Gastroenterology Flashcards
1
Q
_____ is the best test for diagnosis of chronic vomiting.
For vomiting infant, an ____ is often one of the first tests.
A
Endoscopy is the best test for diagnosis of chronic vomiting.
For vomiting infant, an upper GI series is often one of the first tests. Upper GI is good for showing anatomic or motility problems only (malrotation, pyloric stenosis, esophageal stricture, antral webs, achalasia). What it does NOT do is diagnose pathologic reflux.
2
Q
Globus
- Functional esophageal disorder characterized by a sensation of a lump or foreign body in the throat
- Path: Not well understood.
- ______ has been reported in many globus patients.
- May be psychosomatic. Association with stress
- Pt:
- Globus has been described as a sensation of a retained food bolus or tightness in the throat that is not due to an underlying structural lesion, GERD, or esophageal dysmotility disorder. The sensation can worsen with swallowing saliva and become less noticeable with swallowing food or liquids.
- Always present even when not trying to eat
- Dx: A thorough hx and physical exam is usually sufficient for a diagnosis.
- Tx:______
A
Globus
- Functional esophageal disorder characterized by a sensation of a lump or foreign body in the throat
- Path: Not well understood.
- GERD has been reported in many globus patients.
- May be psychosomatic. Association with stress
- Pt:
- Globus has been described as a sensation of a retained food bolus or tightness in the throat that is not due to an underlying structural lesion, GERD, or esophageal dysmotility disorder. The sensation can worsen with swallowing saliva and become less noticeable with swallowing food or liquids.
- Always present even when not trying to eat
- Dx: A thorough hx and physical exam is usually sufficient for a diagnosis.
- Tx: Reassure that globus is a benign disorder.
- There are reports that globus sensation improves after initiating PPIs.
3
Q
Dysphagia
- ____ is an important tool to diagnose structural anomalies of the upper intestine.
A
Dysphagia
- Upper GI series is an important tool to diagnose structural anomalies of the upper intestine.
4
Q
Bilious emesis
- Bilious emesis in a neonate or infant should prompt consideration for intestinal obstruction.
- Bilious emesis in neonate must be evaluated immediately with an _____.
A
Bilious emesis
- Bilious emesis in a neonate or infant should prompt consideration for intestinal obstruction.
- Bilious emesis in neonate must be evaluated immediately with an upper GI contrast study.
5
Q
Cyclic vomiting syndrome
- Strong association with family hx of _______
- Pt: Recurrent, stereotypical bouts of vomiting with intervening periods of normal or baseline health; without an identifiable organic cause
- Diagnosis
- Rome IV criteria, include all within 6 month period
- > =2 periods of intense, unremitting nausea and paroxysmal vomiting that last hours-days within in a 6mo period
- Episodes are stereotypical for each patient regarding onset (acute) and duration (<1 week)
- Episodes are separated by weeks-months with return to baseline health between episodes
- After appropriate medical evaluation, the symptoms cannot be contributed to another condition.
- NASPGHAN criteria
- At least 5 attacks in any interval, or a min of 3 attacks during 6-month period
- Episodic attacks of intense nausea and vomiting lasting 1 hour - 10 days and occurring at least 1 week apart
- Stereotypical pattern and symptoms in the individual patient
- Vomiting during attacks occurs at least 4 times/hour for at least 1 hour
- Return to baseline bw episodes
- Not attributed to another disorder. Lack of lab or radiographic evidence to support an alternative diagnosis.
- Rome IV criteria, include all within 6 month period
- Tx:
- Reassurance
- Supportive therapy is focused on hydration and relief from nausea, vomiting, and abdominal pain.
- Avoidance of triggers
- ____ is often used to abort the acute episode.
- Prophylactic therapy
- _______, an antihistamine, is the 1st line tx for cyclic vomiting syndrome in children __ years old to prevent future episodes; the exact mechanism is unclear
- ____ in children >__ years old
- 2nd line tx is prophylaxis with _____ for children of all ages
- _______, an antihistamine, is the 1st line tx for cyclic vomiting syndrome in children __ years old to prevent future episodes; the exact mechanism is unclear
A
Cyclic vomiting syndrome
- Strong association with family hx of migraines
- Pt: Recurrent, stereotypical bouts of vomiting with intervening periods of normal or baseline health; without an identifiable organic cause
- Diagnosis
- Rome IV criteria, include all within 6 month period
- > =2 periods of intense, unremitting nausea and paroxysmal vomiting that last hours-days within in a 6mo period
- Episodes are stereotypical for each patient regarding onset (acute) and duration (<1 week)
- Episodes are separated by weeks-months with return to baseline health between episodes
- After appropriate medical evaluation, the symptoms cannot be contributed to another condition.
- NASPGHAN criteria
- At least 5 attacks in any interval, or a min of 3 attacks during 6-month period
- Episodic attacks of intense nausea and vomiting lasting 1 hour - 10 days and occurring at least 1 week apart
- Stereotypical pattern and symptoms in the individual patient
- Vomiting during attacks occurs at least 4 times/hour for at least 1 hour
- Return to baseline bw episodes
- Not attributed to another disorder. Lack of lab or radiographic evidence to support an alternative diagnosis.
- Rome IV criteria, include all within 6 month period
- Tx:
- Reassurance
- Supportive therapy is focused on hydration and relief from nausea, vomiting, and abdominal pain.
- Avoidance of triggers
- Ondansetron is often used to abort the acute episode.
- Prophylactic therapy
- Cyproheptadine, an antihistamine, is the 1st line tx for cyclic vomiting syndrome in children <5 years old to prevent future episodes; the exact mechanism is unclear
- Amitriptyline (TCAs) in children >5 years old
- 2nd line tx is prophylaxis with propranolol for children of all ages
- Cyproheptadine, an antihistamine, is the 1st line tx for cyclic vomiting syndrome in children <5 years old to prevent future episodes; the exact mechanism is unclear
6
Q
Irritable Bowel Syndrome
- Pt:
- Pain typically in lower abdomen
- Hallmark: _____________
- Growth and appetite are normal.
- If a pt has constipation one day, normal stools another day, and loose stools another, then it’s IBS!
- Diagnostic criteria for IBS for >2 months:
- Must include all of the following:
- 1. Abdominal pain >=____ days/month associated with >1 of following
- Related to defecation
- A change in frequency of stool
- A change in form (appearance of stool)
- 2. In children with constipation, pain does not resolve with resolution of constipation (children in whom the pain resolves have functional constipation, not IBS)
- 3. After appropriate evaluation, symptoms cannot be fully explained by another medical condition - Tx:
- Nonpharmacologic interventions, such as ____ and _____, have bene shown to be some of the most effective treatments!
- Diet modification (increased water, increasing fiber, decreasing sorbitol/fructose/gas-producing foods)
- _____ has been shown to be effective in reducing pain
- _____ may be helpful to alter the intestinal flora.
A
Irritable Bowel Syndrome
- Pt:
- Pain typically in lower abdomen
- Hallmark: Pain that improves with defecation and frequent changes in stool caliber or frequency.
- Growth and appetite are normal.
- If a pt has constipation one day, normal stools another day, and loose stools another, then it’s IBS!
- Diagnostic criteria for IBS for >2 months:
- Must include all of the following:
- 1. Abdominal pain >=4 days/month associated with >=1 of following
- Related to defecation
- A change in frequency of stool
- A change in form (appearance of stool)
- 2. In children with constipation, pain does not resolve with resolution of constipation (children in whom the pain resolves have functional constipation, not IBS)
- 3. After appropriate evaluation, symptoms cannot be fully explained by another medical condition - Tx:
- Nonpharmacologic interventions, such as exercise and psychotherapy, have bene shown to be some of the most effective treatments!
