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FALL15 N833 Adv Pedi Probs > CRAP > Flashcards

CRAP Flashcards

1
Q

Chronic abdominal pain: intermittent or constant pain defined by what 4 criteria?

A
  1. ≥3 episodes
  2. sufficiently severe to affect activities
  3. period of ≥3 months
  4. organic or functional
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2
Q

What is meant by organic chronic abdominal pain?

A

Identifiable problem within the body

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3
Q

What are characteristics of functional GI DOs?

A
  • no identifiable cause in body
  • (may have visceral hyperalgesia)
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4
Q

Which is more common, functional or organic chronica ab pain?

A

functional

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5
Q

Categories of functional GI DOs per Rome Criteria

A
  • Functional dyspepsia
  • Irritable bowel syndrome
  • Abdominal migraine
  • Functional abdominal pain of childhood
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6
Q

Do alarm features point you to organic or functional cause?

A

Organic!!!

If alarm features, evaluate for organic cause.

If no alarm features, usually not necessary to evaluate further (can cause unnecessary anxiety)

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7
Q

What are some HISTORY alarm features of abdominal pain?

A
  • Weight loss or failure to gain weight appropriately
  • Unremitting abdominal pain
  • Difficult or painful swallowing
  • Significant vomiting
  • Chronic severe or bloody diarrhea
  • Black, tarry stools
  • Unexplained fever
  • Urinary symptoms-dysuria, hematuria, flank pain
  • Back pain
  • Skin changes-rash, eczema, hives
  • Family HX of IBD, celiac disease
  • Unstable vital signs
  • Unexplained physical finding
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8
Q

What are some EXAM alarm features of abdominal pain?

A
  • Deceleration in linear growth, and or delayed puberty
  • Oral aphthous ulcerations
  • Localized RUQ;RLQ;LLQ; suprapubic tenderness
  • Hepatomegaly
  • Splenomegaly
  • CVA tenderness
  • Perianal abnormalities- fissure, skin tags, fistulae
  • Guaiac positive stool
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9
Q

Diagnostic criteria for functional dyspepsia

A
  • W/in preceding 2 mths, at least weekly occurrence of:
    • Persistent or recurring pain or discomfort in upper abdomen
    • Pain or discomfort not relieved by defecation or assoc w/onset of change in stool frequency or form
    • No evidence inflammatory, anatomic, metabolic, neoplastic process to explain sx
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10
Q

Diagnostic criteria for irritable bowel syndrome

A

W/in preceding 2 mths, at least weekly occurrence of:

Abd discomfort/pain assoc w/2+ of following:

  • Relieved w/defecation
  • Onset assoc w/change in frequency of stool
  • Onset assoc w/change in form of stool

No evidence inflammatory, anatomic, metabolic, neoplastic processes to explain sx

may be constipation dominant, diarrhea dominant, or mixed

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11
Q

Diagnostic criteria for abdominal migraines

A

ALL of following:

Organic /other causes R/O

w/in last 12mo, 2+ episodes of:

  • Paroxysmal episodes of intense, acute, periumbilical pain lasting 1+ hours
  • Intervening periods of usual health lasting weeks to months
  • Pain interferes w/normal activities
  • Pain associated w/2+ of following: anorexia, nausea, HA, photophobia, pallor
  • No evidence inflammatory, anatomic, metabolic, neoplastic processes to explain sx
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12
Q

Is there an association btwn abdominal migraines and migraine HAs?

A

Yes. Many go on to develop migraines as adults.

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13
Q

What is the goal of mgmt for functional GI pain?

A

Return to normal function – not complete elimination of pain.

Recognize unique challenge, stress and anxiety experienced by family and children that interferes with life.

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14
Q

MGMT of functional GI pain

A
  • Therapeutic relationship
  • Education: biopsychosocial model of pain
  • Behavior modification
  • Coping: relaxation, distraction, CBT, biofeedback
  • MGMT of triggers, anxiety
  • Possible meds: SSRIs, tricyclics, short term PPI, peppermint oil capsules
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15
Q

Examples of prophylactic antimigraine meds

A

Propranolol, Cyproheptadine, Prizotien

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16
Q

Methods of managing functional dyspepsia

A
  • Avoid high fat foods, caffeinated beverages, NSAIDS
  • Small frequent meals
  • H2 blocker or PPI 4-6 weeks if severe symptoms
  • If sxs >2 mos, refer to GI
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17
Q

MGMT of IBS

A

assess contributing psych/sociologic stressors

  • For constipation-predominant IBS
    • Increase water and fiber
    • Osmotic laxatives if needed
  • For diarrhea-predominant IBS limit cars and non-absorbed carbs (ie sorbitol)
    • Diet low in fermentalble oligo-, di- and mono-saccharides and polyols been shown to reduce IBS sxs (restrict wheat, onion, garlic, legumes and sugar free gums, some fruits and vegetables
    • May need to slow motility with atropine or diphenoyxylate
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18
Q

