CM- Pediatric GI

Question 1

Vomiting described as violent, projectile and forceful is classically associated with what ailment? What age patient does this usually effect? What is treatment?

Answer 1

Pyloric stenosis usually presents in first born male children around 4wks of age (2-6)
Treatment is surgical pyloromyotomy

Question 2

What is bilious vomiting usually associated with?

Answer 2

anatomic obstruction. This is the most emergent situation in children vomiting and usually requires surgery

Question 3

What does the presence of blood in the vomit in a child suggest?

Answer 3

1. upper GI bleed

2. a nosebleed where the child swallowed the blood, and then vomited (more common)

Question 4

Lethargy, irritability and a bulging fontanel can be associated with two severe scenarios. What are they? How are they differentiated?

Answer 4

It is indicative of high intracranial pressure so it is associated with:

1. meningitis - fever
2. child abuse -no fever

Question 5

A newborn baby has delayed passage of meconium (longer than 24 hours of life) and presents with bilous (or non bilous) vomiting. Suction biopsy reveals a lack of ganglion cells and dilation. What is the likely cause ?

Answer 5

Hirschprungs disease

Question 6

A premature baby presents with bilous vomiting. They appear septic. KUB reveals air in the intestinal wall (pneumatosis). What is the problem?

Answer 6

Necrotizing enterocolitis

Question 7

What 2 disorders are you likely to identify in newborns?

Answer 7

1. Hirschprung disease

2. necrotizing entercolitis- premature

Question 8

What 4 presentations are associated with children 0-3 months old?

Answer 8

1. GER
2. malrotation with midgut volvulus
3. pyloric stenosis
4. child abuse

Question 9

What 4 presentations are associated with children 3-12 months?

Answer 9

1. Gastroenteritis
2. Child abuse
3. Intussusception
4. Intracranial mass lesion

Question 10

A 1 year old presents with low grade fever and non-bilious vomiting. They have diarrhea. What is a common presentation?

Answer 10

Gastroenteritis

Question 11

A woman comes into your office and says that her baby has been vomiting green and has a big belly. The baby is 1 week old. What are you suspicious of? How does this problem arise?

What is the danger of this condition?
How do you make diagnosis?
What is treatment?

Answer 11

Malrotation with midgut volvulus- during organogenesis the midgut does not properly rotate 180 degrees and anchor correctly into the abdominal cavity.

The danger is that the bowel can twist and obstruct the SMA leading to ischemic bowel.
Diagnose with an upper GI series (corkscrew with barium).
Treat with emergent surgery.

Question 12

A perfectly happy baby comes to your office and the mother complains that the baby vomits after feeding and she is not sure he is getting enough milk. What is the likely problem? What causes it?
What 2 suggestions can you make to the mother?

Answer 12

It is likely that the baby has GER due to laxity of the LES allowing retrograde movement of gastric contents.
Since the baby is asymptomatic and thriving, you could opt to not treat the baby, but you could suggest:
1. positioning- elevating the head after feedings
2. thickening feedings - add rice cereal/new formula that thickens when it hits stomach acid

Question 13

A mother is concerned that her baby is spitting up after each meal. The baby looks to be in pain and is grimacing and appearing fussy at feedings. The baby is extending their head and stiffening their arms and legs. What is the likely problem and treatment?

Answer 13

GER- the baby is spitting up after feeding.
Because the baby is fussy, it is an indication that you may need to treat with :
1. H2 or PPI
2. prokinetics to move food out of the stomach faster to make room for more food like : erythromycin

Question 14

What are sign that a baby with GER might need a more aggressive treatment than thickened formula?

Answer 14

1. pain- sandifer sign, fussy before/during feeding
2. cough - possible aspiration
3. failure to thrive

Question 15

A dad brings in his first born son for non-bilious vomiting that shoots across the room. The baby is 4 weeks old. “He is starving, eats a lot, projectile vomits and then is starving again”. The dad is concerned he is not getting enough nutrients.

On physical exam you see peristaltic wave after feeding and palpate an “olive”. What does the baby likely have? What are lab values going to show?
How do you make the diagnosis?
What is treatment?