- Diet modification (increased water, increasing fiber, decreasing sorbitol/fructose/gas-producing foods)
- Peppermint oil has been shown to be effective in reducing pain
- Probiotics may be helpful to alter the intestinal flora.
7
Q
Signs and symptoms of concern that suggest an organic etiology include / Alarm features in children with chronic abd pain:
- Symptoms
- Pain that awakens the child at night
- Nighttime awakening from pain: Classic test question! Suspect ______.
- Unexplained intermittent fever
- Weight loss, delayed puberty
- Dysphagia/odynophagia
- Blood/hemoccult positive stool
- Chronically loose stools, significant diarrhea
- Bilious emesis or protracted vomiting
- Oral ulcers
- Arthritis
- Fever
- Unusual rash
- Family hx of IBD, celiac, or PUD
- Pain that awakens the child at night
- Physical Exam
- Weight loss, deceleration of linear growth
- Localized tenderness that is not periumbilical, Localized RUQ or RLQ tenderness
- CVA tenderness
- Hepatosplenomegaly
- Perianal skin tag, fissure, fistula, or abscess
- Grossly bloody or hemoccult positive stool
- Delayed puberty
A
Signs and symptoms of concern that suggest an organic etiology include / Alarm features in children with chronic abd pain:
- Symptoms
- Pain that awakens the child at night
- Nighttime awakening from pain: Classic test question! Suspect H pylori infection.
- Unexplained intermittent fever
- Weight loss, delayed puberty
- Dysphagia/odynophagia
- Blood/hemoccult positive stool
- Chronically loose stools, significant diarrhea
- Bilious emesis or protracted vomiting
- Oral ulcers
- Arthritis
- Fever
- Unusual rash
- Family hx of IBD, celiac, or PUD
- Pain that awakens the child at night
- Physical Exam
- Weight loss, deceleration of linear growth
- Localized tenderness that is not periumbilical, Localized RUQ or RLQ tenderness
- CVA tenderness
- Hepatosplenomegaly
- Perianal skin tag, fissure, fistula, or abscess
- Grossly bloody or hemoccult positive stool
- Delayed puberty
8
Q
Functional Dyspepsia (“Indigestion”)
- Pt:
- Midepigastric area and is strongly correlated with meals
- Normal growth
- Diagnostic criteria
- Must include >=1 of following >=4 days/month for >=2 months:
- Postprandial fullness
- Early satiation
- Epigastric pain or burning not associated with defecation
- After appropropriate evaluation, symptoms cannot be fully explained by another medical criteria
- Must include >=1 of following >=4 days/month for >=2 months:
- Tx:
- Acid blockade with ___ blocker or ____ for pain predominant symptoms
- As many as 50% of pts respond to acid suppression although there is no acid-related damage.
A
Functional Dyspepsia (“Indigestion”)
- Pt:
- Midepigastric area and is strongly correlated with meals
- Normal growth
- Diagnostic criteria
- Must include >1 of following >4 days/month for >2 months:
- Postprandial fullness
- Early satiation
- Epigastric pain or burning not associated with defecation
- After appropropriate evaluation, symptoms cannot be fully explained by another medical criteria
- Must include >1 of following >4 days/month for >2 months:
- Tx:
- Acid blockade with H2 blocker or PPI for pain predominant symptoms
- As many as 50% of pts respond to acid suppression although there is no acid-related damage.
9
Q
Abdominal Migraine
- Diagnostic criteria
- Must include all of the following criteria
- Paroxysmal episodes of intense, acute periumbilical pain lasting for >=1 hour, occurred >=2x in the span of 6 months
- Pain interferes with normal function
- Pain-free periods lasting weeks-months
- Stereotypical pattern and symptoms in individual pt
- Pain associated with >=2 of the following: ___, ___, ___, ___, ___, or ____
- No evidence of organic etiology
- Must include all of the following criteria
A
Abdominal Migraine
- Diagnostic criteria
- Must include all of the following criteria
- Paroxysmal episodes of intense, acute periumbilical pain lasting for >=1 hour, occurred >=2x in the span of 6 months
- Pain interferes with normal function
- Pain-free periods lasting weeks-months
- Stereotypical pattern and symptoms in individual pt
- Pain associated with >=2 of the following: anorexia, nausea, vomiting, headache, photophobia, or pallor
- No evidence of organic etiology
- Must include all of the following criteria
10
Q
Functional abdominal pain syndrome (“Chronic recurrent abdominal pain syndrome”)
- Pt: Chronic abdominal pain (= 2 months duration) in children wo alarm findings who do not meet criteria for other functional abd pain disorders
- Pain is typically periumbilical
- Growth is normal and appetite not affected.
- Symptoms tend to get better on the weekends and during vacations and worse in the morning before school or in the evening before bed.
- Ask about social stressors
- Dx:
- Must be fulfilled >4x/month for 2 months and include all of the following:
- Episodic or continuous abd pain that does not occur solely during physiologic events (eg eating, menses)
- Insufficient criteria for IBS, functional dyspepsia, or abdominal migraine
- After appropriate evaluation, abd pain cannot be fully explained by another medical condition.
- Must be fulfilled >4x/month for 2 months and include all of the following:
- Tx: Reassurance.
A
Functional abdominal pain syndrome (“Chronic recurrent abdominal pain syndrome”)
- Pt: Chronic abdominal pain (= 2 months duration) in children wo alarm findings who do not meet criteria for other functional abd pain disorders
- Pain is typically periumbilical
- Growth is normal and appetite not affected.
- Symptoms tend to get better on the weekends and during vacations and worse in the morning before school or in the evening before bed.
- Ask about social stressors
- Dx:
- Must be fulfilled >4x/month for 2 months and include all of the following:
- Episodic or continuous abd pain that does not occur solely during physiologic events (eg eating, menses)
- Insufficient criteria for IBS, functional dyspepsia, or abdominal migraine
- After appropriate evaluation, abd pain cannot be fully explained by another medical condition.
- Must be fulfilled >4x/month for 2 months and include all of the following:
- Tx: Reassurance.
11
Q
A: Isolated EA \_\_% B: EA + proximal TEF <1% C: EA + distal TEF \_\_\_% D: EA + double TEF <1% E/H: Isolated TEF \_\_\_%
A
A: Isolated EA 8% B: EA + proximal TEF <1% C: EA + distal TEF 87% D: EA + double TEF <1% E/H: Isolated TEF 4%
12
Q
Tracheoesophageal fistula and esophageal atresias
- Path: Occurs when there is improper separation of the esophagus from the trachea; interruption of the developmental process during the 4th week of gestation.
- A clue for esophageal abnormalities prenatally is ~50% of these mothers have ____
- Most common abnormalities:
- Nearly 90% of tracheoesophageal abnormalities present as a blind, upper EA with a fistula between a lower esophageal segment and lower portion of the trachea, near the carina
- Associations:
- Nearly ⅓ of infants have other congenital anomalies. Most common association is ____
- ____ is a known complication following surgical repair of EA, resulting from increased reflux
A
Tracheoesophageal fistula and esophageal atresias
- Path: Occurs when there is improper separation of the esophagus from the trachea; interruption of the developmental process during the 4th week of gestation.