MGMT of abdominal migraines

A
  • is supportive and preventative – avoid food and beverages (esp caffeine) helpful, sleep, lowering stress, reducing bright/flickering lights, avoid prolonged fasting
    • Prophylactic propranolol and cyproheptadine (antihistamine); sumatriptan as abortive for pain and nausea
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19
Q

Organic causes of constipation

A

Infant dyschezia, hirschsprung disease, cows milk intolerance, CF, Celiac

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20
Q

Functional causes of constipation

A
  • withholding feces
  • Original situation: related to toilet training, dietary changes, stressful events, toilet availability, illness or busy schedules
  • Delay in stooling leads to reabsorption of fluids in the colon and increase in size and hardness of the stool
  • Genetics: some families are predisposed to developing constipation
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21
Q

Constipation alarm signs

A
  • Ribbon stools
  • Urinary incontinence or bladder disease
  • Weight loss or poor weight gain
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22
Q

Diagnosis of constipation 4+ yo

A

For at least 2 months:

  • Two or fewer stools per week
  • At least one episode of fecal incontinence per week
  • Stool withholding
  • History of painful or hard bowel movements
  • Presence of large fecal mass in rectum
  • Hx of large diameter stools that obstruct the toilet
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23
Q

Diagnosis of constipation infants and toddlers

A

Same as 4+yo but only one month duration necessary

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24
Q

Two types of IBD

A

Ulcerative Colitis

Crohn Disease

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25
Q

Crohn vs UC: clinical manifestations

A
26
Q

Crohn’s vs UC: which spreads continuously?

A

UC!

Crohn’s skips (much harder to resect), may see mouth sores

27
Q

Diagnostic lab tests for UC & Crohn’s

A
  • Serum:
    • BMP/CMP: esp hypokalemia
    • ESR, CRP
    • CBC: anemia, elevated WBC & PLT
    • Inflammatory markers
    • Albumin: nutrition
  • Fecal Occult blood
  • Stool cultures to rule out or include C.diff (5-25% of flare cases) and other infectious process if diarrhea
  • CT if emergency
  • No definitive dx w/o imaging/endoscopic exam!
28
Q

Why do endoscopic / histologic tests for UC?

A
  • Rule out Cytomegalovirus with colonic biopsies from sigmoid colon
  • Serum testing not specific for colon disease

***Full colonoscopy should be avoided during severe flares due to perforation risk

29
Q

How can UC be treated?

A
  • Steroids, 5-ASA, Pain mgmt (hot packs to opioids – nsaids may exacerbate)
  • Bowel rest not recommended – already have decreased caloric intake and does not change disease process
  • Colectomy: if severe
30
Q

How are Crohn’s and UC definitively distinguished?

A

combination of endoscopy and imaging of the UGI tract

31
Q

Tx for Crohn’s

A
  • Refer to GI
  • Depends on age and classification
  • Mild: aminosalicylates, antibiotics if fistula
  • Mod/Severe: aggressive tx w/glucocorticoids, possible bowel rest w/TPN, transition to methotrexate or thiopurine once in remission
32
Q

Education w/Crohn’s

A

Avoid triggers: meds (ibuprofen, some antibiotics), infections, seasonal changes, stress, smoking, diet

33
Q

IBD in primary care: what to keep in mind

A
  • Monitoring nutritional status
  • Bone health
  • Infection risk
  • Immunizations
  • Eye examinations
  • Psychological issues
  • Transition to adult health care
  • Cancer surveillance
34
Q

3 types of infectious colitis discussed in class

A

H. pylori, VRE, C. diff

35
Q

Presenting sx of C. diff

A
  • fever, diarrhea, abdominal pain/cramping/tenderness, dehydration
  • Hx of antibiotic use or immunodeficiency
36
Q

When to hospitalize for C. diff

A
  • increasing systemic symptoms (fever, hypotension, increased Crt), S&S of ilius or toxic megacolon, increasing WBC (>15,000 cells/microL), severe dehydration,
  • Arrhythmias
37
Q

Diagnosis of C. diff

A
  • Difficult. Many kids, especially under 2yo, are colonized and will have positive stool sample.
  • Antibiotic use is most important factor in Hx. Can be any antibiotic, but esp penicillins, cephalosporins, clindamycin, and fluoroquinolones
38
Q

Differential Dx for c. diff

A
  • Norovirus, rotavirus – viral is much more likely than c. diff, but watch out for hx antibiotics and immunocompromised!
  • Also VRE – risk w/previous antibiotics
39
Q

Tx for C. Diff

A
  • Metronidazole or vancomycin PO
  • Supportive measures: re-hydrate, correct electrolytes and acidosis, pain relief, probiotics, avoid PPI use, hand hygiene!
40
Q

Presenting s/s of H. pylori

A

Bloating, stomach fullness, decreased appetite, N/V,

Bleeding ulcers: tar colored stool, decreased Hgb and Hct

41
Q

Diagnostic testing for H. pylori

A
  • Stool antigen, urea breath test (if on PPIs, both stool and urea breath test can be false neg!)
  • Endoscopy if suspect PUD
42
Q

