GI Flashcards
A concerned parent brings her child to you complaining that he has 2 loose stools /day. Would you Dx diarrhea?
maybe not… it should be >3 LOOSE WATERY stools/day per definition of diarrhea.
a child comes in with diarrhea. what are some of your DDx?
1.infectious 2. diet related 3. IBS 4. inflammatory bowel dz 5. meds (abx), 6. celiac dz 7. intussusception 8. appendicitis
what is infectious diarrhea due to?
viral, bacterial, systemic
what is the common cause of viral diarrhea?
Rota virus
what are two possible causes of diet related diarrhea?
1.toddler’s diarrhea 2. cows/soy milk intolerance
what do you focus on first for Tx of diarrhea?
focus on hydration PO vs IV
what is constipation?
regular passage of firm or hard stools, or the infrequent passage of stools
what are 2 types of constipation?
functional vs. organic
a child comes in with constipation but you find no anatomical biochemical abnormality. What kind of etiology do you suspect for this constipation?
functional constipation
what is organic constipation due to?
anatomic or biochemical cause
what is functional constipation?
voluntary holding of stool –there is no anatomical biochemical abnormality–
why do some kids voluntarily hold their stool?
neg experience, painful…this may result in stool incontinence (encopresis)
when does constipation most likely happen… in kids of course?
intro to solid food, toilet training, start of school
What PE do you do for constipation?
abdominal and anus/rectal
why do you do abd exam for constipation?
decreases bowel sound and distention may be concerning for obstruction
why do you do anus/rectal exam for constipation?
looking for anal fissure, anatomic placement, r/o fecal impaction
when you have a pt with constipation, what Dx study do you do to r/o impaction?
plain film of abdomen
what do you recommend for management of constipation?
fluids, gradual increase in daily fiber intake, decrease dairy, relieve impaction, laxative, counseling and reward program
what should you ALWAYS do for a pt with vomiting?
obtain a reliable history and description of vomits
what do you do to check volume status in pt with vomiting when suspecting dehydration?
check mucous membranes, skin turgor, sunken fontanelle, urine output
what are some infections that cause vomiting?
gastroenteritis, UTI, Pharyngitis
what is GERD?
effortless regurgitation of stomach contents
Is GERD always bad?
no…there are some happy spitters
How do you know if your pt with vomiting is a happy spitter?
vomit in happy spitters is not forceful
if you see hoarseness, dysphagia, respiratory complications with vomiting, is it a happy spitter case?
Nope!
if symptoms of vomiting are severe what do you do?
UGI or endoscopy
what is Tx for GERD?
H2 blocker or/and PPI therapy
what is pyloric stenosis?
increase in size of pylorus muscle causing stenosis of the channel
Pyloric stenosis is most common in:
a. males
b. females
c. second born children
d. first born children
D. poor first born children.
what are clinical presentation of Pyloric Stenosis?
PROJECTILE vomiting after feeding, non-bilious, HUNGRY VOMITER
what might you find in PE exam suspecting Pyloric Stenosis?
- upper abd may be distended
- prominent peristaltic waves moving from L to R
- Olive sized mass in RUQ
you finish your abd exam and you find an Olive sized mass in RUQ . what does this indicate…most likely?
pyloric stenosis from HYPERTROPHY
Is a mass always palpable in pyloric stenosis with hypertrophy?
no…due to early presentation, abd fat, or of course skills of examiner a mass might not be palpable.
What is the test of choice for pyloric stenosis?
Ultrasound
What can you see in ultrasound of a pt with pyloric stenosis?
elongation and thickening of the pylorus
What do you have to look for on UGI of a pt with possible pyloric stenosis?
the string sign on UGI
What is the management of pyloric stenosis?
- IV fluid and electrolyte resuscitation
- pyloromyotomy
- wait for the EXCELLENT prognosis
What is a pyloromyotomy anyway?
incision down to the mucosa and fully across the length of the pylorus
what is congenital atresia?
one or more segments of bowel may be missing and/or obstructed
what are three types of congenital atresia?
Duodenal, jejunoileal,colonic
what type of congenital atresia is a/w congenital abnl such as down syndrome?
duodenal
what is the common etiology of congenital atresia?
it is common with prenatal hx of polyhydramnios
what is the most important clinical presentation of congenital atresia?
bile-stained vomiting begings within first 24 hrs.
A new born has failed to pass meconium. what is your first thought for DX?
congenital atresia
What dx studies do you order when suspecting congenital atresia?
first abd plain film and upper GI series/contrast enema to confirm or identify the exact area.
You see a DOUBLE BUBBLE sign on abd xray of a pt. what is your dx?
duodenal congenital atresia: due to gas and dilation in both stomach and duodenum
You see adilated loops of bowel and air fluid levels on abd xray of a pt. what is your dx?
jejunoileal/colonic congenital atresia: dilated loops of bowel and air fluid levels
what would ultimately resolve the congenital atresia?
you manage via iv fluid to correct electrolytes but surgery intervention is the ultimate.
what is prognosis for surgery intervention for congenital atresia?
> 90% survival
what is a complication of midgut malrotation?
volvulus: narrow mesenteric base increase small bowel mobility
what is volvulus?
small intestine twists around SMA causing vascular compromise
midgut malrotation is not an emergency. is it?
