GI Flashcards
28 yr old G1 Po0 with no prenatal care came in with contractions saying her water broke that morning. A quick bedside US showed a term sized infant and polyhydramnios. Due to the size and position of the infant she couldn’t see much else beside grossly normal skeleton and head size.
What fetal abnormalities lead to polyhydramnios?
not swallowing fluid, kidney problems, obstruction is the most common cause
You (and everyone) immediately notice the mass of intestines outside the baby. As you lay the baby on the warmer you can see that the intestines are separate from the cord and there are no other organs visible.
Gastroschesis
Functional abdominal pain… sx caused by, work up
Sx without pathologic correlate
Lab tests/ work up negative
Variant of normal anatomy
Organic problems… sx caused by, workup
Sx caused by a distinct pathological entity
Labs and workup indicative of underlying pathology
Disease state -requires intervention
CBC shows
infection, inflammation, bleeding
Chem 7 shows
hydration
LFTs show
Bili/ALT /AST/ Alk Phos/ GGT
Coags : PT / PTT / Fibrinogen
amy and lipase show
pancreas
xray shows
Gas patterns, dilation, ileus, retained stool, obstruction
Barium swallow or barium enema shows
Reflux, obstruction, malrotation , ulcer, certain IBD
Colon size, obstruction,intususseption, US
Pylorus, gallbladder, appendicitis
CT shows
Mass, appendicitis
Endoscopy shows
Gastritis, ulcers
what are the most common sources of acute abd pain in young children
Malrotation, intussusception, incarcerated hernia, congenital anomalies
what are the most common sources of acute abd pain in older children?
appendicitis
Chronic abdominal pain is ____70-90% of time
Functional
what are functional problems? 2 ex chronic
constipation or IBS
chronic abd pain is ____10-30% of time:
Organic
short list of causes of chronic abd orgainic pain
Gastritis/ulcer
Lactose intolerance
Parasites
Gall bladder disease
what are symptomos of chronic fxnl abd pain
periumbilical – or not, Pain day and night No weight loss May have pallor, N/V/F Little relationship to bowel habits May be IBS (bloating, postprandial pain, lower abdominal distension)
what are useful tests in chronic fxnl abd pain
CBC, UA/UC , stool for occult blood
how do you treat chronic fxnl abd pain?
: reassurance and explanation of functional pain
Fluids, diet, activity, sleep, emotions
what is IBS also called
Recurrent Abdominal Pain Syndrome of Childhood
what is IBS?
Abnormal electrophysiology of bowel wall
Familial
when does IBS start and what are symp?
Often have diarrhea as infants, then constipation as older children
Abdominal pain in early school years
Often stress-associated, risk of school avoidance
Rarely awakens at night
how do you treat IBS
Important not to “medicalize”
Increased fiber in diet may be helpful
what is the most common cause of vomiting?
Viral Gastroenteritis
what are other things that could cause vomiting
-Obstruction, and acute or chronic inflammation of GI tract
-CNS inflammation, pressure or tumor
-Metabolic derangements
IEM, sepsis, drug intoxication
projectile vomiting is a result of
high obstruction, ie pyloric stenosis
what does bilious vomit mean?
obstruction
Beyond ampulla of vater … duodenal, jejunal, ileal, colonic
** Malrotation
what does bloody vomiting mean?
mallory weis tear
Gastritis
Peptic ulcer?
vomiting in neonates what should you think?
obstruction or stenosis
what is forceful nonbilious vomiting in neonates?
pyloric stenosis
what else should you thing for vomiting in neonates?
-Obstruction Duodenal atresia and stenosis Malrotation / volvulus Pyloric stenosis- forceful, nonbilious -MetabolicAcidosis Sepsis Metabolic disorders / Inborn errors of metabolism
Vom first thing in the morning with HA might mean
CNS related
in older children vomiting is d/t
Viral Illness
Strep pharyngitis
UTI
Otitis media
if chronic vomiting think…
consider CNS
if with pain or bilious emesis in older children?
bowel obstruction, peptic disorders, appendicitis
what labs should you do for vomiting?
