Gastroenterology 𧻠Flashcards
Name some diarrhea red flags
Fever
Blood in stool
Dehydration
Leukocytosis
Persistent symptoms
What is the big deal if a child holds their poop in
Stool may become impacted, and then encopresis may occur (poop builds up until it leaks out involuntarily)
What are the 2 main types of inflammatory bowel disease?
Crohn
Ulcerative colitis
What is the most common congenital anomaly of the GI tract?
Meckelâs diverticulum
How do you treat constipation?
Fluids
Gradual increase in fiber
Juice for infants
If encopresis, relieve impact ion if present
Constipation meds miralax, lactulose, enemas, suppositories, etc
Counseling and positive reinforcement
When is diarrhea considered âchronicâ
If it goes on for more than 1 month
What is the fiber recommendation for a children under 2?
5g/day
What causes damage when someone has a meckelâs diverticulum?
Gastric acid is produced there and causes damage and bleeding
What is the most common cause of infectious diarrhea?
VIRAL ****
(Norovirus, rotavirus, adenovirus, calcivirus)****
Which imaging study is diagnostic AND therapeutic for intussusception?
Hydrostatic/pneumatic enema
Unfolds telescoping 90% of the time
What is the first line treatment for GERD?
Lifestyle modifications
How do you diagnose a Meckelâs diverticulum?
Technetium-99 scan (Meckelâs scan)**
Nuclear medicine scan identifies gastric mucosa in the places itâs NOT suppsed to be!
What is the clinical presentation of appendicitis?
Anorexia
Migrating abdominal pain (belly button to RLQ)
Pain increases with movement
Vomiting
Fever
Peritoneal signs- guarding, rebound tenderness, rovsing, obturator, iliopsoas signs
What will you see on ultrasound of a baby with pyloric stenosis?
Elongation and thickening of the pylorus
How old are babies that get infantile hypertrophic pyloric stenosis?
3-6 weeks old
VERY YOUNG
What are the clinical presentations of meckels diverticulum?
PAINLESS rectal bleeding ***
Obstruction (volvulus or intussusception)
Diverticulitis
What should you be thinking if the baby does not pass meconium
Bowel obstruction
What are the RED FLAGS for a patient with constipation?
Weight loss/ FTT
Anorexia
Fever
Hematochezia
Vomiting
History of delayed meconium passage
Acute onset
Failure to respond to conservative measures
(This was in red)
Who is more likely to be affected by Hirschsprung disease?
Males
Down syndrome pts
Where do you need to start with imaging if you suspect midgut malrotation?
Abdominal X-Ray -rule out bowel perforation
If not perforated, then youâre good to go ahead and get an upper GI contrast study - gold standard for mm
What is another name for Hirschsprung Disease?
Congenital Aganglionic Megacolon*******
What condition do âunhappy spittersâ have?
GERD
Happy spitters have GER
Is reflux in babies common?
Yes common in infants 6 months and less
How do you diagnose Hirschsprung disease?
Contrast enema
Rectal biopsy- GOLD STANDARD
What will you see on an abdominal x ray if the baby has intestinal atresia in the jejunoileal/colonic areas
Dilated loops of bowel with air-fluid levels
What kind of a diet would cause a kid to develop functional constipationâ/
No fiber
Too much dairy
Not enough water
Can congenital intestinal atresia be detected on ultrasound before the baby is born?
Yes
What is the initial test of choice when you suspect intestinal intussusception ?
Abdominal ultrasound
What are some of the complications of infantile hypertrophic pyloric stenosis that may occur as the disease progresses
FTT
Dehydration
What is the classic clinical presentation of midgut malrotation +/- volvulus
Vomiting- bilious green or fluorescent yellow
Abdominal pain
Hemodynamic instability
Hematochezia (sign of bowel ischemia)
How does smoking affect the risk for Crohn disease and UC?
2x increase risk for Crohn
50% decrease in risk of UC
What happens if your patient has intussusception and the hydrostatic enema didnt do anything
Must intervene surgically
Would you expect growth failure and delayed puberty to be signs of an inflammatory bowel disease?
Why yes you would
What will you see on the upper GI contrast study if the patient has midgut malrotation?
