Gastrointestinal/Nutrition (Alice) (10%) Flashcards
3 sx of appendicitis
crampy/colicky periumbilical pain - first sx
anorexia
nausea
describe pain progression w. appendicitis
periumbilical -> RLQ
what is mcburney’s point
2/3 the distnce from the navel to the right ASIS
rebound tenderness at mcburney’s point suggests
appendicitis inflammation has spread to the peritoneum
4 PE signs associated w. appendicitis
mcburney’s point tenderness
rovsing
obturator
psoas
RLQ pain w. palpation of LLQ
rovsing sign
RLQ pain w. internal rotation of the hip
obturator sign
RLQ pain w. hip extension
psoas sign
what on a CBC suggests appendicitis
neutrophilia
extremely fussy infant that pulls his legs up as if he is trying to stool - intractable crying x 4 hours for 4 days in a row
colic
2 hallmark signs of colic
-severe, paroxysmal crying in the late afternoon to evening
-drawing up of knees against the abdomen
colic peaks at _ and ends around _
peaks: 2-3 mo
ends: 4 mo
rule of 3’s for colic
cry > 3 hr/day
3 days/week
x 3 weeks
besides reassurance, 2 things to consider in a colicky baby
formula switch
GERD tx
childhood constipation is almost always
functional
diagnostic parameters for constipation
< 2 BM’s/week
> 1 episode of encopresis/week
what is encopresis
-fecal incontinence/soiling
-repeated passage of stool into clothing
3 mc triggers of constipation
transitioning to solids
potty training
starting school
5 red flags w. constipation
onset prior to one mo old
delayed passage of meconium after birth
ftt
explosive stools
severe abd distension
constipation red flags make you concerned for what d.o (2)
hirschprung dz
metabolic abnormality
supportive care for constipation (5)
increase fiber
decrease cow’s milk
mineral oil
miralax
lactulose
3 most accurate signs of dehydration in peds
prolonged cap refill
poor skin turgor
abnl breathing
others: sunken eyes, lethargy, lack of tears, dry mm
3 tools used for assessment of pediatric dehydration
WHO
gorelick
clinical dehydration scale
2 day old pretern w. abd fullness, bilious aspirate, and absence of distal bowel gas
duodenal atresia
what is duodenal atresia
congenital absence or complete closure of a portion of the lumen of the duodenum
2 complications of duodenal atresia
polyhydraminos
intestinal obstruction
hallmark sign of duodenal atresia
early biliary vomiting in newborn
increased assocaition of duodenal atresia occurs with
down syndrome
what is this showing
double bubble -> duodenal atresia
management of duodenal atresia (6)
suction/drain respiratory secretions
elevate head
IV glucose
IVF
abx
surgery
for dx of encopresis, child must be >/= _ yo
4
encopresis is almost always associated w.
severe constipation
is encopresis mc among males or females
males
encopresis is almost always functional, but you should also consider _ causes
emotional - ex school/divorce
3 associated sx of encopresis
abd pain/fecal mass
dilated rectum packed w. stool
urinary frequency
acute vs chronic tx of encopresis
acute: Peg/Miralax, glycerin suppository
chronic: elliminate cow’s milk, maintenance laxatives, increased fiber/fluids, timed toileting
foreign body aspiration is mc in what age group
6 mo - 3 yo
4 complications of foreign body aspiration
bowel perforation
bowel obstruction
asphyxia
PNA
sx of esophageal foreign body (although often asymptomatic)
bloody saliva
couging
drooling
dysphagia
ftt
anorexia
irritability
stridor
tachypnea
vomiting
wheezing
t/f: foreign objects beyond the esophagus have an increased risk of complications
t!
