GI Flashcards
The most common abdominal emergency in children less than 2 years of age is __________.
Intussusception.
Clinical manifestations of appendicitis in children may include:
●Anorexia
●Periumbilical pain (early)
●Migration of pain to the right lower quadrant (often within 24 hours of onset of symptoms)
●Pain with movement: walking or shifting position in bed or on stretcher
●Vomiting (typically occurring after the onset of pain)
●Fever (commonly occurring 24 to 48 hours after onset of symptoms)
●Right lower quadrant tenderness
●Signs of localized or generalized peritoneal irritation
What is a positive Rosving sign?
Pain in the right lower quadrant with palpation of the left side
What is this?
Pain on flexion and internal rotation of the right hip, which is seen when the inflamed appendix lies in the pelvis and causes irritation of the obturator internus muscle
Positive obdurator sign.
What is a positive psoas sign?
Pain on extension of the right hip, which is found in retrocecal appendicitis)
Appendicitis in neonates (rare) can be difficult to diagnose because they do not follow the typical clinical presentation. What are some s/s that may indicate appendicitis in a neonate?
●Abdominal distension
●Vomiting
●Decreased oral intake
●Abdominal tenderness
●Sepsis
●Temperature instability
●Lethargy or irritability
●Abdominal wall cellulitis
●Respiratory distress
●Abdominal mass
●Hematochezia (possibly representing necrotizing enterocolitis of the appendix)
What are some clinical s/s of bowel obstruction?
Distension, obstipation, rigid abdo, hernia/rectal mass
An infant presents to your clinic. The parents report increasing irritability and crying, and vomiting. The child is inconsolable.
Upon exam, you find a firm, discrete inguinal mass that extends down to the scrotum (or labia majora). What is your diagnosis? Treatment?
Incarcerated inguinal hernia.
Git! Go to ER!
A life-threatening condition that is most often seen in preemies (although full term infants can develop as well) is necrotizing enterocolitis. What s/s might the Bubbins present with?
Vomiting
Distension
Tenderness
Systemic signs:
Apnea
Resp failure
Lethargy
Poor feeding
Temperature instability
Hypotension resulting from septic shock (severe case)
Some common causes of abdominal pain in pediatric patients are:
Constipation
Acute gastrenteritis
UTI
Streptococcal pharyngitis (yes!)
Pneumonia
PID
Mesenteric lymphadenitis
Ruptured ovarian cyst
Foreign body ingestion
Colic
Food allergy
Malabsorption ie. Celiac
Not as common anymore: lead/iron toxin ingestion
What are the 4 IBS subtypes?
IBS-C (predominant constipation)
IBS-D (predominant diarrhea)
IBS-M (Mix of C & D)
IBS-U (unclassified) Rare. Bowel habits cannot be accurately categorized.
What is gastroenteritis?
Clinical syndrome with increased stool frequency with loose consistency, with or without vomiting, fever, or abdominal pain.
What are some risk factors for gastroenteritis?
day care, young age, sick contact, immunocompromised
What factors increase risk specifically for bacterial gastroenteritis?
travel, poorly cooked meat, poorly refrigerated food, antibiotics
What is the most common cause of gastroenteritis- viral, bacterial, or parasitic?
Viral
Which age group (peds) is at higher risk of bacterial gastro?
Text book says kids in first few months of life then school age kids
Toronto notes says 2-4 years olds
What is the most common cause of viral gastro?
- Rotavirus (peaks between 6-24 months)
- Enteric adenovirus
- Norovirus (typically older children)
What are some bacteria that cause gastro?
salmonella, campylobacter, shigella, pathogenic e.coli, yersinia, c.diff,
How is gastro spread?
Fecal oral
Why do you get diarrhea in gastroenteritis?
Diarrhea usually results from imbalance in intestinal handling of water and electrolytes
* Often from active secretion by enterocytes affected by infections/ toxins
Sally plays with Johnny. Two hours later, Sally’s mom gets a call saying Johnny had gastroenteritis! How soon could Sally develop symptoms?
Symptoms usually begin 24-48 hours after exposure if recent infectious contact
Sally gets viral gastro :( How long does it usually last?
-Viral gastroenteritis is usually self limiting (lasts 3-7 days in most cases)
What are some dietary recommendations you could make to a family when there is a pediatric diagnosis of IBS?