Corkscrew appearance of duodenum**
Duodenal obstruction
Displacement of the duodenum
What is the rule of 2âs regarding Meckelâs diverticulum?
2% of the population
2:1 M:F ratio
2% develop complications (usually before age 2)
2 feet from the ileocecal valve
What is a 2nd test you can order to diagnose pyloric stenosis if the ultrasound was non-diagnostic?
Upper GI Barium contrast study
What are you thinking:
-bile stained vomiting in first 48 hrs of life
- Abdominal distention
- failure to pass meconium
Congenital intestinal atresia
What will you find on physical exam on a baby with infantile hypertrophic pyloric stenosis
An âOlive likeâ mass in RUQ
What is the FIRST line treatment for relieving a fecal impaction for a constipated kid with encopresis?
Polyethylene glycol (Miralax)
**THIS HAD A BLUE STAR*****
What pat of the GI tract is affected by Crohn disease?
TRANSMURAL inflammation from your mouth to your asshole
The ~entire!~ GI tract may be affected
What are some possible causes of chronic diarrhea?
Celiac disease
Allergies
Malabsorption (ex Cystic fibrosis)
Toddlers diarrhea (fruit juice)
What kind of vomiting will a baby with infantile hypertrophic pyloric stenosis have?
Nonbilious (obstruction is before biliary grr)**
Projectile vomiting**
RIGHT AFTER eating**
What will you see on an abdominal x ray if a baby has intestinal atresia in the ~duodenum~?
Double Bubble Sign **
Due to gas and dilation in both stomach and duodenum
Youâre working in the ER and a 12 year old rolls in and you take one look at him and say, âslam dunk its appendicitisâ
Can you send him to surgery without even doing any imaging?
Yes
Do we do surgery for kids with IBD
Yes for refractory cases
When are kids most likely to start refusing to poop and causing themselves to get functional constipation?
Intro to solid foods or cows milk
Toilet training
Starting kindergarten
What is the surgical treatment for midgut malrotation?
Ladd procedure
Bowel is untwisted and repositioned in abdomen which creates âadhesionsâ that hold the bowel in place
What is the most common cause of intestinal emergency in kids under 2
Intussusception
What should you be worried about if a baby is irritable, has dystonic neck posturing, refusing feeding, FTT, respiratory complications and may have occult blood in stool?
GERD
What are some diarrhea red flags? (This might be more than something viral)
Fever
Severe abdominal pain
Blood in stool
Recent antibiotics
Persistent symptoms
Dehydration
Leukocytosis
Growth and development affected
Who are the âhungry vomitersâ?
Babies with infantile hypertrophic pyloric stenosis
How do you diagnose celiac disease?
IgA antibodies to tissue transglutaminase
Small bowel biopsy
Leakage of retained stool seen commonly in kids with chronic constipation=?
Encopresis
What is the definition of diarrhea?
> 3 loose watery stools/day
đ§»đœđ§
What is the most common pediatric surgical emergency?
Appendicitis
What would you see if you looked at the intestines of someone affected by Crohn disease?
Cobblestone appearance***
Skip lesions*
Perianal fissures/fistulas
What are some of the medications that may be used for treating inflammatory bowel diseases?
Aminosalicylates: 5-ASA (Sulfasalazine, Mesalamine)
Immunomodulating agents (Mercaptopurine, azathioprine, methotrexate) or Biologics (Remicade, Inflixamad)
Steroids- especially in acute flare
+/- antibiotics
Who is most likely to get infantile hypertrophic pyloric stenosis?
Males/females
First born/second born
First born males
Is constipation a common problem for kids
Yes, it affects 30%of children
What kind of tissue is in meckelâs diverticulum?
Intestinal epithelium
Gastric epithelium (WTF wait what you mean you have stomach tissue in your small intestine that is producing gastric acid in a totally inappropriate spot?!?!?!?!)
What is the treatment for a meckels diverticulum?
Surgical resection (excellent prognosis)
What are some possible causes for organic constipation (aka the kid isnât holding it in on his own and its not his diet)
Anal stenosis
Hypothyroidism
Celiac disease
Hirschsprungs
HYPERkalemia
Cystic fibrosis
What does encopresis mean?