Answer 15

The baby likely has infantile hypertrophic pyloric stenosis.

Labs will show:
hypocholemic, hypokalemic metabolic alkalosis

Diagnosis is made by ultrasound revealing 4mm or more pyloris

Treatment is pyloromyotomy

Question 16

A toddler comes in to the office. The mom claims he has been screaming off and on all night and holding his stomach. He had been vomiting green and seems lethargic between his painful episodes.

On physical exam you palpate a sausage shaped mass in the RUQ. What is the problem? What is the peak incidence of age? What is the cause?

Answer 16

Intussusception - caused by telescoping of one portion of bowel into a distal segment (usually the ileum into the cecum). as a result of lymphatic hypertrophy in Peyer’s patches after a viral infection.

Peak incidence= 3months to 3 years

Question 17

What can intussusception lead to if left untreated? What will show up in the stool?

Answer 17

It can lead to venous congestion, bowel edema.
If still left untreated–> arterial obstruction, bowel necrosis, perforation.

In the stool you would see “currant jelly” stools

Question 18

How is diagnosis made for intussusception?

Which modality is also therapeutic?

Answer 18

1. Plain films - target sign or crescent sign (air/fluid because of the bowel-in-bowel)
2. US- doppler can detect ischemia too
3. Air contrast edema- diagnostic and therapeutic (hydrostatic pressure of contrast enema reduces the telescoping)** contact surgery first in case it perforates

Question 19

A newborn has its first feeding and it all comes straight back out. They have excessive saliva.

What embryological issue could cause this? When does it occur?

Answer 19

Esophageal Atresia- Tracheoesophageal fistula (TEF)

In the 4th wk of embryologic development there was an interruption to the elongation and separation of the trachea and esophagus.

Question 20

What is the most common type of TEF?

Answer 20

A blind esophageal pouch with a distal tracheoesophageal fistula

Question 21

If a baby has esophageal atresia with no fistula, how will the abdomen look on PE?

Answer 21

scaphoid- concave

Question 22

If a baby has a TEF, how will the belly look on PE?

Answer 22

distension from air entry distal to the fistula

Question 23

How is a esophageal atresia and TEF diagnosed?

What is treatment?

Answer 23

1. inability to pass a firm catheter to the stomach
2. CXR confirms coiled catheter in blind end esophagus

Treatment is surgery

Question 24

When a child presents with abdominal pain, you must differentiate between emergent conditions that require intervention and self-limited processes. What are three of the most emergent situations in the pediatric population?

Answer 24

1. appendicitis
2. intussusception
3. testicular torsion

Question 25

What is the most frequent surgical cause of abdominal pain in children?

Answer 25

appendicitis
1/3 of children have it rupture before operative treatment
80-90% rupture rate in children under 4

Question 26

A child presents with RLQ pain, abdominal tenderness and guarding. They have been vomiting and are not hungry. They have a fever. What is it likely that they have? What will labs show?

What tests are done for diagnosis?
What is treatment?

Answer 26

Appendicitis.
labs will show elevated WBC, CRP, sterile pyuria

Diagnose with:

1. US- modality of choice (radiograph is only positive 50% of time)
2. CT if US is unavailable

Treatment:

1. Surgical consult–> surgical removal
2. fluid rescuscitation
3. broad spectrum antibiotics

Question 27

A 5 year old child presents with papable purpura on the lower extremities. He has colicky abdominal pain with vomiting and bloody stool. He also has arthritis and hematuria. What is the problem? What specifically is causing the GI symptoms?

What is treatment?

Answer 27

Henoch-Schonlein Purpura

GI symptoms are due to :

1. vasculitis leading to bowel wall edema and hemorrhage
2. edematous bowel may lead to intussusception (ileal-ileal)

No real treatment. Self-limiting in 4 wks

Question 28

A child presents with periumbilical pain without etiology. It is not associated with meals, and rarely wakens them from sleep. The child says bullies have been picking on him recently. What is the most likely cause and how do you manage the pain?

Answer 28

Functional Abdominal pain.

Treat by acknowledging the pain and following up for red flags.