Increase dietary fibres such a psyllium and bran. (May increase flatulence due to fiber fermentation.)
Low FODMAP diet has been shown to be beneficial. Difficult to introduce and follow, expensive, and a dietician should be involved.
Gluten-free diet. Non-celiac gluten sensitivity has been increasing over the last decade.
Probiotics.
Which psychological interventions have proven to be successful in the management of pediatric IBS?
CBT and hypnotherapy.
Yoga has shown some promise but not enough evidence is available to make it a recommendation.
Which classes of medications are recommended for pharmacological interventions for pediatric IBS? (age dependent)
Antispasmodics
Antidepressants
Abx
Prokinetics
Laxatives
Mineral oil p.o. is a 1st line tx for constipation in babies < 1 year old.
True or false?
False!
Risk of aspiration -> lipid pneumonia.
What are the S&S of gastroenteritis?
-Diarrhea
-Vomiting
-Fever
-Anorexia
-Abdominal cramps
-HA
-Myalgias
How do the symptoms differ between viral and bacterial gastroenteritis? (Any differences in fever? abdo pain? type of diarrhea?)
Viral: Slight fever, malaise, vomiting, vague abdominal pain
Bacterial: High fever, severe abdominal pain, poss bloody diarrhea
What are the recommended pharmacological interventions in an infant <1 year old with constipation?
Glycerin suppository
Lactulose
PEG 3350
In constipated babies >6 months old, what are some nutritional interventions you could suggest?
Apple/pear/prune juice (1-3 ml/kg/day)
Whole grain cereal
Cooked legumes
Vegetables and/or fruit.
What is the single most important thing to assess in a child with gastro?
DEHYDRATION AND THE EXTENT OF IT
How is gastro diagnosed?
Typically clinically
CBC, lytes, stool studies in severe cases, if IV hydration required, or if atypical presentation
Outline the non pharm management of gastroenteritis
-Prevention/ treatment of dehydration most important
-Early refeeding advisable, with age appropriate diet upon completion of rehydration
-Notify public health authorities if appropriate
-Promote regular handwashing
When can kids with gastro return to school?
24 hours after last diarrhea episode
Encourage good handwashing
What are the pharmacologic management options for gastro?
-Ondansetron for suspected gastroenteritis with mild to moderate dehydration or failed ORT and specific vomiting
-Antibiotic or antiparasite therapy when indicated
-Antidiarrhea medications not indicated
-Rotavirus vaccine
You may recall that assessment/ prevention/ management of dehydration is one of the most important parts of caring for a kid with gastro. What exactly are you assessing for in your PE for dehydration?
C BASE H2O
* Cap refill
* BP
* Anterior fontanelle
* Skin turgor
* Eyes (sunken)
* HR
* Oral mucosa
* Output (urine)
T/F Decreased blood pressure is an early sign of dehydration in pediatric patients
Very false
BP is a LATE sign and quite ominous
Everything else will go first
Earliest signs are decreased urine output, dry oral mucosa, thirst
Then increased pulse, sunken fontanelles, decreased skin turgor, and increased cap refill
Then weak pulses, decreased BP, anuria, prolonged CRT >3 seconds
What is oral rehydration therapy?
Give kid a set amount of fluid/ pedialyte (usually age or weight based) every 10 min
What is the recommended treatment regimen for impacted fecal constipation in children >1 year old and adolescents?
as per RXFiles
- PEG 3350 x 3 day
- Try another osmotic (Lactulose, milk of magnesia) or add a stimulant (senna, bisocodyl)
- Switch to enemas dosed every 2-3 days until disempaction resolves
AVOID manual disempaction when possible.
When is ORT indicated?
Mild to mod dehydration
When would IV rehydration be indicated?
IV rehydration if
-severe dehydration requiring close monitoring and frequent assessment of electrolytes
-inability to tolerate ORT
-failure of ORT to provide adequate rehydration
T/F Round worm parasitic infections of GI tract rarely occur in developed countries like Canada
False
-One of the most common parasitic infections
-Occurs worldwide, all SES groups
Name some RED FLAGS in childhood constipation.