Electrolytes, BUN/Cr , CBC, UA/UC , amylase, lipase, LFT
what will US pick up for vomiting?
pyloric Stenosis, gallstones, renal stones, hydronephrosis, biliary obstruction, pancreatitis, appendicitis, malroattion, intussusception.
what should you do if you suspect appendicitis?
CT
how do you treat vomiting?
Treat underlying cause if identified
Management of fluid and electrolytes
Anti-emetics: very carefully
Acute diarrhea nearly always
infectious
how do you manage viral diarrhea?
Management is supportive – fluids, Na, K
Oral rehydration, starvation prolongs diarrhea
Avoid lactose is helpful
what is the most common cause of diarrhea in kids?
rota virus
what does rotavirus affect?
Rotavirus affects small intestine
how does rotavirus present?
Vomiting first in 80-90% pt followed by low fever
Diarrhea next .. Can last 4-8 days
who does rotavirus affect and when
Mainly infants 3-15mo
Peaks in winter ….. Transmitted fecal- oral
what are complications of rotavirus
Pt become dehydrated / hypernatremic, metabolic acidosis, ketosis from poor intake
how do you treat rotavirus?
No antidiarrheal medications- ineffective, poss worsening illness
should be vaccinized at 246 mo
what are bacterial causes of diarrhea in kids?
Bacterial – Campylobacter, Salmonella, Shigella, E. coli, Yersinia, C diff
Shigella patients often have
high fever
Suspect if blood in stool (colitis); if foreign travel
bacterial diarrhea
what is shigella dysenteriae?
Shigella dysenteriae, Shigatoxin producing bacteria (E coli O157:H7)
how do you work up bacterial diarrhea?
CBC stool culture
what is chronic diarrhea?
Healthy appearing – probably functional
Normal 5-8 stools /day for infants
if have wt loss FTT and seem ill with diarrhea what should you think?
probably organaic
what are fxnl causes of chronic diarrhea?
Functional causes
Irritable bowel syndrome
Toddler’s diarrhea
what are organic cuases of chronic diarrhea?
Organic causes
Food allergies
Malnutrition / Malabsorption syndromes
Impaction
what are causes of malabs diarrhea?
Lactose Intolerance
Celiac disease (gluten enteropathy)
Cystic fibrosis
steatorrhea
what are other causes of diarrhea?
Inflammatory bowel disease
Hirschsprung’s disease
Immune deficiency syndromes
what is Psedomembranis colitis caused by?
C diff
who gets cdiff
pt taking abx (Clindamycin, cephalosporins, ampicillin
how does cdiff present?
Fever, tenesmus, abdominal pain with diarrhea
how do you treat cdiff?
oral metronid or vanco
what is definition of chronic constipation?
2 or more of the following for 2 months:
1) < 3 BM/Wk 2)> 1 episode of encoporesis/wk 3) impaction of rectum with stool 4) stool that plugs toilet 5) retentive posturing and fecal withholding 6) pain with defecation
what is most childhood constipation
functional
what are fxnl constipation causes?
Withholding
Slow transit times (Irritable Bowel Syn.)
what are organic causes of constipation?
Hirschsprung’s disease (obstruction)
Hypothyroidism, cystic fibrosis, anorectal malformation
what is hirschsprungs disease?
poor innervation of lg intestines: Absence of Meissner and Auerbach plexi
Sympathetic hyperactivity leading to tonic contraction (doesn’t relax)
what is encorpresis?
Chronic constipation with dilatation of rectal ampulla and fecal soiling – soft stool comes out around
what does encorpresis require?
Requires stool evacuation followed by chronic management to avoid reaccumulation of stool,
Stool softeners important
how do you treat constipation non pharm? 2 ways
-Diet
Whole grains, fruits, and vegetables. Recommended fiber amount, add 5 to age until 15 then adult amount.