- A clue for esophageal abnormalities prenatally is ~50% of these mothers have polyhydramnios
- Most common abnormalities:
- Nearly 90% of tracheoesophageal abnormalities present as a blind, upper EA with a fistula between a lower esophageal segment and lower portion of the trachea, near the carina
- Associations:
- Nearly ⅓ of infants have other congenital anomalies. Most common association is VACTERL
- Barrett esophagus is a known complication following surgical repair of EA, resulting from increased reflux
13
Q
EA with Distal TEF (Type C)
- Most common form of esophageal abnormality
- Dx: Place NG tube into stomach. Blind pouch of esophagus prevents its passage
- Management:
- Discontinue all oral feeds, place OG catheter
- After cardiac evaluation rules out potential cardiac abnormalities, perform surgery as soon as possible. Optimal tx is to perform anastomosis of distal esophagus and ligation of the fistula.
- If the 2 ends of the esophagus are far apart, the surgeon will place a gastrostomy tube, then wait to perform anastomosis
- In very ill or small infant, you can delay anastomosis by doing gastrostomy
- Main complication of surgery is ____ of material through anastomosis area
- Another complication is ____ formation.
A
EA with Distal TEF (Type C)
- Most common form of esophageal abnormality
- Dx: Place NG tube into stomach. Blind pouch of esophagus prevents its passage
- Management:
- Discontinue all oral feeds, place OG catheter
- After cardiac evaluation rules out potential cardiac abnormalities, perform surgery as soon as possible. Optimal tx is to perform anastomosis of distal esophagus and ligation of the fistula.
- If the 2 ends of the esophagus are far apart, the surgeon will place a gastrostomy tube, then wait to perform anastomosis
- In very ill or small infant, you can delay anastomosis by doing gastrostomy
- Main complication of surgery is leakage of material through anastomosis area
- Another complication is stricture formation.
14
Q
Isolated EA without TEF (Type A)
- Although EA is more commonly seen with TEF, EA can occur in isolation.
- Pt: Excessive oral secretions with choking. Dilated esophageal pouch and a _____ on XR (not seen in those with TEF)
- Tx: Surgically create an anastomosis between the 2 esophageal ends.
- If gap ____cm, esophageal lengthening by bougienage or magnets
- If gap ___cm, esophageal replacement is necessary. This is delayed until 1 year of age.
- In EA without fistula, ______ may be used to improve the likelihood of completing a primary repair of the esophagus.
A
Isolated EA without TEF (Type A)
- Although EA is more commonly seen with TEF, EA can occur in isolation.
- Pt: Excessive oral secretions with choking. Dilated esophageal pouch and a flat, gasless abd on XR (not seen in those with TEF)
- Tx: Surgically create an anastomosis between the 2 esophageal ends.
- If gap <3-4 cm, esophageal lengthening by bougienage or magnets
- If gap >4cm, esophageal replacement is necessary. This is delayed until 1 year of age.
- In EA without fistula, waiting before repair may be used to improve the likelihood of completing a primary repair of the esophagus.
15
Q
TEF (H-type)
- Pt: Choking during feeds in early infancy.
- Not associated with ______ bc esophagus is normal and without GI obstruction.
- Dx: Diagnosed using _______. Diagnosis can be tricky; barium swallow frequently misses H-type.
- H-type TEF may escape detection for prolonged periods because it is the only type of TEF that is unassociated with esophageal atresia
- Tx: _____
A
TEF (H-type)
- Pt: Choking during feeds in early infancy.
- Not associated with polyhydramnios bc esophagus is normal and without GI obstruction.
- Dx: Diagnosed using bronchoscopy and/or esophagoscopy. Diagnosis can be tricky; barium swallow frequently misses H-type.
- H-type TEF may escape detection for prolonged periods because it is the only type of TEF that is unassociated with esophageal atresia
- Tx: Surgery to tie off fistula
16
Q
Achalasia
- Disorder of esophagus characterized by incomplete relaxation of the LES and a lack of normal esophageal peristalsis. Is a ___ problem (not anatomic problem)
- Path: Due to loss of _____ cells in the esophagus and to dorsal motor nuclei reduction of vagus nerve signals. Many have antibodies to the ____ plexus.
- Dx:
- ____ typically reveals a dilated esophagus that terminates in a beaklike manner due to persistent contraction of the LES
- ____ examination is needed to confirm diagnosis.
- Tx:
- ___ or ___.
- ______ is a more definitive form of treatment.
- For pts unable to undergo these procedures, use ____ therapy. If therapy fails, use _____.
A
Achalasia
- Disorder of esophagus characterized by incomplete relaxation of the LES and a lack of normal esophageal peristalsis. Is a motor problem (not anatomic problem)
- Path: Due to loss of ganglion cells in the esophagus and to dorsal motor nuclei reduction of vagus nerve signals. Many have antibodies to the Auerbach plexus.
- Dx:
- Barium swallow typically reveals a dilated esophagus that terminates in a beaklike manner due to persistent contraction of the LES
- Manometric examination is needed to confirm diagnosis.
- Tx:
- Graded pneumatic dilation or laparoscopic surgical myotomy with partial fundoplication.
- Surgical myotomy is a more definitive form of treatment.
- For pts unable to undergo these procedures, use botulinum toxin therapy. If botulinum toxin therapy fails, use calcium channel blockers.
- Graded pneumatic dilation or laparoscopic surgical myotomy with partial fundoplication.
17
Q
GER
- Peaks at ___mo. Resolves spontaneously by ___mo.
- Tx:
- Reassurance and education: Burping, avoid overfeeding, smaller more frequent feeds
- Try hydrolyzed formula for 2 weeks. 2013 NASPGHAN guidelines on GER recommend a 2-week trial of low-allergy formula due to common occurrence of reflux in children with milk-protein allergy.
- Do not give medications to infants with uncomplicated GER.
A
GER
- Peaks at 4-5mo. Resolves spontaneously by 12mo.
- Tx:
- Reassurance and education: Burping, avoid overfeeding, smaller more frequent feeds
- Try hydrolyzed formula for 2 weeks. 2013 NASPGHAN guidelines on GER recommend a 2-week trial of low-allergy formula due to common occurrence of reflux in children with milk-protein allergy.
- Do not give medications to infants with uncomplicated GER.
18
Q
Sandifer syndrome
- Occurs in children with ____ who have paroxysmal acrocyanosis associated with brief episodes of limpness, stereotypical positioning, or tonic clonic motions suggestive of a seizure, or apnea.
- Typically resolves with tx of GER.
A
Sandifer syndrome
- Occurs in children with GER who have paroxysmal acrocyanosis associated with brief episodes of limpness, stereotypical positioning, or tonic clonic motions suggestive of a seizure, or apnea.
- Typically resolves with tx of GER.
19
Q
GERD
- GER with complications:
- Poor growth/failure to thrive
- Feeding refusal, dysphagia
- Respiratory symptoms (wheezing, coughing, pneumonia)
- Discomfort and inconsolable (due to pain)
- Sleep problems
- Tx for infants
- A 4-8 week trial of acid suppression may be considered.
- Tx for older children
- Dietary measures:
- Small meals while also avoiding carbonated drinks, high-fat foods, acidic foods, caffeine, and nicotine (usually secondhand)
- Avoid bedtime snacks
- Tx obesity
- Positioning: Keep upright for 20-30 minutes following a meal
- Medications: Antisecretory agent, such as PPI (omeprazole)
- 2009 NASPGHAN guidelines and 2013 AAP review suggest ___ are superior to ____ in healing esophagitis and improving symptoms
- Surgical therapy is the final option, esp for those with severe respiratory or neurologic dx. Most commonly used procedure is the ___
- Dietary measures:
- Prognosis
- If esophagitis is severe and prolonged for many years without therapy, the esophagus can develop strictures or Barrett esophagus can occur.
- The incidence of Barrett esophagus in the pediatric population is incredibly rare
A
GERD
- GER with complications:
- Poor growth/failure to thrive
- Feeding refusal, dysphagia
- Respiratory symptoms (wheezing, coughing, pneumonia)
- Discomfort and inconsolable (due to pain)
- Sleep problems
- Tx for infants
- A 4-8 week trial of acid suppression may be considered.
