GI Flashcards
Appendicitis definition, sx, dx, tx
*obstruction of the lumen of the appendix, resulting in inflammation & bacterial overgrowth
*MC 10-30yrs
*MC cause of acute abdomen in children 12-18yrs
Etiologies: fecalith & lymphoid hyperplasia MC, inflammation, malignancy or foreign body, lymphoid hyperplasia due to infection MC cause in children
sx
Classic presentation: anorexia & periumbilical or epigastric pain followed by RLQ pain (12-18hrs), N/V (vomiting usually occurs after the pain)
Retrocecal appendix 🡪 atypical pattern (diarrhea), + rectal or gynecologic examination; appendix may also be pelvic
Appendiceal inflammation stimulates nerve fibers around T8-T10, causing vague periumbilical pain – once the peritoneum becomes irritated, it radiates to the RLQ
PE: rebound tenderness, rigidity, guarding; retrocecal appendix may have atypical findings
*Rovsing: RLQ pain w/ LLQ palpation
*Obturator: RLQ pain w/ internal & external hip rotation w/ flexed knee
*Psoas: RLQ pain w/ right hip flexion/extension (raise leg against resistance)
*McBurney’s point tenderness: point 1/3 the distance from the ASIS & navel
dx
Adults – CT scan preferred
U/S, MRI – reserved for radiosensitive populations (pregnant, children)
In children 🡪 surgical consult often obtained prior to imaging to determine if imaging is needed, depending on the risk
tx
Refer to GI surgery STAT
Nonsurgical: may be treated w/ abx but high likelihood of recurrence
Surgical: appendectomy (laparoscopic preferred)
*board spectrum abx prior to surgery w/ gram neg & anerobic coverage
-cephalosporins + metronidazole
-piperacillin-tazobactam
Colic definition, sx, dx, tx
Severe & paroxysmal crying in the later afternoon to evening
Peaks 2-3mo, ends around 4mo
Very common, cause unknown
sx
*unexplained paroxysms of irritability, fussing, crying that may develop in agonized screaming
*an infant may draw up knees against the abdomen
Rule of 3s 🡪 cry > 3hrs/d, 3d/wk, for 3wks
dx
Complete history
PE: r/o pathology
tx
Parent education & reassurance
*DON’T SHAKE YOUR BABY
*assure them their baby is healthy & crying can increase & likely stop by 3-4mo
*assure them they are not to blame
*make sure the baby is not hungry, soiled, or tired
*swaddle, gentle motions, pacifier
*get help from family to get a break!
*possible formula switch or GERD tx
Constipation definition
Childhood constipation is a common & almost always functional w/o an organic etiology
Stool retention can lead to functional incontinence in some pts
<2 bowel movements/wk
>1 episode of encopresis/wk (poop in the rectum, loose stool leaks)
The MC triggers of constipation are transitioning to solid foods from breastmilk & formula, potty training, & starting school
*starting solid foods can lead to reduced fiber & fluid intake causing harder stools
*children may start to withhold stools when they start potty training or going to school – they may be scared to use the toilet itself or scared to use the toilet at school
Constipation sx
At least 2 of the following in a child w/ a developmental age <4 years
-less than 2 BM per week
-at least 1 episode of incontinence/week after the acquisition of tioleting skills
-hx of excessive stool retention
-hx of painful or hard BM
-presence of a large fecal mass in the rectum
-hx of large diameter stools that may obstruct the toilet
At least 2 of the following in a child w/ a developmental age of >4 years w/ insufficient criteria for IBS
- less than 2 BM in toilet /week
- at least 1 episode of fecal incontinence
- hx of retentive posturing of excessive voluntary stool retention
- hx of painful or hard BM
- presence of a large fecal mass in the rectum
- hx of large diameter stools that may obstruct the toilet
Constipation dx and tx
Often, medical hx & PE are sufficient to diagnose functional constipation
Further evaluation for Hirschsprung disease, a spinal cord abnormality, or a metabolic disorder may be warranted in a child w/ red flags:
*onset before 1mo of age