Sorbital-containing fluids (prune or apple juice)
Consider milk elimination trial
-Behavior Modification-based on age and individual factors
Regular sitting on the toilet for 5-10minutes after meals/ gastrocolic reflex. Make sure child has a stepstool if they cannot touch the floor.
Motivation-rewards
Diary/calendar with stickers
Biofeedback-no resources as of yet.
what are signs of organic constipation? 5
No passage of meconium within 2 days of birth
Hard, infrequent stooling since birth, especially if breast fed
Poor growth/ development
Distended abdomen
Abnormally placed anus, commonly anteriorly
how do you treat constipation with pharm?
Laxatives(MAINSTAY
-Osmotic
Lactulose
Magnesium hydroxide
Magnesium citrate
PEG 3350 (MiraLax, Glycolax)-mix in smallest
amount of fluid like water or crystal light
what is the ideal consistency of poo?
ideal consistency- Soft mushy banana or peanut butter like.
what else besides laxatives do you treat constipation with?
Osmotic enema-phosphate enemas Lavage-Polyethylene glycol-electrolyte solution (GoLytely) Lubricant-Mineral oil Stimulants Senna-Little tummies Bisacodyl Glycerin suppositories
what are causes of GI bleeding that cause significant amt?
uncommon Peptic ulcer disease Meckel’s diverticulum Colitis Intussusception
what are causes of minor bleeding in GI
not uncommon
Anal fissures
Mallory-Weiss tear
Swallowed nasopharyngeal blood
what are the causes of rectal bleeding in infants?
Colitis (from milk protein) allergy, anal fissure, milk protein allergy
what are the causes of rectal bleeding in older children?
Inflammatory Bowel Disease, Meckel’s diverticulum
how do you work up GI bleed? labs, imaging
CBC/ CoAgs/ LFT’s/ Stool for blood and culture
xrays
Colonoscopy, Barium enema, CT with contrast
Meckel scan (nuclear med test)
what are functional obstructions?
Disordered paristalsis
Paralytic ileus
Septic ileus
Dysmotility
what are mechanical obstructions
Narrowing of lumen
Malrotation
Intraluminal obstruction
Meconium plug / CF
what are etiologies of obs?
Adhesive
Intussuseptive
Malignant
obstruction nonbilious vom? problem is?
proximal to ampulla of Vater
obstruction bilious vom? problem is
distal to ampulla of Vater
often considered surgical issue
what is crampy midline pain from?
distension and increased paristalsis
what is pain Increasing or progressing in severity and frequency
suggestive of ischemia
if no stool in the first 24 hrs…
think about hirschprungs
if have fever obstruction could be
+ with gastroenteritis or UTI or sepsis
if have fever the obstruction is probably not
intestinal perforation
what can cause polyhydramnios?
doesn’t swallow… or obstruction
obstruction often high
esophageal atresia , duodenal atresia
what imaging do you do for obstructions?
KUB, crosstable lateral
Distension? Loops of bowel visible?
Ileus.
Discoloration? Neonates.. Blueish hue .
Perforation, bleeding
Erythema
underlying peritonitis
increased bowel sounds?
Paralytic ileus, obstruction, ischemia
palpations Bowel loops? Guarding? Rebound tenderness
Mass – intussesseption
pyloric stenosis, early appendicitis
on a CBC with diff may show
Thrombocyptopneia
left shift -> ischemia, sepsis
increased lymphocytes ->
viral, gastroenteritis
neutropenia
neutropenia -> poor sign
what is GER
is the exposure of the esophagus to gastric contents
is GER norm in infants?
yes norm to have weakened LES so acid goes up
what may cause reflux? 7
Increased frequency of sphincter relaxation
Decreased lower esophageal sphincter resting tone
Poor esophageal clearance of refluxed material
Slow gastric emptying
Eosinophilic Esophagitis
Food Allergies
H Pylori infection
how do you treat obstruction?
Hydration -> NS/LR IV Sepsis treatment -> translocation of bacteria broad spectrum antibiotics, anaerobes? NG decompression Surgery
when is spitting up concerning?