SEEPING STOOL*****
What will you find on physical exam of a pt with Hirschsprung disease?
Abdominal distention
TIGHT ANAL SPHINCTER*****
Postive squirt sign đ
Continuous, red, friability in rectum and large colon=
Ulcerative colitis
What age group is most likely top get appendicitis?
10-20 yr olds
RARE before 5
Is it possible for inflammatory bowel diseases like Crohn and UC to affect places other than the intestines?
Yes.
Mouth, skin, joints, liver, eye, etc
TRANSMURAL inflammation from mouth to anus, skip lesions=
Crohn disease
Embryonic remnant of the vitelline duct that can cause GI bleed=
Meckelâs diverticulum
When are most cases of Hirschsprung disease discovered?
Before 6 weeks of age
What is the prognosis for GERD?
Usually goes away in 9-12 months because the baby is sitting up when its fed
What kind of vomiting will a bay with congenital intestinal atresia have?
Bile-stained within the first 48 hours of life
Is the classic triad of intestinal intussusception seen in every patient?
No, less than 15% of patients with intussusception have the triad
Why is bilious vomit an emergency?
It indicates an OBSTRUCTION
Malrotation, or congenital intestinal atresia
Which one is an emergency:
Bloody vomit
Bilious vomit
Bilious
What can cause midgut malrotation?
Incomplete rotation of the midget during embryonic development
What the HELL is Hirschsprung disease?
There are NO ganglion cells in the colon which causes:
Spasm and abnormal motility
Colon does not relax= obstruction
Rectum and sigmoid colon are constricted
Areas behind the constriction get swollen
What are skip lesions and what type of IBD are they associated with?
Areas in the intestine that look totally NORMAL (not really a lesion at all)
Associated with Crohn
What kinds of lifestyle mods may be helpful for GERD?
UPRIGHT positioning for 30 min after feeding (sitting STRAIGHT up, not in a bouncer or whatever)
Hypoallergenic diet
Donât overfeed
Avoid cigarette smoke
Thickened milk with cereal
What will you see on contrast enema in Hirschsprung disease?
A âtransition zoneâ where the narrowed aganglionic segment dilated to the proximal colon
What will you see on rectal biopsy of Hirschsprung disease?
Absence of ganglion cells
What causes the bleeding when someone has a meckels diverticulum?
Mucosal ulceration
How do you manage congenital intestinal atresia?
Withhold feeding
Antibiotics
Surgery
Are routine stool cultures recommended for most cases of diarrhea?
NO *****
How do you treat acute diarrhea?
HDYRATION ALWAYS
Antibiotics sometimes
Anti-motility agents rarely
What the F is a squirt sign?
If a finger is inserted into the rectum of a pt with hirschsprungs, the obstruction is relieved and there is an explosive release of gas and stool when the finger is removed đ„œ
Periumbiuliucal pain, +rovsings, obturator, Psoas, McBurneyâs point tenderness =
Appendicitis
What is the recommended fiber intake for kids over 2?
(Childs age) + 5-10g
So a 10 year old should be getting 15-20g of fiber/day
What is the classic presentation of Hirschsprung disease?
Newborn failing to pass meconium in first 48 hours of life*****
Bilious vomiting
Abdominal distention
How do older children present with Hirschsprung disease?
Chronic constipation
FTT
(The later the diagnosis, the less severe the disease)
One or more segments of bowel may be absent or obstructed at birth=?
Congenital intestinal atresia
Is the treatment of inflammatory bowel diseases like crohn and UC a âone size fits allâ approach?
NO
âChoice of treatment varies based on the severity of diseaseâ
This was written twice in blue
Which part of the bowel is most commonly affected by congenital intestinal atresia?
Duodenum
What will you see on an UGI Barium contrast study in a baby with pyloric stenosis
âString signâ
Which is the narrowed lumen of the pylorus
Should we give kids with diarrhea Imodium?
Not recommended
What would you expect to see if you looked at the rectum and colon of someone with UC?
CONTINOUS (no skip lesions) edema, erythema, friability, and ulceration
What are the thoughts on giving antibiotics to well-appearing children who have acute bloody diarrhea?