- Tx for older children
- Dietary measures:
- Small meals while also avoiding carbonated drinks, high-fat foods, acidic foods, caffeine, and nicotine (usually secondhand)
- Avoid bedtime snacks
- Tx obesity
- Positioning: Keep upright for 20-30 minutes following a meal
- Medications: Antisecretory agent, such as PPI (omeprazole)
- 2009 NASPGHAN guidelines and 2013 AAP review suggest PPIs are superior to H2 receptor blockers in healing esophagitis and improving symptoms
- Surgical therapy is the final option, esp for those with severe respiratory or neurologic dx. Most commonly used procedure is the Nissen fundoplication.
- Dietary measures:
- Prognosis
- If esophagitis is severe and prolonged for many years without therapy, the esophagus can develop strictures or Barrett esophagus can occur.
- The incidence of Barrett esophagus in the pediatric population is incredibly rare
20
Q
Rumination syndrome
- Associated with ______ deprivation
- Pt:
- Effortless (semipurposeful), voluntary habitual regurgitation within minute-hours of eating,
- Regurgitation of food into the mouth followed by re-chewing and re-swallowing or expulsion.
- Consider rumination for an adolescent pt who leaves the table multiple times during dinner to “throw up” mouthfuls of food in the bathroom. Many pts have comorbid anxiety or depression.
- Dx: Clinical (History, exam, observation of feeding and rumination episodes)
- Must include all of the following for >2 months:
- Repeated regurgitation and rechewing or expulsion of food that
- Not preceded by retching
- After appropriate evaluation, symptoms cannot be fully explained by another medical condition. Eat disorder must be ruled out.
- Rome criteria
- Repetitive contractions of the abdominal muscles, diaphragm, and tongue followed by regurgitation of stomach contents, which are then expectorated or chewed and re-swallowed
- 3 of the following criteria are required
- Onset between 3-8 mo of age
- Does not respond to management for GERD, anticholinergics, formula changes, gavage, or gastrostomy tube feedings
- Unaccompanied by signs of nausea or distress
- History will reveal that these episodes do not occur during sleep or when infant is actively involved in engaging activities/ interacting w individuals
- Must include all of the following for >2 months:
- Management: _______
A
Rumination syndrome
- Associated with severe sensory and emotional deprivation
- Pt:
- Effortless (semipurposeful), voluntary habitual regurgitation within minute-hours of eating,
- Regurgitation of food into the mouth followed by re-chewing and re-swallowing or expulsion.
- Consider rumination for an adolescent pt who leaves the table multiple times during dinner to “throw up” mouthfuls of food in the bathroom. Many pts have comorbid anxiety or depression.
- Dx: Clinical (History, exam, observation of feeding and rumination episodes)
- Must include all of the following for >2 months:
- Repeated regurgitation and rechewing or expulsion of food that
- Not preceded by retching
- After appropriate evaluation, symptoms cannot be fully explained by another medical condition. Eat disorder must be ruled out.
- Rome criteria
- Repetitive contractions of the abdominal muscles, diaphragm, and tongue followed by regurgitation of stomach contents, which are then expectorated or chewed and re-swallowed
- 3 of the following criteria are required
- Onset between 3-8 mo of age
- Does not respond to management for GERD, anticholinergics, formula changes, gavage, or gastrostomy tube feedings
- Unaccompanied by signs of nausea or distress
- History will reveal that these episodes do not occur during sleep or when infant is actively involved in engaging activities/ interacting w individuals
- Must include all of the following for >2 months:
- Management:
- Supportive, relying on psychotherapy and cognitive behavioral therapy.
- Behavioral modifications
- Increasing overall levels of environmental stimulation. Engage child in activities during feeding.
21
Q
Eosinophilic Esophagitis (EoE)
- Suspect this disorder in any child with a hx of food bolus becoming stuck or who describes frequent odynophagia (pain with swallowing) or dysphagia.
- Many pts also have some other form of atopy (eg asthma, food allergies, eczema, chronic rhinitis)
- Dx:
- Gold standard is ____
- Histology findings: >____ per high power field indicates EOE
- Gold standard is ____
- Management:
- Most experts recommend high-dose acid suppression with a ____ (NOT ____), specific food elimination, or _______
- As many as 60% of children with EOE improve symptomatically with the elimination of dietary ____. Some patients require a more complex “six-food elimination diet”
A
Eosinophilic Esophagitis (EoE)
- Suspect this disorder in any child with a hx of food bolus becoming stuck or who describes frequent odynophagia (pain with swallowing) or dysphagia.
- Many pts also have some other form of atopy (eg asthma, food allergies, eczema, chronic rhinitis)
- Dx:
- Gold standard is upper endoscopy
- Histology findings: >15 eosinophils per high power field indicates EOE
- Gold standard is upper endoscopy
- Management:
- Most experts recommend high-dose acid suppression with a PPI (NOT H2 blockers), specific food elimination, or swallowed steroids (fluticasone or budesonide swallowed via MDI)
- As many as 60% of children with EOE improve symptomatically with the elimination of dietary cow’s milk. Some patients require a more complex “six-food elimination diet”
22
Q
Pill-Induced Esophagitis
- Tetracycline, doxycycline, aspirin, NSAIDs, and slow-release potassium are the pills most often implicated
- The most common location for the pill to become stuck is midesophagus
- Look for adolescent who comes in with chest pain and a hx of doxycycline for acne.
- Management:
- Symptoms generally resolve in 1-3 weeks.
- No specific therapy is necessary other than advising the pt to swallow pills with water so the pill clears the esophagus rapidly.
A
Pill-Induced Esophagitis
- Tetracycline, doxycycline, aspirin, NSAIDs, and slow-release potassium are the pills most often implicated
- The most common location for the pill to become stuck is midesophagus
- Look for adolescent who comes in with chest pain and a hx of doxycycline for acne.
- Management:
- Symptoms generally resolve in 1-3 weeks.
- No specific therapy is necessary other than advising the pt to swallow pills with water so the pill clears the esophagus rapidly.
23
Q
Infections of the esophagus
- Most common organisms to cause infection in esophagus: Candida, CMV, HSV
A
Infections of the esophagus
- Most common organisms to cause infection in esophagus: Candida, CMV, HSV
24
Q
Ingestion of foreign bodies
- X-ray 2 view PA and lateral, look for coin sign in AP view (negative coin sign, en face, which means it is in the ____) or lateral (positive coin sign, en face in sagittal plan/lateral film or on-end/linear on AP, which means it is in the ____)
- Removal with rigid bronchoscopy or rigid endoscopy
- Emergent removal (less than __ hours from presentation):
- ____
- _____
- ___ should be removed
- Urgent removal (less than ___hours from presentation):
- _____ in stomach of small bowel in asymptomatic children less than ___yo AND battery width >____mm.
- All ____ require removal within 24 hours.
- Sharp or long objects (>___mm long) if in the esophagus or stomach.
- Emergent removal (less than __ hours from presentation):
In children with a hx of button battery ingestion, ongoing progression of esophageal injury, even after the operative removal of the battery, has been reported. Progression of esophageal injury has been reported days-weeks after removal of esophageal button batteries, resulting in serious sequelae, including esophageal perforation and aortoesophageal fistula formation.