PAIN causes Behaviors: Arching (Sandifer’s Syndrome), crying, oral aversion
GROWTH FAILURE Failure to Thrive (FTT) Pain during or after feeding results in
feeding difficulty
feeding aversion
decreased intake of food
PULMONARY COMPLICATIONS
ESOPHAGITIS
what are pulm complications of reflux?
Aspiration pneumonia
Broncho-pulmonary disease
Asthma/reactive airway disease
Apnea and bradycardia
what is esphagitis?
irritation of the esophagus
what cases of GER are disease and need treatment?
Pain in person of any age
Possible cause of severe colic
Family Stress
Crying
Not sleeping
Near-miss SIDSwhat tests do you do for GER?
Upper GI Series pH Probe/Impedance Scan Video swallow study Upper Endoscopy (EGD) Gastric Emptying Study
what is Sandifer’s Syndrome halmarked by?
GER
what are easy treatments for GER?
Time-honored, sm freq meals, positioning
Thickened feeds: -may or may not help -risk of choking -may decrease intake Change of formulas
what are NOT approved with treatment of GER?
Prone position: NOT used now because of SIDS risk
what do you use pharm for GER
H2 antag, or PPIs
what is blackbox warning on reglan?
unacceptable irritability
what do you do if no meds work for GER
NG tube feeds Surgical Procedures: -Nissen fundoplication -PEG procedure: -G-tube, J-G-tube
what has syptoms of copious oral secretions,choking aspiration
TE fistula
how do you test for TE fistula?
unable to pass NG tube. Xray showing coiled NG tube at ~ T3
what is TE fistula associated with?
VACTERL
what has associated anomalies with Vertebral 70% Anal atresia 50% Cardiac 30% TE –F 70% Renal 50% Limb anomalies 70%
esophageal atresia
who gets umbilical hernias?
Girls> boys
African Americans> others
how do you repair umb hernias
Repair surgically at 1-2 years if > 2 cm.
Bands/taping doesn’t help
who gets ing hernias?
Boys > girls 9:1
More prevalent in premature infants (30% in < 1000g)
how do you treat ing hernias?
Rarely incarcerated
Surgical correction per surgeon.
what has Projectile, nonbilious vomiting
Usually starts 2-6 weeks of life
pyloric stenosis
what causes pyloric stenosis?
Hypertrophy of pylorus - cause unknown
Progressive gastric outlet obstruction
oral Erythromycin in neonatal period has been associated with higher incidence of pyloric stenosis in infants < 30days
if kid shows Constipation, dehydration, weight loss, apathy think..
pyloric stenosis
what is the gold standard diag of pyloric stenosis
US
what is less common cause of peptic disease?
Hpylori
what is the common age of peptic ulcers?
12-18
what are causes of peptic disease?
In childhood most are secondary to underlying illness, toxins, or drugs causing a breakdown in mucosal defenses.
CNS disease, burns, sepsis, multiorgan failure
Pulmonary insufficiency, Crohn disease, RA
in kids under six sx for PUD are
vomiting and UGI bleeding
in older kids what is sx for PUD?
abd pain hours after meals
what is the most accurate test for PUD
UGI shows ulcer crater. Endoscopy most accurate test.
pain with peptic ulcer disease..
Pain usually several hours after meals
Can awaken pt at night
Eating relieves pain
Gastric ulcers may be more painful with eating
where are intestinal atresias most likely?
jejunum
what is intestinal atresia?
Complete or partial blockage by stenosis, webs or atresia
what is the end result of atresias?
End result is obstruction with dilated bowel proximally, small disused bowel distally
what obstruction presents sooner with distension and possible emesis
complete
sx =polyhydramnios, bilious emesis, abdominal distension within hours of birth
dudoenal atresia
what Can pass meconium normally
associated with
Esophageal atresia, intestinal atresias, cardiac and renal abnormalities
Down Syndrome 20-30%
duodenal atresia
what is the work up of duodenal atresia?