Onset from birth or first few weeks of life
> 48 hr delay in passing meconium
Undiagnosed weakness in legs
Locomotor delay
Abdo distension with vomiting
Persistent blood in stool
Ribbon stools
Which of the following is not ROME IV criteria for constipation in children/adolescents?
A. Hx of excessive stool retention.
B. Malodorous flatulence.
C. Less than or equal to 2 BMS per week.
D. Hx of large diameter stools.
B. All toots are stinky.
Round worm infections are most frequently observed in what age group?
School age kids (5-10 years)
Uncommon <2 yrs
Risk factors for round worm infection?
Closed, crowded conditions
Lack of handwashing
How are parasitic GI tract infections transmitted?
Fomites
Direct contact
Fecal oral route
Where do adult round worms live (just for a fun fact)
Human host
They live in the cecum!
What is symptom that is highly suggestive of roundworm infection?
Severe nocturnal perianal itching
Why does severe nocturnal perianal itching occur?
Pregnant roundworms migrate from their home in the cecum through the rectum onto the perianal skin to deposit their eggs at night! The body triggers an inflammatory reaction to the worms and eggs.
What are other symptoms of worms?
-Can have asymptomatic carriers
-Note that secondary bacterial infection can result if the excoriation is severe
-Occasional vaginitis
-Can have ectopic migration to appendix or other pelvic organs
-High worm burden can cause abdominal pain, nausea, vomiting
Can you see round worms?
Yep- pin shaped, 8-13mm, may look like cotton thread- confirm by lab ID
Are stool exams helpful in diagnosing round worm?
Usually not- worms and eggs are not passed in the stool
How is round worm diagnosed?
-Visual inspection of the anal verge, undergarments
-Samples collected from under the fingernails may be analyzed for pinworm eggs
-Sticky tape test: eggs adhere to tape applied to perianal skin (need 5-7 tests to rule out)
-Examination of perianal skin at night may reveal adult worms
-Usually no eosinophilia as no tissue invasion (ie no need for labs)
DDx for parasitic infection with round worms?
- Infectious (abscesses, STI (condyloma, herpes, syphilis, gonorrhea), bacterial (S. aureus), scabies, candida)
- Dermatologic (fissures, fistulas, SCC, psoriasis, contact dermatitis, atopic dermatitis)
- Other causes (prolapse internal hemorrhoids, poor hygiene, diarrhea, dietary irritants
Non pharm management for round worm GI tract infection?
-Change underwear, bathe in morning, pajamas to bed, wash hands, trim fingernails
-Wash bedding and clothes
-Treat all family members simultaneously
-Re-infection common
Pharm management for round worm?
Anti-helminthic: Mebendazole 100mg orally once, repeat in 2 weeks; Abendazole 400mg orally once on empty stomach, repeat in 2 weeks (inhibits microtubule formation and glucose uptake; nonspecific GI AE. CI in pregnancy and infants.
-Pyrantel 11mg/ kg (max 1g) once orally; repeat in 2 weeks in pregnancy
-Cure rate 90-100%
What is failure to thrive?
Child not growing and developing at an appropriate rate for their age
Risk factors for FTT?
o Poverty = risk for undernutrition, inadequate access to food
o Neglect, depressive episode in mother
o A home with problems such as domestic violence, many children, substance use, etc
Differentiate organic FTT from non-organic FTT.
o Organic FTT – underlying medical problem causing FTT, ex. CF or CHD
o Nonorganic FTT – inadequate growth d/t lack of nourishment and a non-nurturing home environment (also called environmental deprivation)
o Can be a mix of the two – called multifactorial or mixed FTT
Describe underlying patho of all FTT.
Insufficient calories to meet nutritional needs
For example:
o Insufficient intake of food: inadequate access to food, poverty, improper formula preparation, eating difficulties, vomiting
o Increased caloric needs (chronic lung disease, congenital heart disease)
o Increased loss of ingested food (diarrhea, malabsorption syndromes)
o Impaired caregiver-infant relationship (especially maternal depression)
How do kiddos with FTT present?
Low weight, weight loss, short stature, poor appetite, failure to gain weight or grow
How to diagnose FTT?
