5

Reye Syndrome

Answer 5

Causes: Aspirin given for a viral infection children - Commonly varicella or influenza

Presentation:
“hepatoencephalopathy” in child
Early: Rash, vomiting, headache, confusion
-> Hypoglycemia, Stupor, coma -> death

Tx: supportive

Question 6

Necrotizing enterocolitis

Answer 6

Ischemic necrosis of the intestinal mucosa - Inflammation leads to epithelial cells sloughing

Risk factors: Preterm birth, enteral feeding - Gut not mature enough to handle food

Presentation:
Bilious vomiting, lethargy, poor feeding, diarrhea, hematochezia, abdominal distension/tenderness, signs of shock

Dx:
Metabolic acidosis, hyponatremia
Abd XR: Bowel distention, free air under the diaphragm, pneumatosis intestinalis
US

Tx:
Stop enteral feeds and changes to parenteral nutrition
Abx: Ampicillin (or vanc if MRSA risk high), cefotaxime, metronidazole - 20-30% lead to bacteremia
Surgery

70-80% survival

Question 7

GERD in infants

Answer 7

Presentation:
Poor weight gain
Vomiting - Rule out other causes of vomiting
irritability with feeds

Dx:
pH probe
Upper G.I. series - r/o Pyloric stenosis
If refractory to treatment -> EGD
Labs:
FOBT
CBC
Metabolic panel
Celiac panel

Tx:
Trial of milk free diet
Thicken formula/breast milk
Acid suppressive therapy - PPI (Short term - rebound, increased PNA risk, diarrhea; long term B12/iron def, osteoporosis), H2 blockers (Will not decrease frequency of reflux only help with chronic irritation)
-no PPI or H2blocker In uncomplicated reflux infant