Xray = double bubble sign
Absence of gas distal to obstruction suggests atresia , severe obstruction
BE may help determine malrotation or atresia in lower GI
how do you treat duodenal atresia?
surgery – duodenoduodenoscopy (bipass stenosis)
what are common congenital issues?
Gastroschisis
Omphalocele
CDH
what is an Abd wall defect Rt of umbilicus No sac over intestines Associated with atresias Surgical correction Motility probems common
gastroschisis
what is a Herniation through cord
Associated with anomalies
Esp cardiac
Liver and stomach involvement
omphalocele
Abdominal contents in chest due to failure in diaphragm formation at 8-10wk gestation
what is this?
Congenital Diaphragmatic Hernia
how do you treat CDH?
NPO, NG for gastric decompression, Surgery
if CDH is small….
Can present in toddlerhood with worsening respiratory distress and failure to thrive
what is Outpouching of ileum in mid to distal ileum
meckels diverticulum
what Can be a lead point for intussusception or volvulus
meckels divertic
what are symptoms of meckels?
Sx can mimic appendicitis if inflammed
Dx: via history, nuclear medicine testing
how do you treat meckels?
surgery
what is absence of ganglion cells in all or part of the colon (colon unable to relax)
hirschsprungs disease
90% of infants with Hirschsprung’s in the first____ 24 hours of life.
fail to pass meconium
how do you treat hirschsprungs?
Surgery. Diverting colostomy, anastomosis
what are sx of hirschsprungs? in neonates
Neonatal – failure to pass meconium by 24 h
Vomiting (can be bilious), abdominal distention, poor feeding
Enterocolitis with fever, explosive diarrhea withhigh mortality.
Accounts for 15-20% of neonatal intestinal obstrx
what are sx of hirschsprung in late infancy?
obstipation and distension
what are sx of hirschsprung in older child?
constipation
what has Foul smelling stools and ribbon-like / abd distension with prominent veins
or FTT as the only presentation
hirshsprungs
what are complications of hirshsprungs and sx of it?
Major complication (25%): enterocolitis (fever, foul-smelling diarrhea – significant mortality)
what is Telescoping of bowel that causes progressive edema and ischemia
intussusception
what ages does intuss occur?
Occurs from 3 months to 3 years (peak 9 months)
what is the Hx of intuss?
~20 minute cycles of intermittent pain,
vomiting
Heme positive stools(jelly like) (95% of the time.)
how do you treat intuss?
Contrast enema are 95% diagnostic
60-80% therapeutic
what are complications of intuss?
CI: peritonitis, suspected perforation, shock
what is Most frequent cause of intestinal obstruction in 1st 2 yrs of life – idopathic
intuss
what presents as Paroxysmal pain and screaming, drawing up legs
Vomiting / Diarrhea 90%
Blood in stools with mucus 50% within next 12 hrs
Lethargy, febrile
intuss
Most common indication for emergency abdominal surgery in childhood
appendicitis
who gets appendicitis?
Frequency peaks ages late teenage years
what are sx of acute append?
Sx :Fever +/- N/V and periumbilical pain RLQ “mcburney’s point”
Peritoneal irritation
Anorexia, vomiting (sometimes bilious) , constipation, diarrhea
Atypical presentations serial exams
Children< 2yr often perf before surgery due to vague sx
what labs should you get for append?
Labs: WBC < 15K; pyuria, fecal leukocytes, guiac + stool occasionally ( obtain amylase/lipase/LFT/ UA /Ucx)
Studies: fecolith on xray ~60% , US shows thickened appendix in 93%
CT IS GOLD STANDARD
how do yu treat appendicitis
surgery whenever appendicitis cannot be ruled out
who gets IBD?
2nd generation but single greatest risk is fhx
where does crohns affect? sx?
anywhere in GI tract Most often in terminal ileum (50-70%) Obstruction, fistulas, absess formation Perforation or hemorrhage rare Not continuous –> skip lesions Sx : abd pain, diarrhea, weight loss Extra-intestinal symptoms suggest RA, SLE, hypo pit Fever, poor growth, uveitis, renal stones, erythema nodosum, microcytic anemia BE for small bowel disease Slight increased risk of colon cancer
UC where? sx?
