Disorders of the Stomach

Question 1

What is the male:female ratio in pyloric stenosis.

Answer 1

Boys are affected 6x more often than girls, but do not dismiss a female infant with compatible symptoms.

Question 2

List four risk factors for the development of pyloric stenosis.

Answer 2

Prematurity, parental history of pyloric stenosis, caucasian race, and early (<2 weeks of age) exposure to erythromycin.

Question 3

How does pyloric stenosis typically present?

Answer 3

Pyloric stenosis usually presents between 3 weeks and 2 months of age with progressively worsening nonbilious vomiting. The infant is hungry and eager to feed.

Question 4

What type of acid-base disorder can be seen with pyloric stenosis?

Answer 4

If vomiting is prolonged, hypochloremic metabolic alkalosis can develop, along with dehydration. Hypokalemia can also occur due to exchange of hydrogen ions and potassium in the kidney.

Question 5

What physical exam finding is pathognomonic for pyloric stenosis?

Answer 5

Palpation of a mobile pyloric mass known as an “olive” is pathognomonic.

Question 6

What imaging study is commonly used to make the diagnosis if pyloric stenosis?

Answer 6

Abdominal ultrasound will show the thickened and lengthened pyloric muscle.

Question 7

What is the recommended treatment for pyloric stenosis?

Answer 7

Initial management should be aimed at correcting dehydration and electrolyte abnormalities prior to surgical correction with a pyloromyotomy.

Question 8

What is the most common cause of congenital gastric outlet obstruction?

Answer 8

Congenital gastric outlet obstruction is very rare, but is most commonly caused by pyloric webs (extra gastric mucosa and submucosa that prolapse into the duodenum).

Question 9

How do patients with complete pyloric atresia present?

Answer 9

Polyhydramnios, nonbilious emesis, and an enlarge, gas-filled stomach - with the rest of the abdomen gasless on abdominal x-ray.

Question 10

What genetic condition is associated with pyloric atresia?

Answer 10

Pyloric atresia is seen with an autosomal recessive disorder in which infants also have junctional epidermolysis bullosa.

Question 11

What causes stress gastropathy?

Answer 11

Stress gastropathy is due to severe phyiologic stress, such as occurs with shock, metabolic acidosis, sepsis, burns, and head injury (think sick ICU patient with an upper GI bleed).

Question 12

How should stress gastropathy be treated?

Answer 12

Prompt control of the underlying disorder improves the gastropathy more than acid-suppression/neutralization. However, control of the underlying disorder is often impossible, so acid suppression is standard clinical practice.

Question 13

What is a Curling ulcer?

Answer 13

Gastropathy in a burn patient.

Question 14

What is a Cushing ulcer?

Answer 14

Gastropathy in a patient with a head injury or recent brain surgery.

Question 15

What are Mallory-Weiss tears?

Answer 15

Mucosal tears caused by profound/extended retching which are located in the distal esophagus at the GE junction and can extend into the gastric cardia. They are rare in children.

Question 16

List three drug classes which have been associated with the development of gastropathy.

Answer 16

NSAIDs, alcohol, and corticosteroids.

Question 17

What is the most common identifiable cause of chronic gastritis in children?

Answer 17

H. pylori

Question 18

What two gastric malignancies have been linked to infection with H. pylori?

Answer 18

H. pylori is the primary identified cause of gastric adenocarcinoma. It is also the cause of a rare, slow-growing gastric lymphoma called mucosa-associated lymphoid tissue (MALT).

Question 19

How does the gastric mucosa appear in patients with H. pylori gastritis?

Answer 19

The gastric mucosa often appears nodular in these patients.

Question 20

What is Menetrier disease?

Answer 20

A protein-losing gastropathy that results in hypoproteinemia. Typically, it presents as peripheral edema with nausea and vomiting, often after an apparent viral illness.

Question 21

What usually causes Menetrier disease?

Answer 21

It is almost always due to CMV infection.

Question 22

What is the natural course of Menetrier disease?

Answer 22

It resolves over several weeks to months in children, but is a chronic unremitting disease in adults.

Question 23

Which organism is responsible for most PUD in children?

Answer 23

H. pylori

Question 24

What percentage of children with H. pylori are symptomatic? How does this translate into recommended testing strategies?

Answer 24

Only 20% of infected children are symptomatic. Therefore, it is important to first diagnose the pathology (i.e. chronic gastritis or PUD) and only then look for H. pylori.

Question 25

What diagnostic test should be performed if PUD is suspected?

Answer 25

Upper endoscopy.

Question 26

When and how do you diagnose H. pylori infection?

Answer 26

Only once a diagnosis of PUD or chronic gastritis is made should one test for H. pylori infection. A urea breath test or rapid urea test (RUT) on the tissue can be used to make the diagnosis.

Question 27

Are antibody tests useful in diagnosing active PUD?

Answer 27

No. Antibody tests only confirm past infection and should not be used to make a diagnosis of active H. pylori infection.

Question 28

What is the treatment for H. pylori infection?

Answer 28

2 weeks of a PPI + clarithromycin + either amoxicillin or metronidazole.

Question 29

What type of organism is H. pylori?

Answer 29

It is a gram negative spiral rod.

Question 30

How should H. pylori eradication be confirmed in patients who presented with ulcers + complications (bleeding, perforation, or penetration)?

Answer 30

In these patients, healing and eradication of H. pylori should be confirmed with follow-up endoscopy.

Question 31

How should H. pylori eradication be confirmed in patients who presented with uncomplicated ulcers?

Answer 31

For patients with uncomplicated ulcers, confirm H. pylori eradication with symptom resolution and a follow-up urea breath test or stool antigen test 4-6 weeks after acid suppression therapy has ended.

Question 32

What is Zollinger-Ellison syndrome?

Answer 32

It is rare in children, but is characterized by markedly excessive stomach acid due to a gastrin-secreting tumor (gastrinoma), typically located in the pancreas or duodenal wall. Multiple ulcers are common, and frequently involve unusual sites for ulcers.

Question 33

What genetic disorder is associated with the development of gastrinomas?

Answer 33

Multiple endocrine neoplasia type 1 (MEN1)