*delayed passage of meconium after birth
*failure to thrive
*explosive stools
*severe abdominal distention
Abdominal x-ray
tx
Increase fiber to 11-24g/day 🡪 wheat, fruits, veggies, fluids
Decrease cow’s milk 🡪 slows intestinal motility
*<24oz/d (16oz preferably)
Mineral oil 15-30mL/year of age/day
Polyethylene glycol 3350 (MiraLAX) 1.5g/kg/d
Lactulose 1mL/kg/d once or twice per day, single dose or in two divided doses
Fiber, decrease milk, increase fluids
Enema, bathroom training
Referral to a subspecialist is recommended only when there is a concern for organic disease or when constipation persists despite adequate therapy
Dehydration definition
Dehydration is a significant depletion of body water, and to varying degrees, electrolytes
Dehydration is typically divided into mild (3-5%), moderate (6-9%), & severe (≥10%) cases
In children, the most accurate signs of moderate or severe dehydration are prolonged capillary refill, poor skin turgor, & abnormal breathing
Other useful finings (when used in combination) include sunken eyes, decreased activity, a lack of tears, & dry mouth
A normal urinary output & oral fluid intake is reassuring
Laboratory testing is of little clinical benefit in determining the degree of dehydration; thus, the use of urine testing or U/S is generally not needed
Duodenal Atresia definition, sx, dx, tx
Complete absence or closure of apportion of the duodenum, leading to a gastric outlet obstruction
Risk Factors: polyhydramnios (increased amniotic fluid), Down Syndrome
Associated w/ other congenital defects
sx
Neonatal intestinal obstruction
*shortly after birth (within the first 24-38hrs)
*bilious vomiting
*abdominal distention
dx
Abdominal x-ray: double bubble sign
*distended air-filled stomach + smaller distended duodenum separated by the pyloric valve
Upper GI series: often performed preoperatively to assess the GI tract
tx
Decompression of the GI tract, electrolyte & fluid replacement
Duodenoduodenostomy 🡪 definitive
Encopresis (Fecal Incontinence) definition, sx, dx, tx
Definition: repetitive, voluntary or involuntary, passage of stool in inappropriate places by children ≥4yrs
Almost always associated w/ severe constipation: liquid stool leaks around a hard, retained stool mass & is involuntarily release through the distended anorectal canal
Seen predominantly in males
Causes:
*functional: chronic constipation
*emotional: school, divorce, etc.
sx
*abdominal pain, fecal mass
*dilated rectum packed w/ stool
*urinary frequency
Goal 🡪 daily, soft stools w/o pain every 1-2d w/o incontinence
dx
Rectal exam
KUB
tx
Acute treatment:
*Peg/MiraLAX
*glycerin suppository for infants up to 3d
Chronic treatment:
*elimination of all cow’s milk 1-2wk trial
*maintenance of laxatives for 6mo-1yr
*high fiber diet & increase fluids
*toilet sitting same time 5-10min after meals
Gastroenteritis: viruses
VIRUSES (75-90%):
1) Rotavirus – children <5y, peaks in cooler months
sx: S/SXS: generally begins w/ vomiting followed by watery diarrhea; high fevers in 1/3 of cases
DX: antigen detection via EIA, PCR
2) Norovirus – outbreaks in care centers, cruise ships
*MCC of foodborne disease outbreaks
sx: S/SXS: sudden onset vomiting, watery diarrhea, abdominal pain, fever
DX: PCR; stool antigen tests have lower s/s
3) Sapovirus, Adenovirus, Astrovirus – primarily <4yo
sx: S/SXS: milder than rota/nora; watery diarrhea (vomiting/fever less common)
DX: sapovirus/astrovirus: PCR; adenovirus: EIA
tx: supportive
Gastroenteritis: bacterial causes
1) Campylobacter jejuni – poultry, unpasteurized milk, untreated water, new pets, dairy farms
S/SXS: bloody diarrhea w/ severe abdominal pain, fever, occasional bacteremia
*Immune-Mediated Manifestations: Guillain-Barre, Miller-Fisher, reactive arthritis
DX: culture using selective media (preferred), EIA, PCR
TX: usually supportive; azithromycin x3d or erythromycin x5d can shorten duration when given early in illness