Should NOT be used unless a specific pathogen has been isolated (donât want to induce HUS)
What part of the GI tract is affected by ulcerative colitis?
Rectum and large colon
Mucosal layer ONLY
(Inflammation STARTS at the rectum and moves proximally into the colon)
What is the gold standard test to detect midgut malrotation
Uppper GI contrast study
What kids of findings suggest that constipation is from an organic cause and not functional?
Failure to pass meconium
FTT
Abdominal distention
Lumbosacral problems
Neurological abnormalities
Anteriorly placed anus ?
Occult blood in stool
What is the DEFINITIVE MANAGEMENT of pyloric stenosis?
Surgery- âpyloromyotomyâ
What are you supposed to feed a baby that is allergic to milk or soy?
A hydrolyzed or free amino acid based formula (Ex: Nutramigen)
Why donât we pump kids with IBD full of steroids
Concern for bone density, growth and development
What is the most common cause of a âlead pointâ that causes intestinal intussusception
Meckels diverticulum
What is congenital intestinal atresia?
One or more segments of bowel are absent or obstructed at birth
There is an association between infantile hypertrophic pyloric stenosis and ______________
Macrolide antibiotics during the first few weeks of life
Azithromycin, erythromycin, clarithromycin in case you forgot
Which is bad:
GER or GERD
GERD is bad
GER is normal happy babies spitting up
6 month old with abdominal pain and currant jelly stools=
Intussusception
What will you see on ultrasound if patient has intussusception?
Target Sign
Coiled Spring
What is the cause of 95% of pediatric constipation?
Functional constipation (psychological or diet reasons)
How do you treat Hirschsprung disease?
Surgical resection of the aganglionic segment of colon.
Overall a good prognosis
Abnormal position of the intestines in the abdomen that increase the risk of volvulus
Midgut malrotation
What are some possible signs and symptoms that a kid might have celiac disease, other than diarrhea?
FTT*
Anemia
Foul smelling stools
What is the classic triad of intestinal intussusception?
Abdominal pain
Abdominal mass (sausage shaped)
Currant jelly stools (blood + mucus)
****this was red and had a blue star
What is a major risk of a malrotation?
Volvulus- where the small bowel twists around the superior mesenteric artery= HUGE RISK of small bowel ischemia!!!
EMERGENCY!!!!***
What is this:
âVitelline duct (embryonic remnant) leads to formation of a congenital outpouching of the small intestineâ
Meckelâs diverticulum
After surgery for midgut malrotation, is recurrence common?
No
Which rotavirus vaccine was taken off the market due to a 22x risk of intussusception
Rotashield
đĄ
What kinds of things in a kidâs diet might cause diarrhea?
Fruit juice- Functional âToddlerâsâ diarrhea
Milk/soy enteropathy (allergy)
What kinds of medications are used for GERD in kids who donât get better with lifestyle mods?
PPI (Omeprazole)
H2 blocker (Ranitidine)
Congenital aganglionic megacolon, rectal biopsy is the gold standard=
Hirschsprung
What is this:
âImmune mediated inflammatory disease of the small intestine caused by gluten sensitivityâ
Celiac disease
What should you do if your patient has GER?
Nothing, because it is a normal physiologic process that declines with age without ANY complications or consequences
If you see a test question that has a 1st born 3 week old baby boy, who is always hungry, and projectile vomits immediately after eating, what is the answer
Infantile hypertrophic pyloric stenosis
Intestinal atresia is more common in patients with these two conditions:
Cystic fibrosis
Down syndrome
What causes intestinal intussusception?
Idiopathic 75% of the time
âLead pointâ 25% - lesion/variation in the intestine gets dragged by peristalsis into a distal segment.
What is the TEST OF CHOICE for diagnosing infantile hypertrophic pyloric stenosis?
Ultrasound
How do you diagnose crohn disease
Colonoscopy*
5 week old, hungry, with projectile vomiting=
Pyloric stenosis
Is there an increased risk of colon cancer if you have UC?
Yes
Whyyyyyyyyy do you need to evaluate a child with constipatin
You need to rule out an anatomic or biochemical cause