A
Ingestion of foreign bodies
- X-ray 2 view PA and lateral, look for coin sign in AP view (negative coin sign, en face, which means it is in the esophagus) or lateral (positive coin sign, en face in sagittal plan/lateral film or on-end/linear on AP, which means it is in the trachea/airway)
- Removal with rigid bronchoscopy or rigid endoscopy
- Emergent removal (<2 hours from presentation):
- Button batteries in esophagus as they can cause immediate liquefactive necrosis (due to sodium hydroxide generated by current) within 2 hours of swallowing. An internal ring / 2 concentric circles signs a button battery.
- Symptomatic patients with button batteries
- Magnets should be removed
- Urgent removal (<24 hours from presentation):
- Button batteries in stomach of small bowel in asymptomatic children <5yo AND battery width >20mm.
- All esophageal ingestions require removal within 24 hours.
- Sharp or long objects (>50mm long) if in the esophagus or stomach.
- Emergent removal (<2 hours from presentation):
In children with a hx of button battery ingestion, ongoing progression of esophageal injury, even after the operative removal of the battery, has been reported. Progression of esophageal injury has been reported days-weeks after removal of esophageal button batteries, resulting in serious sequelae, including esophageal perforation and aortoesophageal fistula formation.
25
Q
Esophageal perforation
- Spontaneous perforation can occur in pts with ___ and ___ syndromes.
- Do NOT perform ___ in these pts!
A
Esophageal perforation
- Spontaneous perforation can occur in pts with Ehlers-Danlos and Marfan syndromes.
- Do NOT perform endoscopy in these pts!
26
Q
Malrotation
- Malration is due to nonrotation, incomplete rotation, paraduodenal hernia, or reverse rotation
- _____ is the most common malrotation abnormality
- Cecum on the L and small intestine to the R of the small mesenteric artery. Results in a short mesentery and little fixation of the bowel. The duodenum is small and fuses with the colon, using a common mesentery around the SMA.
- _____ is the most common malrotation abnormality
- Pt: Infants classically present with acute development of _____ in the 1st month of life (90% present within the 1st year)
- Dx:
- Gold standard is_____ bc fluoroscopic study can evaluation positioning of duodenum
- Upper GI can demonstrate classic _______ of the 2nd or 3rd portion of the duodenum, where the gut is twisted. Demonstrates intestinal malrotation (3rd portion of duodenum does not cross midline/vertebral bodies) and volvulus (“corkscrew” of small intestine if duodenum is partially obstructed)
- Upper GI can identify abnormal positioning of the duodenojejunal junction (normally located at the level of ligament of Treitz). In malrotation, the ligament of Treitz is on the _____ side of the spine and is inferior to the duodenal bulb. Contrast from the upper GI series fill the jejunal loops on the ____ side of the abdomen.
- X-ray will show ____ + _____ pattern beyond
- Gold standard is_____ bc fluoroscopic study can evaluation positioning of duodenum
- Tx: Surgical emergency, resuscitation and emergent laparotomy with operative correction of the volvulus and malrotation (Ladd procedure).
A
Malrotation
- Malration is due to nonrotation, incomplete rotation, paraduodenal hernia, or reverse rotation
- Nonrotation is the most common malrotation abnormality
- Cecum on the L and small intestine to the R of the small mesenteric artery. Results in a short mesentery and little fixation of the bowel. The duodenum is small and fuses with the colon, using a common mesentery around the SMA.
- Nonrotation is the most common malrotation abnormality
- Pt: Infants classically present with acute development of bilious emesis in the 1st month of life (90% present within the 1st year)
- Dx:
- Gold standard is upper GI series bc fluoroscopic study can evaluation positioning of duodenum
- Upper GI can demonstrate classic “bird’s beak” of the 2nd or 3rd portion of the duodenum, where the gut is twisted. Demonstrates intestinal malrotation (3rd portion of duodenum does not cross midline/vertebral bodies) and volvulus (“corkscrew” of small intestine if duodenum is partially obstructed)
- Upper GI can identify abnormal positioning of the duodenojejunal junction (normally located at the level of ligament of Treitz). Normally, ligament of Treitz is to the L of the spine at the level of gastric antrum and is fixed to the posterior body wall. In malrotation, the ligament of Treitz is on the R side of the spine and is inferior to the duodenal bulb. Contrast from the upper GI series fill the jejunal loops on the RIGHT side of the abdomen.
- X-ray will show double bubble + normal gas pattern beyond
- Gold standard is upper GI series bc fluoroscopic study can evaluation positioning of duodenum
- Tx: Surgical emergency, resuscitation and emergent laparotomy with operative correction of the volvulus and malrotation (Ladd procedure).
27
Q
Duodenal atresia
- Associated with multiple anomalies
- 40% of duodenal atresia have ___.
- Pt: Generally presents within first 24-48 hours (on the 1st day of life) after birth, with persistent emesis and/or bilious emesis
- Dx:
- Abdominal radiograph with “_____” resulted from the dilated stomach and proximal duodenal bulb. This is diagnostic if the rest of the bowel is ___. If there is distal gas, confirm with an ___.
- Tx: Bowel decompression and surgical repair
A
Duodenal atresia
- Associated with multiple anomalies
- 40% of duodenal atresia have Trisomy 21. Is more common in children with trisomy 21/down syndrome.
- Pt: Generally presents within first 24-48 hours (on the 1st day of life) after birth, with persistent emesis and/or bilious emesis
- Dx:
- Abdominal radiograph with “double bubble,” resulted from the dilated stomach and proximal duodenal bulb. This is diagnostic if the rest of the bowel is airless. If there is distal gas, confirm with an upper GI study.
- x-ray shows double bubble + no gas pattern beyond
- Tx: Bowel decompression and surgical repair
28
Q
Jejunoileal atresia
- Path: Impaired intrauterine vascular supply, which leads to localized ischemia. In theory, in utero exposure to nicotine from cigarette smoking causes vasoconstriction
- Different from duodenal atresia in that jejunoileal atresia is NOT associated with other congenital anomalies.
- Abd XRs show multiple, dilated loops of bowel with air-fluid levels.
- x ray shows ____ + _____
- Dx: Best made with an ____
- Tx: Surgery
A
Jejunoileal atresia
- Path: Impaired intrauterine vascular supply, which leads to localized ischemia. In theory, in utero exposure to nicotine from cigarette smoking causes vasoconstriction
- Different from duodenal atresia in that jejunoileal atresia is NOT associated with other congenital anomalies.
- Abd XRs show multiple, dilated loops of bowel with air-fluid levels.
- x ray shows double bubble + multiple air fluid levels
- Dx: Best made with an upper GI or lower GI study.
- Tx: Surgery
29
Q
Hypertrophic pyloric stenosis
- RF
- Early (<2 weeks of age) exposure to _____ is also a frequently tested RF for pyloric stenosis.
- Pt:
- Progressive nonbilious nonbloody vomiting. Usually presents between 3 weeks and 2 months
- Labs: ___kalemia, __chloremic metabolic ___
- Dx:
- Physical exam by observing visible peristalsis and palpating for a mobile pyloric mass “olive,” which is pathognomonic for pyloric stenosis.
- Abdominal US with pyloric muscle thickness (PMT), pyloric muscle length (PML), and pyloric diameter (PD) measured to confirm diagnosis.
- On US, if the pyloric channel is thicker than __mm and longer than __mm, pyloric stenosis is highly likely.
- If US inconclusive, Upper GI shows elongation and thickening of the pylorus
- Management:
- Initial assessment of hydration status, evaluate for electrolyte abnormalities (particularly hypokalemia and alkalosis)
- Semi-normalization of chloride may be the most important and most relevant metabolic change indicating metabolic alkalosis has resolved, suggesting surgical optimization.
- Cl level should be normal-high normal prior to surgery; some data suggest a level of 106mmol/L is the goal.