5 sx of foreign body obstructions beyond the esophagus
abd pain
n/v
fever
hematochezia
melena
5 common foreign body obstruction locations
cricopharyngeal
middle 1/3 of esophagus
lower esophageal sphincter
pylorus
ileocecal valve
3 CXR findings of foreign body aspiration
regional/asymmetric hyperinflation
collapse/atelectasis
normal
_ is indicated for ALL suspected inhaled foreign bodies regardless of CXR results, unless pt is completely asymptomatic w. normal PE AND CXR
bronchoscopy
indication for cultures w. foreign body aspiration
post-obstructive PNA
management of foreign body thought to be in the esophagus (3)
observe x 24 hr
serial CXR
endoscopic removal after 24 hr
management of foreign body aspiration if timeframe is unknown or if symptomatic
bronchoscopy
3 indications for immediate bronchoscopy w. foreign body aspiration
sharp object
batteries
symptomatic
management of foreign body aspiration distal to the esophagus
small blunt object: obs w. serial CXR; remove if not past pylorus in 3-4 weeks
large object > 3 cm or sharp object: bronchoscopy removal if in the pylorus; serial imaging if beyond pylorus
management of acid/alkali ingestion (3)
do NOT induce emesis
monitor ABCs
endoscopy in 2-3 weeks
gastroenteritis/infectious diarrhea usually lasts < _
2 weeks
4 HPI clues for gastroenteritis
foreign travel
playing in creek
daycare
poultry
gastroenteritis mc has _ etiology
viral
mcc of severe gastroenteritis in kids vs adults
kids: rotavirus
adults: norovirus
2 parasitic causes of gastroenteritis
giardia
cryptosporidium
4 bacterial causes of gastroenteritis
campylobacter
e.coli
clostridium
salmonella
reptiles make you think of what cause of gastroenteritis
salmonella
7 common food sources of gastroenteritis
raw/undercooked meat
seafood
eggs
raw sprouts
unpasteurized milk
soft cheese
f/v juices
3 indications for stool cultures w. gastroenteritis
bloody stools
suspect food poisoning
recent travel
+/- : children < 5 yo, elderly, immunocompromised
7 red flags w. gastroenteritis
bloody/mucous stools
wt loss
hypotn
sunken fontanelle
dry mm
no crying
decreased urine output
rare complication of campylobacter gastroenteritis
reactive arthritis
travelers diarrhea pathogen
enterotoxigenic e. coli (ETEC)
diarrhea after a picnic w. egg salad
s. aureus
diarrhea from shellfish
vibrio cholerae
diarrhea from poultry/pork
salmonella
diarrhea w. poorly canned foods
c perfingens
diarrhea breakout in daycare
rotavirus
diarrhea and horrible muscle cramps after a cruise
norovirus
diarrhea 1-3 weeks after camping
waxing/waning foul-smelling bulky stool
giardia
3 indications for abx w. gastroenteritis
abx
fever
bloody diarrhea
abx used for pediatric gastroenteritis (4)
cipro
doxy (?)
azithromycin
bactrim
t/f: mild reflux is common in all infants
t!
7 complications of pediatric GERD
ftt
aspiration pna
esophagitis
choking
apnea
hematemesis
anemia
mcc cause of pediatric GERD
overfeeding
indication that pediatric reflux is NOT GERD
emesis independent of meals
work up for mild pediatric reflux
pH probe
work up for severe pediatric reflux or projectile emesis (2)
abd US
barium swallow
CXR
lab finding associated w. severe pediatric reflux
hypochloremic, hypokalemic metabolic alkalosis
supportive management of mild pediatric GERD (3)
-small, frequent feedings w. head in upright position x 20 mins after feeding
-thickened feeds
-elliminate cow’s milk
indications for PPI/H2 blocker w. pediatric GERD
suspect esophagitis
surgery for pediatric GERD
nissen fundoplication
t/f: ppi’s are preferred over H2 blockers for pediatric GERD
t!
jaundice, clay colored stool, icterus, hepatosplenomegaly
neonatal hepatitis
mcc of cholestasis in the newborn
neonatal hepatits
t/f: neonatal hepatitis has a male predispsotion
t!
50% of neonatal hepatitis present w. what 2 sx
jaundice
hepatomegaly
t/f: neonatal hepatitis is usually self limited
t!
supportive tx for neonatal hepatitis (3)
MCT containing formula
fat soluble vitamins
+/- TPN
pharm for neonatal hepatitis
ursodeoxycholic acid (bile acid)
what must you do before using ursodeoxycholic acid
exclude biliary obstruction
2 mcc of pediatric viral hepatitis
hep A and B
CMP finding of hepatitis
uniformly elevated LFTs
lab that is pathognomonic for active hep B dz and is used in hep B vaccine eval
HBsAg (surface antigen)
Hep B lab value that can be positive as a result of vaccination OR natural infxn
HBsAb (surface abs)
Hep B lab value that results from natural infxn but NOT vaccination, and persists lifelong
HBcAb (core abs)
hep B lab value useful in assessing acute infxn
HBeAg (e antigen)
Hep B lab value useful in assessing late infxn
HBeAb (e abs)
hep B lab value used for both dx and assessing response to therapy
HBV polymerase chain rxn (PCR)
what lab value confirms hep A infxn
anti HAV IgM
managment of hep B in infants of infected mothers
vaccine
PLUS
HBV immunoglobulin at delivery
indication for referral w. pediatric hep B
chronic hep B w. persistently abnl ALT
2 week old w. no BM x 5 days, 5th %ile for weight, distended abdomen, absence f stool in rectal vault, dilated loops of bowel, and megacolon
hirschprung dz
congenital aganglionic bowel dz caued by lack of caudal migration of ganglion cells from the neural crest -> contraction of distal segment of colon -> obstruction w. proximal dilation
hirschprung dz
hirschprung dz is caused by absent _, which regulate bowel fxn
ganglion plexuses
t/f: hirschprung dz has a 5x male predominance
t!