Colon Sx: rectal bleeding, diarrhea, abd pain Extra-intestinal symptoms Arthritic, uveitis, liver disease Continuous disease – crypt absesses Colonoscopy with mucosal biopsy best diagnostic BE also has nearly pathognomonic findings Increased risk of colon cancer
disease is a multifactorial, autoimmune disorder that occurs in genetically susceptible individuals.
celiac
what is trigger for celiac?
Trigger is an environmental agent-gliadin component of gluten. The enzyme tissue transglutaminase (tTG) has been discovered to be the autoantigen against which the abnormal immune response is directed.
what are classic sx of celiac?
Abdominal pain Diarrhea, constipation Gassiness, distention, bloating Anorexia Poor weight gain, FTT (but can be obese) Irritability, lethargy
what are 2ndary problems in celiac
Anemia, fatigue Vitamin deficiencies Muscle wasting Osteopenia Short stature Recurrent abortions / infertility Delayed puberty Dental enamel hypoplasia Dermatitis Herpetiformis Aphthous ulcers
only tx of celiac?
fluten free diet
how do you dx celiac?
Serum immunoglobulin A (IgA) endomysial antibodies and IgA tissue transglutaminase (tTG) antibodies. Sensitivity and specificity > 95%.
Testing for gliadin antibodies is no longer recommended because of the low sensitivity and specificity for celiac disease.
The tTG antibody test is less costly because it uses an enzyme-linked immunosorbent assay; it is the recommended single serologic test for celiac disease screening in the primary care setting.
IgA deficiency can give false negative
what is the gold standard of diagnostic of celiac disease
Confirmatory testing, including small bowel biopsy,
what is cholestasis? labs?
= reduced bile flow elevated direct bilirubin
generally appear well but jaundiced with
biliary atresia
what does biliary atresia progress to?
progresses to cirrhosis
how do you treat pyloric stenosis?
pyloromyotomy
how do you treat Imperforate anus and Hirschsprungs ?
temporary colostomy
how do you treat intestinal atresias?
primary anastomosis
how do you treat malrotation/adhesions?
lysis of adhesions and resection of nonviable intestine
how do you treat mec ileus?
therapeutic enemas (peds surgery)
what has Upper abdomen distended after feeding
pyloric stenosis
what labs do you do for pyloric stenosis?
Hypochloremic alkalosis, low K+
what will UGI show for pyloric stenosis?
narrowing of pylorus, retention of contrast
what is Due to abnormal movement of intestine around the superior mesenteric artery as intestine reenters abdominal cavity at ~10 weeks
malrotation
what is midgut volvulus?
duodenojejunal junction-> mid transverse colon. Supplied by superior mesenteric artery
what is the most common anomaly in malrotation?
cardiac
when do you malrotation present? and how?
> 50% present as high obstruction in 1st weeks of life
Bilious vomiting, distension, bleeding
what are late presentations of malrotations?
intermittent intestinal obstruction, malabsorption,diarrhea
what does UGI show for malrotation?
UGI shows abnormal placement of ligament of Treitz. (DJ junction rt of spine)
how do you treat malrotation?
Absolute Surgical Emergency .. Bowel ischemia and necrosis
what is a disease that is primarily of prematurity
Translocation of Bacteria to bowel wall.
NEC
what does radiography show for NEC?
pneumatosis, fixed loop, stacking of bowel, free air
how do you treat NEC
Medical NEC – ABX, bowel rest
Surgical NEC - perforation
if pt is perfectly still what should you think?
peritonitis
if distended abd and loops of bowel visible on radiograph?
ileus
if have a blue belly
perforation or bleeding
if have erythema on belly
underlying peritonitis
increased BS
obs or gastroenteritis
decreased bowel sounds
paralytic ileus, obs, ischemia
palpation tenderness, guarding, rebound tenderness and distended bowel loops
intuss pyloric stenosis or early appendicitis