- Surgical procedure of choice is _______
A
Hypertrophic pyloric stenosis
- RF
- Early (<2 weeks of age) exposure to erythromycin is also a frequently tested RF for pyloric stenosis.
- Pt:
- Progressive nonbilious nonbloody vomiting. Usually presents between 3 weeks and 2 months
- Labs: Hypokalemic, hypochloremic metabolic alkalosis
- Dx:
- Physical exam by observing visible peristalsis and palpating for a mobile pyloric mass “olive,” which is pathognomonic for pyloric stenosis.
- Abdominal US with pyloric muscle thickness (PMT), pyloric muscle length (PML), and pyloric diameter (PD) measured to confirm diagnosis.
- On US, if the pyloric channel is thicker than 3mm and longer than 14mm, pyloric stenosis is highly likely (3.14 pi).
- If US inconclusive, Upper GI shows elongation and thickening of the pylorus
- Management:
- Initial assessment of hydration status, evaluate for electrolyte abnormalities (particularly hypokalemia and alkalosis)
- Semi-normalization of chloride may be the most important and most relevant metabolic change indicating metabolic alkalosis has resolved, suggesting surgical optimization.
- Cl level should be normal-high normal prior to surgery; some data suggest a level of 106mmol/L is the goal.
- Surgical procedure of choice is pyloromyotomy
30
Q
Stress Gastropathy
- Path: Due to severe physiologic stress, such as occurs with shock, metabolic acidosis, sepsis, burns, and head injury
- Curling ulcer - gastritis in a ___ pt
- Cushing ulcer - pt with ___
A
Stress Gastropathy
- Path: Due to severe physiologic stress, such as occurs with shock, metabolic acidosis, sepsis, burns, and head injury
- Curling ulcer - gastritis in a burn pt
- Cushing ulcer - pt with head injury or brain surgery
31
Q
H pylori Gastritis
- Path: H pyloris is the most common identifiable cause of chronic gastritis in children.
- Pt:
- 80% of infected children are ____.
- Associations
- H pylori is the primary cause of ___.
- H. pylori is the cause of ___
- Noninvasive testing can be utilized for non-acute situations and for posttreatment testing
- Includes urea breath testing, serological testing, and stool antigen assay.
- Dx:
- When pathology is determined with ____ visualization (can be normal, often results in gastric mucosa appearing nodular) and ______ (show gram-neg spiral rods on surface of glandular epithelium under the mucous layer when using special stains), a _______ (13C or 14C) or a rapid urea test (RUT) on the tissue is done to confirm the cause is H. pylori.
- 1st diagnose pathology and only then look for H. pylori. Do not test for H. pylori initially as an aid for diagnosis of abdominal pain bc presence of H pylori alone is not helpful as a diagnostic indicator.
- Serum antibody tests confirm ________, so do not use for diagnosis of active H pylori infection.
- Stool antigen test can be helpful to determine if _____, but guidelines discourage its use for initial diagnosis.
- Gold standard: _____
- Alternate: Endoscopy with positive histology findings and +rapid urease test/PCR/FISH
- Posttreatment: Urea breath testing, stool Ag testing
- When pathology is determined with ____ visualization (can be normal, often results in gastric mucosa appearing nodular) and ______ (show gram-neg spiral rods on surface of glandular epithelium under the mucous layer when using special stains), a _______ (13C or 14C) or a rapid urea test (RUT) on the tissue is done to confirm the cause is H. pylori.
- Tx:
- ESPGHAN recommends eradication treatment for all children with H pylori-associated gastric and/or duodenal ulcer disease. The presence of ulceration is a key factor considered in the management
- “Triple therapy,” which includes a ___, ___, and ____ for 7-14 days.
- ESPGHAN recommends eradication treatment for all children with H pylori-associated gastric and/or duodenal ulcer disease. The presence of ulceration is a key factor considered in the management
A
H pylori Gastritis
- Path: H pyloris is the most common identifiable cause of chronic gastritis in children.
- Pt:
- 80% of infected children are asymptomatic.
- Associations
- H pylori is the primary cause of gastric adenocarcinoma.
- H. pylori is the cause of gastric lymphoma called mucosa-associated lymphoid tissue (MALT)
- Noninvasive testing can be utilized for non-acute situations and for posttreatment testing
- Includes urea breath testing, serological testing, and stool antigen assay.
- Dx:
- When pathology is determined with endoscopic visualization (can be normal, often results in gastric mucosa appearing nodular) and biopsy (show gram-neg spiral rods on surface of glandular epithelium under the mucous layer when using special stains), a urea breath test (13C or 14C) or a rapid urea test (RUT) on the tissue is done to confirm the cause is H. pylori.
- 1st diagnose pathology and only then look for H. pylori. Do not test for H. pylori initially as an aid for diagnosis of abdominal pain bc presence of H pylori alone is not helpful as a diagnostic indicator.
- Serum antibody tests confirm only past exposure, not active, ongoing infection, so do not use for diagnosis of active H pylori infection.
- Stool antigen test can be helpful to determine if known infection is eradicated, but guidelines discourage its use for initial diagnosis.
- Gold standard: Endoscopy with positive culture
- Alternate: Endoscopy with positive histology findings and +rapid urease test/PCR/FISH
- Posttreatment: Urea breath testing, stool Ag testing
- When pathology is determined with endoscopic visualization (can be normal, often results in gastric mucosa appearing nodular) and biopsy (show gram-neg spiral rods on surface of glandular epithelium under the mucous layer when using special stains), a urea breath test (13C or 14C) or a rapid urea test (RUT) on the tissue is done to confirm the cause is H. pylori.
- Tx:
- ESPGHAN recommends eradication treatment for all children with H pylori-associated gastric and/or duodenal ulcer disease. The presence of ulceration is a key factor considered in the management
- “Triple therapy,” which includes a PPI, amoxicillin, and clarithromycin for 7-14 days.
- ESPGHAN recommends eradication treatment for all children with H pylori-associated gastric and/or duodenal ulcer disease. The presence of ulceration is a key factor considered in the management
32
Q
Peptic Ulcer Disease
- Path:
- Majority caused by H pylori (esp duodenal ulcers) and then NSAIDs (esp gastric ulcers).
- Zollinger-Ellison syndrome
- Rare in children. Produces markedly excessive stomach acid due to______), typically located in the pancreas or duodenal wall.
- Gastrinomas associated with ___. (so evaluate for hyperparathyroidism and adrenal tumors)
- Dx:
- If suspect PUD, perform an ____. Remember, endoscopy is the best test for children with upper GI bleeding, recurrent vomiting, or persistent, unexplained abdominal pain.
- Just as with chronic gastritis, when the pathology is determined when endoscopic visualization and biopsy, a urea breath test or a RUT on the tissue is done to confirm the cause is H pylori.
- Tx:
- 2 weeks of a _ plus _, plus _ or _.
- In areas where clarithromycin resistance is high, quadruple therapy is used: ___, __, ___, and either ___ or __
- In the presence of a positive H pylori test, give anti-H pylori therapy only when PUD is proven or in MALT lymphoma. In children, do not tx H pylori colonization indiscriminately.
- Surgery is rarely indicated except for following circumstances: perforation of stomach or duodenum, active bleeding that cannot be controlled, gastric outlet or duodenal obstruction, or failed medical therapy.
- Follow-up
- For uncomplicated ulcers, confirm H pylori eradication with symptom resolution and a follow-up ____ after acid suppression has ended. Do not recommend dietary modification.
- Ulcers with complications (bleeding, perforation, or penetration) commonly relapse, so confirm healing and eradication of H pylori with a follow-up ____.
A
Peptic Ulcer Disease
- Path:
- Majority caused by H pylori (esp duodenal ulcers) and then NSAIDs (esp gastric ulcers).