t/f: at birth, hisrschprung dz is asymptomatic
t!
hallmark sx of hirschprung dz
inability to pass meconium 48 hr postpartum
work up for hirschprung (4)
rectal suction
bx
barium assisted radiography
DRE
show absence or paucity of ganglion cells
tx for hirschprung dz (2)
resection of affected segment
colostomy
mc type of pediatric hernia
direct: thru external/superficial inguinal ring at hesselbach triangle
management of indirect inguinal hernia
asymptomatic: elective repair w.in 14 days
symptomatic: emergent referral if concern for bowel incarceration
2 sx of bowel incarceration w. hernia
erythema of overlying skin
pain/tenderness
pathway of indirect inguinal hernia
deep inguinal ring -> scrotum
which type of hernia passes thru hesselbach’s triangle
direct
management of direct inguinal hernia
monitor
+/- surgical repair
12 mo old w. recurrent belly aches x 2 weeks that culminate in sudden colicky pain q 15-20 min w. vomiting - pt presents squatting w. knees to chest
intussusception
2 hallmark findings of intusussception
bloody/mucus stool (currant jelly)
sausage shaped abd mass in RUQ
intusussception occurs when a _ portion of the intestines invaginates/telescopes into a _ portion
proximal portion invaginates/telescopes into distal portion
peak age incidence for intussusception
5-9 mo
mcc cause of neonatal bowel obstruction in infants < 2 yo
intussuception
PMH clue for intussuception in peds vs adults
peds: viral infxn
adults: cancer
management of intussusception that is diagnostic and therapeutic
barium enema
2 XR findings of intussuception
crescent sign
bull’s eye/target/coiled spring lesion sign
what is this showing
crescent/meniscus sign (intussusception)
what is this showing
target sign -> intussusception
neonatal jaundice appears when bilirubin levels exceed
2 mg/dL
sx of physiologic jaundice (5)
-isolated unconjugated hyperbilirubinemia
-no co-existing illness
-bilirubin rises < 0.2 mg/dL/hr OR 5 mg/dL/day
-bilirubin remains < 18 mg/dL
-hyperbilirubinemia resolves w.in 1 week in fullterm OR 2 weeks in preterm
sx of pathologic jaundice
-unconjugated hyperbilirubinemia w.in 24 hr after birth
-serious illness
-bilirubin rises >2 mg/dL/hr OR >5 mg/dL/day
-bilirubin rises > 18 mg/dL
-hyperbilirubinemia lasts > 1 week in term OR > 2 weeks in preterm
pathologic jaundice is mc due to a _ cause
prehepatic
work up for neonatal jaundice
coombs test:
positive: consider Rh OR ABO incompatability
negative: check Hgb levels
in neonatal jaundice, if coombs is negative and Hgb levels are low, consider _
if Hgb levels are high, consider _
low Hgb: hematomas
high: diabetic mother, twin-twin or maternal fetal transfusion, delayed cord clamping
work up for neonatal jaundice if coombs is negative and Hgb levels are normal, consider _
hemolysis
lab findings of hemolysis
increased: reticulocytes, LDH
decreased: haptoglobin
dx for hemolysis
-smear: sphreocytosis or elliptocytosis
-presence of G6PD or pyruvate kinase deficiency
-Hgb electrophoresis for thalassemia and SSA
you should consider bf’ing jaundice if
normal coombs
normal Hgb
normal LDH and haptoglobin
2 neonatal syndromes associated w. jaundice
gilbert
crigler najjar syndromes
what type of hyperbilirubinemia is mc benign
unconjugated
3 causes of conjugated bilirubin
hepatocellular
dubin johnson
rotor syndrome
what should you consider if AST and ALT levels are high in setting of conjugated bilirubin (6)
hepatitis
TORCH infxns
hemochromatosis
wilson dz
alpha 1 antitrypsin deficiency
galactosemia
elevated conjugated bilirubin PLUS elevated ALP
post hepatic jaundice -> biliary tree obstruction
3 causes of neonatal biliary tree obstruction
biliary atresia
choledochal cysts
alagille syndrome
what is borborygmi and what does it make you think of in peds
rumbling stomach
lactose intolerance
sx of lactose intolerance mc occur w.in _ min of eating
30
but may take up to 2 hr
pt w. lactose intolerance may need _ supplementation
calcium
lactose intolerance is mc a clinical dx, but what is the definitive dx
lactose hydrogen breath test
alternative: fecal pH test
lactose hydrogen breath test positive findings
post lactose breath hydrogen value rises > 20 ppm over baseline