Weight <5th percentile
Height <5th percentile
Weight for height <5th percentile
Rate of growth lower than expected
Deceleration of growth rate
Delayed developmental milestones
Disturbed interactional skills
Parental concern about the child’s eating
What labs might you consider in a child with FTT?
o Routine: Hgb, lead level (based on risk factors), urinalysis
o Other as indicated: stool O&P (if diarrhea), thyroid function or GH levels if indicated by history, genetic consultation/chromosomal assessment if dysmorphic features
o Consider radiography to determine bone age in short stature not related to parental heights
What are some management considerations for FTT with regard to caloric intake?
Adequate caloric intake
* Base ideal caloric intake on ideal weight rather than actual weight
* Review formula mixing to ensure not overly diluted. Some infants may require increased formula concentration or calorie additives
* Observe breastfeeding session to assess milk supply and ability of infant to suck and swallow
* Older children can be placed on supplemental feedings like boost /instant breakfast drinks prepared with whole milk. This should be in addition to a balanced diet
* Many children tolerate 6 small meals a day better than 3 larger meals
* If children are picky, it is better they freely consume the foods they like than nothing
What are some management consideration for FTT with regard to parents?
- Can refer to parenting programs, drug treatment programs, counseling for MH conditions
- Avoid conflicts about meals with children, encourage independence in toddlers around mealtime
- Refer to supplementary services for food and financial resources
- Home visitation can be useful
What are red flags for FTT/ need to seek further care?
- Child protective services may be needed if severely malnourished, parent/guardian is unable to comply with medical recommendations or intentional neglect is occurring
- Hospitalization may be needed for severe malnourishment, recurrent illness or concern for refeeding syndrome
Is stool testing recommended in acute (<7 days) cases of pediatric diarrhea?
No.
What is the Infectious Diarrhea Panel (IDP)? When should you order it?
A new test that replaces stool cultures and O&P, also detects C. Diff.
IDP detects the most common enteric viral, bacteril and protozoal pathogens.
It should be ordered if diarrhea is severe of prolonged >7 days. It should only be ordered once/episode.
If a diarrhea sample comes back with a positive C. Diff result, should you treat?
Only if symptomatic as the test doesn’t differentiate b/n infection and colonization.
What are the characteristics of severe diarrhea?
Any time duration of:
-10 or more stools /24 hrs
-bloody stools
-fever 38.5+
-severe pain
Diarrhea is defined as the passage of _____ or more loose or liquid stools per 24 hours OR more frequent than is normal for an individual.
3
What are some possible causes of non-infectious diarrhea?
Meds
Dietetic Foods
Fish-Associated toxins
Plant-associated toxins
Allergic reactions
Carbon monoxide poisoning
MSG
Ethanol
Heavy metals
Opiate withdrawals
If you suspect IBD, what are some recommended tests to order?
Fecal calprotectin or fecal lactoferrin (Low quality of evidence)
Giardia (High) If no travel, low quality evidence suggests this test not be done.
Celiac disease (moderate)
Bile acid diarrhea (low)
What is the most common transmission route of infectious diarrhea?
Fecal-oral.
Ewwwww
Supportive-care recommendations for children with acute diarrhea:
-Avoid dehydration. Offer smaller amounts of fluids more often, offer breast/bottle more often.
Oral rehydration solution may be recommended.
Protect diaper area with zinc oxide or another barrier cream.
Wash hands wash hands!
Keep child home while having diarrhea.
Little Timmy Doubledouble, age 6, is on amoxicillin for an ear infection. Two days after starting his medication, his mom calls to report that he has started having diarrhea. His intake is unchanged, he is afebrile and not complaining of pain. Do you recommend that Timmy stop receiving his abx?
No, abx diarrhea is a common S/E and often resolves within 1-2 after finishing the course.
Counsel about hydration, red flags and when to reach out to HCP again.
What is the recommended amount or oral rehydration solution for mild dehyrdration in children?
500 mls per 10 kg of body weight over 4 hours.
Are antidiarrheal agents recommended in pediatric populations with acute, non-severe diarrhea?
No. Benefits do not outweigh risks.
What is the most common cause of acute diarrhea in kids?
Viral infection.
Describe the handy relationship between pain and vomiting in pediatric cases in relation to whether it is likely a surgical or medical cause?
if pain precedes vomiting, it is likely a surgical cause;
however, if the pain follows vomiting, it is more likely to be a medical cause