- Zollinger-Ellison syndrome
- Rare in children. Produces markedly excessive stomach acid due to gastrin-secreting tumor (gastrinoma), typically located in the pancreas or duodenal wall.
- Gastrinomas associated with MEN1. 25% of people with gastrinoma have MEN1 (so evaluate for hyperparathyroidism and adrenal tumors)
- Dx:
- If suspect PUD, perform an upper endoscopy. Remember, endoscopy is the best test for children with upper GI bleeding, recurrent vomiting, or persistent, unexplained abdominal pain.
- Just as with chronic gastritis, when the pathology is determined when endoscopic visualization and biopsy, a urea breath test or a RUT on the tissue is done to confirm the cause is H pylori.
- Tx:
- 2 weeks of a PPI plus clarithromycin, plus amoxicillin or metronidazole.
- In areas where clarithromycin resistance is high, quadruple therapy is used: bismuth salicylates, PPIs, tetracycline, and either amoxicillin or metronidazole
- In the presence of a positive H pylori test, give anti-H pylori therapy only when PUD is proven or in MALT lymphoma. In children, do not tx H pylori colonization indiscriminately.
- Surgery is rarely indicated except for following circumstances: perforation of stomach or duodenum, active bleeding that cannot be controlled, gastric outlet or duodenal obstruction, or failed medical therapy.
- Follow-up
- For uncomplicated ulcers, confirm H pylori eradication with symptom resolution and a follow-up urea breath test or stool antigen test at least 4-6 weeks after acid suppression has ended. Do not recommend dietary modification.
- Ulcers with complications (bleeding, perforation, or penetration) commonly relapse, so confirm healing and eradication of H pylori with a follow-up endoscopy.
33
Q
Anal fissures
- Most common cause of rectal bleeding in children of all ages
- Suspect Crohn dx in older child if anal fissure does not heal with stool softeners, warm sitz baths, and generous lubrication in anal skin
- Suspect sexual abuse if multiple anal fissuures of signs of genital trauma
A
Anal fissures
- Most common cause of rectal bleeding in children of all ages
- Suspect Crohn dx in older child if anal fissure does not heal with stool softeners, warm sitz baths, and generous lubrication in anal skin
- Suspect sexual abuse if multiple anal fissuures of signs of genital trauma
34
Q
Hemorrhoids
- the most common cause of symptomatic hemorrhoids is ______ with chronic straining
- Differential: Sometimes mistaken for _____. Can distinguish by noting hemorrhoids do not involve entire rectal mucosa and do not have a hole in the center of bulging tissue
- Manage: Conservative with avoidance of straining w defecation, minimizing toilet time, increasing fluids and fiber to relieve constipation, or prescribing stool softener. Warm water sitz baths alleviate symptoms.
- Preparation H for >12yo
A
Hemorrhoids
- the most common cause of symptomatic hemorrhoids is constipation with chronic straining
- Differential: Sometimes mistaken for rectal prolapse. Can distinguish by noting hemorrhoids do not involve entire rectal mucosa and do not have a hole in the center of bulging tissue
- Manage: Conservative with avoidance of straining w defecation, minimizing toilet time, increasing fluids and fiber to relieve constipation, or prescribing stool softener. Warm water sitz baths alleviate symptoms.
- Preparation H for >12yo
35
Q
Intussusception
- Typically affecting children between 2mo and 5yo, with peak incidence between 4-10mo.
- Path:
- Most originate near the ___ junction, and many believe these are due to a virus-induced swelling of ___.
- In older children, intussusception is less common, and the cause is often more apparent by an intraluminal lesion as a ____ the most common cause is a ____
- Pt:
- Colicky abdominal pain, often with vomiting (esp bilious vomiting). Awakens with crying and has flexion of knees and hips.
- Severe abdominal pain interspersed with asymptomatic intervals
- Gross blood per rectum with mucus (“currant jelly” stools)
- Abd exam may be significant for distension and palpable “_______” mass in RUQ
- Triad of _____, ____, and _____ is seen in about 20% of children
- Dx: Abd US is study of choice, with positive study revealing a “_____”
- Tx:
- ______, which is both diagnostic and therapeutic procedure of choice
- ______ is an absolute contraindication. Bowel obstruction is a relative contraindication.
- In children with peritoneal signs, and those for whom attempts to reduce the intussusception by air contrast enema have failed, urgent operative management with ______ is indicated.
- ______, which is both diagnostic and therapeutic procedure of choice
A
Intussusception
- Typically affecting children between 2mo and 5yo, with peak incidence between 4-10mo.
- Path:
- Most originate near the ileocecal junction, and many believe these are due to a virus-induced swelling of Peyer patches.
- In older children, intussusception is less common, and the cause is often more apparent by an intraluminal lesion as a “leading edge”; the most common cause is a Meckel diverticulum.
- Pt:
- Colicky abdominal pain, often with vomiting (esp bilious vomiting). Awakens with crying and has flexion of knees and hips.
- Severe abdominal pain interspersed with asymptomatic intervals
- Gross blood per rectum with mucus (“currant jelly” stools)
- Abd exam may be significant for distension and palpable “sausage-shaped” mass in RUQ
- Triad of bilious emesis, abdominal mass, and blood per rectum is seen in about 20% of children
- Dx: Abd US is study of choice, with positive study revealing a “target sign”
- Tx:
- Air-contrast enema, which is both diagnostic and therapeutic procedure of choice
- Peritonitis is an absolute contraindication. Bowel obstruction is a relative contraindication.
- In children with peritoneal signs, and those for whom attempts to reduce the intussusception by air contrast enema have failed, urgent operative management with laparotomy is indicated.
- Air-contrast enema, which is both diagnostic and therapeutic procedure of choice
36
Q
Meckel’s Diverticulum
- Path: Remnant of the fetal _______ with failure of closure.
- Ectopic _____ mucosa in the diverticulum
- Rule of 2’s
- Present in 2
- Located within 2
- Measures 2
- Measures 2
- 2:1 _ ratio
- Usually symptomatic before 2 yo (if and when symptoms are present)
- 1 in 2 positive on_
- Pt:
- Many children are asymptomatic.
- Painless rectal bleeding (due to gastric mucosa)
- Associated with other congenital anomalies, , including esophageal atresia (6x risk), imperforate anus (5x risk), neurologic anomalies (3x risk), and cardiovascular anomalies (2x risk).
- Dx:
- Diagnosis is difficult.
- Most sensitive test is Meckel radionuclide scan with ____, which is specifically targeted at the ectopic _____ mucosal cells found in a Meckel diverticulum.
- Tx:
- Surgical excision - segmental ileal resection to include the diverticulum and the ulcer.
A
Meckel’s Diverticulum
- Path: Remnant of the fetal omphalomesenteric duct/vitelline duct with failure of closure.
- Ectopic gastric mucosa in the diverticulum
- Rule of 2’s
- Present in 2% of the population (usually asymptomatic)
- Located within 2 feet of the ileocecal valve
- Measures 2 inches in length
- Measures 2 cm in diameter
- 2:1 male-to-female ratio
- Usually symptomatic before 2 yo (if and when symptoms are present)
- 1 in 2 positive on meckel scan
- Pt:
- Many children are asymptomatic.
- Painless rectal bleeding (due to gastric mucosa)
- Associated with other congenital anomalies, , including esophageal atresia (6x risk), imperforate anus (5x risk), neurologic anomalies (3x risk), and cardiovascular anomalies (2x risk).
- Dx:
- Diagnosis is difficult.
- Most sensitive test is Meckel radionuclide scan with technetium-99m pertechnetate, which is specifically targeted at the ectopic gastric mucosal cells found in a Meckel diverticulum.