12 yo who easily sunburns and c/o non healing sunburns - PE shows wide stance gait w. instability, extensive erythematous scaling, and hyperkeratotic rash on face, neck, arms, and legs
niacin deficiency
4 d’s of niacin (b3) deficiency
dermatitis - pellagra (raw skin)
diarrhea
dementia
death
what is this showing
pellagra dermatitis - photosensitive pigmented dermatitis
rf for niacin deficiency
diets low in tryptophan/niacin -> corn staple diets
6 dietary sources of niacin
yeast
meats
grains
legumes
tortillas
seeds
pediatric RDA for niacin
12 mg/day
niacin status can be assessed by measuring (2)
urinary N- methylnicotinamide
erythrocyte NAD:NADP ratio
6 week old w. projectile vomiting after feeding x 24 hr
pyloric stenosis
hallmark PE finding of pyloric stenosis
olive shaped mass in epigastric region
what is pyloric stenosis
congenital condition:
pyloric hyprplasia/hypertrophy -> obstruction of pyloric valve
lab finding of pyloric stenosis
hypochloremic, hypokalemic metabolic alkalosis
2/2 to dehydration
mc age group for pyloric stenosis
< 3 mo old
hallmark sx of pyloric stenosis
projectile vomiting after every feeding
dx for pyloric stenosis
US
2 US findings of pyloric stenosis
double track
string/shoulder sign
what is this showing
thickened, hypoechoic muscular wall and elongated pyloric canal -> double track sign -> pyloric stenosis
what is this showing
stirng sign -> pyloric stenosis
tx for pyloric stenosis
pyloromyotomy (ramstedt’s procedure)
persistent opening of the umbilical ring, which spontaneously closes
umbilical hernia
complete closure of the umbilical ring occurs in almost all children by _ yo
5
can take up until 11 yo
umbilical hernias are mc asymptomatic, but pt’s can exhibit
poor feeding
hernias may become symptomatic when children _
cry
due to increased intraabdominal pressure
peds should be referred for surgery if umbilical hernias persist > _ yo
2 yo
3 causes of vitamin a deficiency
inadequate intake
fat malabsorption
liver d.o
3 sx of vitamin a deficiency
rashes
dry eyes
night blindness
4 sources of preformed vit A (retinols)
liver
kidney
egg yolk
butter
3 sources of provitamin A (beta carotene)
leafy greens
sweet taters
carrots
dx for vitamin A deficiency
serum retinol levels < 20 mcg/dL
tx for vitamin A deficiency based on age
6-12 mo: 100,000 IU orally q 4-6 mo
12-59 mo: 200,000 IU q 4-6 mo
8 sx of vitamin C deficiency
gingival hemorrhage
bruising
petechial rash
hemarthrosis
anemia
poor wound healing
perifollicular and supperiosteal hemorrhages
corkscrew hair
t/f: the human body can NOT synthesize vit C
t!
2 rf for vit C deficiency
-food insecurity
-infants eating evaporated/boiled cow’s milk
dx for vit C deficiency
plasma and leukocyte vit C levels
2 MRI findings of vit C deficiency
-sclerotic, lucent, metaphyseal bands
-soft tissue edema
most specific sx of vit C deficiency
perifollicular abnl’s
follicular hyperkeratosis
perifollicular hemorrhage
petechiae
coiled hairs
what is this showing
perifollicular abnl’s -> vit C deficiency
vit C repletion recs: peds vs adults
peds: 100 mg ascorbig acid tid x 1 week, then qd until resolved
adults: 300-1,000 mg qd x 1 mo
w. vit C deficiency, constitutional sx resolve w.in _
bruising, gingival bleeding resolve w.in _
constitutional: 24 hr
bruising/bleeding: several weeks
t/f: breastmilk provides adequate vit C for newborns/infants
t!
4 PE findings of rickets
bowed legs
fractures
costochondral thickening
dental caries
what is this showing
rachitic rosary - costochondral thickening -> rickets
2 rf for vitamin D deficiency
dark skin pigmentation
exclusive bf’ing beyond 3-6 mo
what is sufficienct sun exposure for vit D for people w. light skin
10-15 min
t/f: reduced vit D stores in MOC correlate w. lowr vit D levels in infant
t!
what pt pop makes you think about vit D deficiency (3)
dark skinned pregnant women
higher latitudes in winter mos
premature infants
dx for vit d deficiency
serum 250 HD levels:
sufficiency: 20-100 ng/mL
insufficiency: 12-20 ng/mL
deficiency: < 12 ng/mL
8 vit D rich foods
oily fish
cod liver oil
liver
egg yolk
milk
OJ
bread
cereal
vit D supplementation recs for breastfed infants
400 IU qd w.in a few days after birth
vit D supplementation recs for children 1-18 yo
600 IU qd