Yes!!!! it is a surgical emergency because it can lead to necrosis, perforation, peritonitis, sepsis, and you being sued!
a 14 day old pt comes in with BILIOUS vomiting, abd pain and HEMATOCHEZIA what are you thinking of?
midgut malrotation w/wo volvulus
you do an abd exam on a week old infant and you see abd distention and VISIBLE PERSITALSIS. what are you thinking of for Dx?
midgut malrotation …at least
what dx studies do you do when suspecting midgut rotation and why?
UGI to see obstruction and displacement of duodenojejeunal jxn to the RIGHT of the spine
why would you order barium enema for dx of midgut malrotation?
if DX in question or to confirm dx (cecum in RUQ)
what is tx of midgut malrotation?
surgery with a good prognosis in 90% of pts
what is intussusception?
invagination of one portion of intestine into another usually PROXIMAL to ILEOCECAL VALVE.
what is the most frequent cause of intestinal obstruction in the first 2 years of life?
intussusception. Remember it is rare in newborns.
a 1.5 yo pt comes in for abd cramp where he draws his legs to the chest. his mom also reports vomiting, not feeding, and currant jelly stools. what is your DX?
intussusception
what are you looking to find in abd exam when suspecting intussusception?
tender/distended abd and a sausage shaped mass in upper mid abd secondary to swollen bowel
what dx studies when suspecting intussusception?
- abd ultrasound
- Barium enema (dx and therapeutic ~90%)
- air enema ( to avoid risk a/w perforation)
how do you manage intussusception?
- IV fluid
- emergent surgical consult
- reduction w/barium enema
- SURGERY if BE unsuccessful
Can you skip reduction in managing intussusception?
NOPE! if reduction not performed, can be fatal
what is meckel’s diverticulum?
embroyonic remnant of the omphalomesenteric duct or Vitelline duct
what does an abnormal pouch/opening from small intestine called?
Meckel’s diverticulum
where do you expect to fine Meckel’s diverticulum?
usually located mid to distal ileum
what is the dz of 2’s?
meckel’s diverticulum
what does the dz of 2’s mean?
2% of population
2:1 M:F
2% become symptomatic
<2yo more symptomatic
what are some clinical presentation of meckel’s diverticulum?
painLESS rectal bleeding
obstruction (volvulus or intussusception)
DiverticulITIS (may look like Appendicitis)
What dx studies do you order when suspecting meckel’s diverticulum?
Technetium-99 scan (meckel’s scan)
You are about to dx a pt with Meckel’s diverticulum but you are also thinking of something else. what is that dx?
acute appendicitis
You have dx a patient with Meckel’s dovertoculum. what’s next?
Surgical resection of the diverticula and the omphalomesenteric remnant.
you just sent a pt for surgery b/c of meckel’s diverticulum. the family asks you about the prognosis. what do you say?
prognosis is excellent!!
what is hirschsprung dz?
congenital aganglionic megacolon
hirschsprung dz occurs secondary to what?
absence of ganglion cells in mucosal and muscular layers of colon and begins in DISTAL bowel usually RECTOSIGMOID
in hirschsprung dz pt does not have ganglion cells in parts of colon. So what?
peristalitic waves cannot extend beyond this zone of denervation and the bowel may become obstructed
what kind of obstruction is a/w hirschsprung dz?
functional obstruction (REMEMBER hirschsprung dz is ORGANIC CONSTIPATION)
SPASM and abnl motility in affected portion of the colon is a/w what?
hirschsprung dz
what is most common cause of LOWER bowel obstruction in neonates?
hirschsprung dz
hirschsprung dz has concurrence with which of the chromosomal abnormalities?
down syndrome
a new born fails to pass meconium within the first 24 hr, followed by bilious vomiting, abd distention, reluctance to feed. there is no hematochezia and visible persitalsis. abd xray does not show double bubble. What is your dx?
hirschsprung dz
Can you dx hirschsprung dz if pt has passed meconium?
YES!! new born may passes meconium with symptoms developing later. pt may present with progressive constipation and partial obstruction.
what are PE findings when suspecting hirschsprung dz?
abd distention
anal canal may feel narrow on rectal exam
anal canal and rectum devoid of fecal material–>gush of stool when finger removed
gush of stool when finger removed on rectal exam is a/w what?
hirschsprung dz
what dx studies when suspecting hirschsprung dz?
rectal bx–confirms absence of ganglion cells
how do you manage hirschsprung dz?
- resection of aganglionic segment
2. colostomy
what do you need to consider when thinking of colostomy for hirschsprung dz?
- allow pt to recover before reparative surgery
2. colorectal anastomosis performed later
what is inflammatory bowel dz?
immune mediated inflammation of GI including ulcerative colitis and crohn’s
cobblestone appearance is a/w what dz?
crohn’s dz
erythematous and friable mucosa with small erosions is a/w what dz?
ulcerative colitis
how do you treat inflammatory bowel dz?
dz maintenance
- 5-ASA (sulfasalazine, asacol)
- immunimodulating agents (6-MP)
- biologics (remicade)
- steroids
when do you use steroids for inflammatory bowel dz?
during flares
what are the concerns for using steroids for inflammatory bowel dz?
bone density and growth and development
What often results from functional constipation in children?
stool incontinence (encopresis) often results from functional constipation
Corkscrew sign on Xray is a/w ?
Volvulus