- Tx:
- Surgical excision - segmental ileal resection to include the diverticulum and the ulcer.
37
Q
Celiac Disease
- HLA typing shows only 2 HLA types are associated with celiac disease, ___ and __.
- Pt:
- Classic GI form of the disease presents in the child <2yo, with symptoms that include malabsorptive diarrhea, poor weight gain, abdominal distention, and proximal muscle wasting.
- Triad of ___, ____, and ___
- May present with recurrent _____ in children with type 1 diabetes
- ______ is an itchy, vesicular rash that erupts symmetrically on the extensor surfaces of the arms and legs and on the buttocks. The lesion is pathognomonic for celiac disease.
- Associations
- Celiac disease is so common in children with ____ and ____ deficiency that many physicians recommend universal screening for both disease in these patients.
- In addition, there is a 5-16 fold increased risk of celiac disease in children with _____.
- Labs: Iron and folate-deficiency anemia, elevated liver transaminases and fat-soluble vitamin deficiencies
- Unexplained _____ prompts you to look for celiac disease.
- Presence of ____ in the stool in the absence of pancreatic insufficiency (normal pancreatic elastase) and inflammation (no evidence of blood or WBCs in the stool).
- Screening
- In all individuals, except those with IgA deficiency, both ____ and ____ levels should be obtained. Individuals who are IgA deficient should be evaluated with tTG-IgG, endomysial antibody-IgG, or deamidated gliadin peptide antibody-IgG.
- Gold standard for diagnosis: ______
- Important: Do NOT place the pt on a gluten-free diet prior to endoscopy bc this can cause a false negative result.
- Histopathologic findings of celiac disease include villous atrophy with intraepithelial lymphocytes.
- 2 mandatory requirements for diagnosis:
- 1) ____
- 2) _____
- Management:
- Gluten-free diet (wheat, barley, rye) with nutritional education
- Evaluation for celiac disease should be performed for _____ and in individuals with autoimmune thyroid disease, autoimmune liver disease, trisomy 21, type 1 DM, Williams syndrome, Turner syndrome, and IgA deficiency.
A
Celiac Disease
- HLA typing shows only 2 HLA types are associated with celiac disease, DQ2 and DQ8.
- Pt:
- Classic GI form of the disease presents in the child <2yo, with symptoms that include malabsorptive diarrhea, poor weight gain, abdominal distention, and proximal muscle wasting.
- Triad of failure to thrive, bloating, and diarrhea
- May present with recurrent hypoglycemia in children with type 1 diabetes
- Dermatitis herpetiformis is an itchy, vesicular rash that erupts symmetrically on the extensor surfaces of the arms and legs and on the buttocks. The lesion is pathognomonic for celiac disease.
- Associations
- Celiac disease is so common in children with Type 1 DM and selective IgA deficiency that many physicians recommend universal screening for both disease in these patients.
- In addition, there is a 5-16 fold increased risk of celiac disease in children with Down syndrome.
- Labs: Iron and folate-deficiency anemia, elevated liver transaminases and fat-soluble vitamin deficiencies
- Iron deficiency anemia is common at diagnosis, and unexplained iron deficiency prompts you to look for celiac disease.
- Presence of excessive fat in the stool in the absence of pancreatic insufficiency (normal pancreatic elastase) and inflammation (no evidence of blood or WBCs in the stool).
- Screening
- In all individuals, except those with IgA deficiency, both tTG-IgA and total IgA levels should be obtained. Individuals who are IgA deficient should be evaluated with tTG-IgG, endomysial antibody-IgG, or deamidated gliadin peptide antibody-IgG.
- Tissue transglutaminase (TTG) immunoglobulin IgA is the best screening test
- Gold standard for diagnosis: Duodenal biopsy with endoscopy.
- Important: Do NOT place the pt on a gluten-free diet prior to endoscopy bc this can cause a false negative result.
- Histopathologic findings of celiac disease include villous atrophy with intraepithelial lymphocytes.
- 2 mandatory requirements for diagnosis:
- 1) Characteristic histology on small intestine biopsy
- 2) Complete clinical remission with a gluten-free diet
- Management:
- Gluten-free diet (wheat, barley, rye) with nutritional education
- Evaluation for celiac disease should be performed for 1st degree relatives of individuals with celiac disease and in individuals with autoimmune thyroid disease, autoimmune liver disease, trisomy 21, type 1 DM, Williams syndrome, Turner syndrome, and IgA deficiency.
38
Q
Dermatitis Herpetiformis
- Pt: Pruritic, pink papules and vesicles on extensor surfaces (elbows, knees, buttocks, and lower back)
- Tx: _____, which helps to promptly alleviate the eruption. Although a gluten-free diet often mitigates the need for dapsone, it can take months to help.
A
Dermatitis Herpetiformis
- Pt: Pruritic, pink papules and vesicles on extensor surfaces (elbows, knees, buttocks, and lower back)
- Tx: Dapsone, which helps to promptly alleviate the eruption. Although a gluten-free diet often mitigates the need for dapsone, it can take months to help.
39
Q
Appendicitis
- Most common surgical emergency in children.
- Pt: At the time of appendiceal perforation, there may be a rapid clinical improvement because of a sudden decrease in intraluminal pressure in the appendix
- PE:
- Guarding
- Psoas sign (pain on extension of R thigh)
- Rovsing sign (pain in RLQ when press on LLQ)
- Obturator sign (pain elicited with flexion and internal rotation of hip)
- Markle sign (pain when jump)
- Dx:
- Best initially evaluated by ultrasonography.
- CT of abdomen/pelvis shows enhancement and dilation of the appendix. Normal appendix width is less than __mm.
- Simple/Early appendicitis = appendicitis without evidence of perforation or gangrene
- If nonperforated appendicitis, receive single ppx dose of broad abx (cefoxitin, piperacillin and tazobactam, ceftriaxone, metronidazole) before operation. IVF, analgesia.
- Delayed lap appendectomy within 24 hrs
- Complex/Advanced appendicitis = perforated or gangrenous appendix
- Urgent appendectomy,
- Give broad spectrum IV antibiotics until the pt is afebrile and clinically improved.
- One can consider a “triple” regimen (ampicillin, gentamicin, and clindamycin or metronidazole) or a combination regimen (ceftriaxone-metronidazole, or ticarcillin-clavulanate plus gentamicin).
A
Appendicitis
- Most common surgical emergency in children.
- Pt: At the time of appendiceal perforation, there may be a rapid clinical improvement because of a sudden decrease in intraluminal pressure in the appendix
- PE:
- Guarding
- Psoas sign (pain on extension of R thigh)
- Rovsing sign (pain in RLQ when press on LLQ)
- Obturator sign (pain elicited with flexion and internal rotation of hip)
- Markle sign (pain when jump)
- Dx:
- Best initially evaluated by ultrasonography.
- CT of abdomen/pelvis shows enhancement and dilation of the appendix. Normal appendix width is <6mm.
- Simple/Early appendicitis = appendicitis without evidence of perforation or gangrene
- If nonperforated appendicitis, receive single ppx dose of broad abx (cefoxitin, piperacillin and tazobactam, ceftriaxone, metronidazole) before operation. IVF, analgesia.
- Delayed lap appendectomy within 24 hrs
- Complex/Advanced appendicitis = perforated or gangrenous appendix
- Urgent appendectomy,
- Give broad spectrum IV antibiotics until the pt is afebrile and clinically improved.
- One can consider a “triple” regimen (ampicillin, gentamicin, and clindamycin or metronidazole) or a combination regimen (ceftriaxone-metronidazole, or ticarcillin-clavulanate plus gentamicin).