2) C. diff – spectrum: mild diarrhea – pseudomembranous colitis – toxic megacolon
S/SXS: fever, crampy abdominal pain, foul-smelling, watery stools
*Pseudo Colitis: diarrhea w/ blood/mucus, abdominal pain, fever, systemic toxicity
DX: two-step: enzyme immunoassay for glutamine dehydrogenase w/ confirmatory toxin testing by NAAT or toxin immunoassay
*CBC: leukocytosis; anemia possible if bloody
TX: metronidazole 30mg/kg/d divided 4x daily x10d; vancomycin 40mg/kg/d divided 4x daily x10d if severe; *fidaxomicin for continuous relapse
3) E. coli, Shiga-toxin-producing (STEC) – beef, greens, unpasteurized milk, petting zoos, person-person
S/SXS: hemorrhagic colitis w/ bloody diarrhea appearing 3-4d after sxs onset; *may cause HUS
DX: culture on sorbitol containing selective media, EIA for Shiga toxin – monitor: CBC/BUN/Cr for HUS
TX: supportive; abx not recommended d/t HUS risk
3) E. coli, Enterotoxigenic – “Traveler’s diarrhea” (resource-limited settings)
S/SXS: watery diarrhea, abdominal cramping
DX: clinic; PCR; *culture cannot distinguish from normal flora
TX: azithromycin or cipro x3d may ↓ duration
4) Nontyphoid Salmonella – poultry/beef, dairy, contaminated water, reptiles/amphibians, MC <4yo
S/SXS: diarrhea, abdominal cramps, fever
*Complications – bacteremia, osteomyelitis, brain abscess, meningitis
DX: stool culture
TX: initial dose of ceftriaxone followed by PO (azithromycin or amoxicillin or Bactrim)
* only in pts @ high risk of invasive disease – <3mo, chronic GI dz, HIV/immunocompromised
4) Salmonella typhi – humans are only hosts; resource-limited settings
S/SXS: initially – fever, malaise, myalgias, abdominal pain, constipation or bloody diarrhea; then – HSM & rose spots by wk2
*Associated w/ bacteremia & meningitis
DX: blood culture, bile culture, bone marrow aspirate *stool cultures often negative
TX: empiric – ceftriaxone or azithromycin; then definitive therapy based on cultures x7-14d
*steroids may be beneficial in children w/ enteric fever (delirium, coma, shock)
5) Shigella – infection requires low inoculum; childcare outbreaks
S/SXS: varies; watery stools w/o other sxs – bloody stools + high fever, abdominal pain, tenesmus
*S. dysenteriae – HUS; seizures, reactive arthritis
DX: stool culture
TX: azithromycin, ceftriaxone, or FQ
7) Vibrio cholerae – shellfish; “rice water diarrhea”
S/SXS: painless, watery diarrhea w/ significant electrolyte imbalances
DX: stool culture (must request selective media)
TX: single dose doxy or azithromycin; erythromycin, cipro, or tetracycline x3d
8) Yersinia enterocolitica – SWINE; pork, milk, well water, chitterlings, tofu; uncommon in US
S/SXS: fever, abdominal pain, bloody diarrhea in young children
*Pseudo-Appendicitis: mesenteric lymphadenitis w/ fever, abdominal pain/tenderness, leukocytosis – older children
DX: stool EIA or DFA
TX: parenteral 3rd gen ceph, Bactrim, aminoglycosides, FQs, tetracycline, doxy, chloramphenicol – only for neonates/IC
Gastroenteritis: parasitic causes
1) Giardia lamblia – daycare, camping trips, contaminated water; “backpacker’s diarrhea”
S/SXS: acute – watery diarrhea, foul-smell, flatulence, anorexia; can 🡪 FTT
DX: stool EIA or DFA
TX: tinidazole x1, metronidazole x5-10d, nitazoxanide x3d
2) Entamoeba histolytica – resource-limited
S/SXS: intestinal amebiasis MC – gradual onset bloody diarrhea, lower abd. pain, tenesmus, wt loss; complications: toxic megacolon, fulm. colitis
DX: stool O&P, serologic testing
TX: metronidazole or tinidazole then iodoquinol or paromomycin
GERD definition, sx, dx, tx
Gastroesophageal Reflux (GER): physiologic process of stomach contents regurgitating into esophagus
*NORMAL IN INFANTS
PATHO: transient LES relaxation allows gastric contents to flow in a retrograde direction up into the esophagus; decreased gastric compliance in infants
sx
Functional/Simple GER in Infancy: silent oral regurgitation, effortless spitting, or forceful vomiting
*Peak: 1-4mo
*Resolve: 12-18mo
GERD:
Esophagitis: crying, irritability, food aversion, heartburn, epigastric/chest pain, dysphagia/odynophagia, hematemesis, anemia, guaiac-positive stool
Respiratory: laryngospasm, bronchospasm, microaspiration pneumonia
Neurobehavioral: Sandifer syndrome (opisthotonic posturing, head tilting, sz-like activity); back arching
Infants: FTT; older children: heartburn, regurgitation
DX: clinical
Differentials, infant: pyloric stenosis, malrotation, allergic proctocolitis of infancy, eosinophilic esophagitis, colic
Differentials, older children: eosinophilic esophagitis, functional dyspepsia, H. pylori, peptic ulcer, achalasia, rumination, hiatal hernia
Testing to Consider:
*Upper GI series: to exclude malrotation, pyloric stenosis, webs, atresias
*Scintigraphy (“milk-scan”): detects delayed gastric emptying & pulmonary aspiration
*Impedance Probe: combined w/ pH monitoring to detect both acid & nonacid reflux
*Endoscopy: dx pathological mucosal disease
tx
Conservative: thicken formula w/ rice cereal, smaller-volume feeds, hold upright during/after feeding, sleep w/ head elevated, formula change
Antacid – magnesium hydroxide/aluminum hydroxide (Maalox, Mylanta)
H2Ras – ranitidine, famotidine
PPIs – omeprazole, lansoprazole, esomeprazole
Surgical: fundoplication – indicated for severe disease w/ failure of maximal medical therapy
Meckel’s (Ileal) Diverticulum definition, sx, dx, tx
*Persistent portion of embryonic vitelline duct (yolk sac, omphalomesenteric duct) in the small intestine
*MC congenital anomaly of the GI tract
Rule of 2’s: 2% of population, within 2ft from ileocecal valve, 2% symptomatic, 2in in length, 2 types of ectopic tissue (gastric-MC, pancreatic), 2yrs MC age at presentation, 2x MC in males
PATHO: ectopic gastric or pancreatic tissue may secrete digestive hormones, leading to bleeding
sx
*usually asymptomatic – often incidental finding during abdominal surgery for other cause
*painless rectal bleeding or ulceration
*pain *periumbilical
Infants 🡪 intussusception, volvulus, obstruction
Adults 🡪 diverticulitis
dx
Meckel scan: looks for ectopic gastric tissue in the ileal area
Mesenteric arteriography
Abdominal exploration
tx: surgical excision if symptomatic
Neonatal Hepatitis definition, sx, dx, tx
Idiopathic hepatic inflammation during the neonatal period
MCC of cholestasis in the newborn
Incidence is 1/5,000-10,000 live births, MC in males
sx
Transient jaundice, acholic stools 🡪 liver failure, cirrhosis, portal HTN
Presenting features in the first week of life include jaundice & hepatomegaly in 50% of pts
*FTT & more significant liver disease occurring later in infancy in 33% of pts
The course of the disease is generally self-limited, with full recovery during infancy in as many as 70% of pts
dx
Diagnosis of exclusion
Based on clinical presentation, results of liver bx, & exclusion of other causes of cholestasis
tx
Supportive
*decreased fat absorption may lead to growth failure & vitamin deficiencies; increased nutritional supportive w/ concentrated calories, use of medium-chain-triglyceride-containing formulas, & provision of fat-soluble vitamins ADEK are indicated; TPN may be needed in growth remains problematic
*Ursodeoxycholic acid, a bile acid, is used to enhance bile flow & to reduce bile viscosity; not used until biliary obstruction has been excluded as a possibility
*liver transplant may be necessary in cases of severe liver failure
Hep A transmission, sx, dx, tx
Fecal-oral
sx
Prodromal sxs:
*anorexia, N/V
*fatigue, malaise, arthralgias, myalgias
*HA, photophobia
*pharyngitis, cough, coryza
1-2wks later 🡪 jaundice, +/- RUQ pain
Dark urine, clay-colored stools – may appear 1-5d before onset of jaundice
dx
Acute: IgM anti-HAV
Past exposure: IgG anti-HAV
LFTs: ↑ AST/ALT & bilirubin
tx
No treatment needed (self-limiting)
Post-Exposure Prophylaxis:
*healthy, age 1-40: HAV vaccine preferred over immunoglobulin (within 2wks of exposure)
*immunocomp, chronic liver disease: HAV vaccine + HAV immunoglobulin (within 2wks)
