Gastroenterology

Question 1

Hirschsprung Disease

Answer 1

Aganglionic megacolon

S/S: Often presents with delayed passage of meconium; constipation is a later presenting symptom; can lead to enterocolitis. On exam, palpable fecal mass in LLQ, but no stool in rectal vault.

Dx: Rectal biopsy (gold standard), barium contrast enema can be used.

Tx: Initially decompress with NGT; rectal irrigations.

Question 2

Intussussception

Answer 2

Most frequent cause of intestinal obstruction in the first 2 years of life!
- Telescoping of the colon usually starting proximal to the ileocecal valve. Swelling, haemorrhage, incarceration and eventual perforation and peritonitis can occur if not managed quickly.

S/S: Intermittent colicky abdominal pain (child draws legs up), vomiting, currant jelly stools, sausage-shaped mass in RUQ.

Dx: Barium or air contrast enema

Tx: Barium or air enema with surgical backup.

Question 3

Pyloric Stenosis

Answer 3

Narrowing of the pylorus.

• Occurring the first few months of life.
• Electrolyte disorder - metabolic alkalosis.

S/S: Nonbilious projectile vomiting; weight loss, dehydration, often hunger after vomiting and eager to feed, 2 cm olive-shaped mass in mid-epigastric area beneath liver edge; + gastric peristaltic waves.

Tx: Stabilize electrolytes, rehydration, surgery.

Question 4

Acute Malrotation (Volvulus)

Answer 4

Acquired obstructions.
- Volvulus occurs with 50% of malrotations.

S/S: Bilious vomiting is a surgical emergency.

Tx: Surgical correction with Ladd procedure is indicated for malrotation.

Question 5

Appendicitis

Answer 5

Progressive inflammatory process that involves the lumen of the appendix with occlusion.

S/S: Focal right lower quadrant pain to periumbilical pain, fever (not always), testicular pain, flank and back pain, nausea, vomiting, and anorexia.

PE: McBurney point tenderness, rebound tenderness, + psoas sign, + obturator sign.

Dx: Abdominal CT is choice imaging, but ultrasound is often used.

Tx: Urgent surgery, infection prevention if ruptured.

Question 6

Toxic Megacolon

Answer 6

Typically occurs in children/adolescents with inflammatory bowel disease.

• Associated with infection, antidiarrheal agents, electrolyte disturbances.
• Marked dilation of the colon.

S/S: Presents with fever, abdominal distention, tenderness, tachycardia, hypotension, leukocytosis, hypokalemia, hypoalbuminemia.

Question 7

Bowel Perforation

Answer 7

Rupture of the entire wall of the stomach, small intestine, large bowel, or gall bladder.
- This condition is a medical emergency!

S/S: Acute abdominal pain, hemodynamic instability with presence of acidosis.

Dx: Xrays of the chest or abdomen may show air in the abdominal cavity (not in the stomach or intestines), suggesting a perforation. CT scan of the abdomen often shows the location of the perforation. The WBC is often higher than normal.

Complications: Bleeding, infection (including widespread sepsis, which can lead to death), intra-abdominal abscesses.

Tx: Immediate surgical exploration, treatment with broad-spectrum antibiotics and fluid/metabolic stabilization.

Question 8

Inflammatory Bowel Disease

Answer 8

Crohn’s Disease and Ulcerative Colitis

Question 9

Crohn’s Disease

Answer 9

Involves any segment in the GI tract, mouth to anus.

• Skip lesions.
• Malabsorption of Fe, Zn, Folate, vit B12.

S/S: Abdominal pain, diarrhea, rectal bleeding, fissures/tags, fistulas, anorexia, weight loss.

Question 10

Ulcerative Colitis

Answer 10

Limited to the colon.
- Starts in the rectum and ascends continuously.

S/S: Bloody mucoid diarrhea, urgency to defecate.

Dx: Endoscopy (gold standard).

Tx: (First line) Salicylates, antibiotics, steroids.
- Hospitalization admission for severe exacerbation, bowel rest with IV nutrition, diagnostic procedures.

Question 11

Pancreatitis

Answer 11

Inflamed pancreas, elevated pancreatic enzymes.

S/S: Sharp epigastric pain, radiating to left and back, nausea, vomiting.

Dx: Amylase level rises early and lasts 3-5 days, Lipase more specific - elevated longer, CRP peaks 36-48, Abdominal X-ray, CXR to rule out pleural effusion, abdominal ultrasound (repeat q3-4 days).

Tx: NPO, NGT decompression, IVF and parenteral nutrition, pain control, maintain on low fat diet until complete recovery.

Question 12

Assessing Acute Abdominal Pain

Answer 12

Consider:

• Intestinal obstruction
• Pancreatitis
• Cholelithiasis
• Genito-urologic disorders

Question 13

Features of GI Obstruction

Answer 13

Esophageal level (excessive secretions, vomiting), stomach (nonbilious vomiting), duodenum/jejunum (bilious emesis), ileum/colon (bilious emesis)

Question 14

Abdominal Compartment Syndrome

Answer 14

Can be a differential in the assessment of abdominal pain.

It occurs when a fixed compartment, defined by myofascial elements or bone, becomes subject to increased pressure, leading to schema and organ dysfunction.

It is well recognized to occur in the extremities and in the abdomen as well!