H. pylori Tx

A
  • Triple therapy: PPIs, amoxicillin (or metronidazole) and clarithromycin.
  • Quadruple therapy: add bismuth subsalicylate
43
Q

Criteria for diagnosis of PUD

A

Usually Sx 2-5 hrs after a meal or on an empty stomach

May be at time of circadian stimulation of maximal acid secretion (11pm-2am)

*kids rarely present with upper GI bleed or occult blood in feces, weight loss

44
Q

PUD on PE

A
  • Mouth: ulcers or dental enamel erosion
  • Lungs: wheezing (bronchospasm can be due to or exacerbate by gastroesophageal reflux)
  • Periumbilical abdominal pain
45
Q

Causes of PUD in kids

A
  • H. Pylori (less than adults), NSAIDs, idiopathic
  • <10yo: medication (steroids) nsaids, stress
  • often functional!
46
Q

Diagnosing PUD

A
  • HISTORY! Med use
  • Test for H. pylori (not recommended as a routine)
  • Treat for GERD but not improving / can’t wean off med –> upper endoscopy
  • Definitively shown on endoscopy
  • If unsure of Dx/complications: Also CBC w/diff (anemia), ESR (inflammation), LFTs (bleeding d/t liver dz/coagulopathy?), BMP (increased BUN)
47
Q

Tx PUD

A

PPI duration depends on etiology

Possible antibiotic tx if H. pylori

48
Q

Sx of Lactose Intolerance

A

Diarrhea,bulky frothy watery stools, abdominal pain (periumbilical, LQ), nausea, flatuelence

49
Q

Patho of Lactose intolerance

A

Can’t absorb lactose d/t missing lactase enzyme

unabsorbed lactose:

  • atracts fluid into bowel lumen.
  • Converted to FAs and H+ gas by bacterial flora via fermentation
50
Q

Diagnosis of Lactose intolerance

A
  • Lactose free diet
  • Hydrogen breath test (measures lactose malabsorption)
  • Fecal pH: nonspecific marker
  • **routine screening for LI not recommended!
51
Q

MGMT lactose intolerance

A
  • Restrict lactose
  • Encourage consumption of calcium rich foods or calcium & vit D supplementation (lactose may enhance calcium absorption)
52
Q

When to refer for Lactose Intolerance?

A

Refer to GI if secondary LI suspected (underlying intestinal d/o)

53
Q

S/S of Celiac Dz

A

Gi: chronic diarrhea, anorexia, abdominal distension and pain, failure to thrive/wt loss, vomiting (rare)

Non GI: poor growth & dvpt, neuro/behavioral dz, iron deficiency, dermatitis herpetiformis, bone loss

54
Q

Diagnostic testing for celiac dz

A
  • Serologic: IgA Abs, tissue transglutaminase (tTG-IgA); Anti endomysial Abs (EMA); Deaminated Giladin Peptide (DGP)
  • Intestinal biopsy: histological changes GOLD STANDARD
  • Changes in sx w/gluten free diet not conclusive to establish dx
55
Q

MGMT of Celiac Dz

A
  • Gluten=free diet for life
  • Oats: only if guaranteed pure and free of contamination
  • All referred to nutritionist
  • Serologic testing at 6mo intervals until levles have normalized
56
Q

S/S of Chronic Pancreatitis

A
  • Pattern varies and fluctuates
  • Typically epigastric pain, radiating to back, w/N/V, may be relieved by sitting upright and leaning forward, worse 15-30 min after eating
  • Fat malabsorption: loose, greasy, foul smelling stools that are difficult to flush
  • Clinically symptomatic vit def (fat soluble ADEK), rare
57
Q

Diagnosis of chronic pancreatitis

A
  • Recurrent acute pancreatitis
  • Routine tests, usually normal: CBC, LFT, electrolytes
  • Pancreatic enzymes elevated
  • Can progress to stool fat, imaging (ERCP, abdominal CT), genetic testing, etc
58
Q

Tx chronic pancreatitis

A

pain management, correction of pancreatic insufficiency, and management of complications

59
Q

Patient education: when to call for office visit r/t abdominal pain

A
  • Chronic constipation (less than 2-3 bowel movements per week)
  • Loss of appetite, weight loss, or becoming full after small meals
60
Q

Patient education: when to seek immediate medical attention

A
  • Bloody stools, severe diarrhea, or recurrent vomiting
  • Severe abdominal pain that lasts longer than one hour or that comes and goes for more than 24 hours
  • Your child gets upset or screams when you touch their belly
  • High fever (higher than 101-102) for more than 3 days
  • Pain when urinating or frequent urination
  • No wet diaper in a span of 4-5 hours in an infant. No urine output in 6-8 hours in an older child
  • Lethargy or behavioral changes
  • Refusal to eat or drink for a long period of time
61
Q

When can a pcp diagnose functional abdominal pain (w/o need for further evaluation)?

A

No alarm sx, PE nl, no occult blood in stool

FALL15 N833 Adv Pedi Probs (10 decks)

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