GI Flashcards
Infants with gastroesophageal reflux
Usually benign, self limited (85% resolve by 12 mo)
When to treat infants with GER?
- FTT
- Rumination
- Apnea
- Aspiration
- Irritability
- Neck contortions (Sandifer syndrome)
What is Sandifer syndrome?
Infants with gastroesophageal reflux and associated neuro symptoms (neck contortions)
What is a red flag a/w gastroesophageal reflux in infants?
Bilious vomitus (indicates malrotation with vovlulus, intussusception)
How do older children with gastroesophageal reflux present?
Adult-type symptoms: heartburn, dysphagia, cough, reactive airways
Purpose of antacid trial in GER?
Both diagnostic and therapeutic
Treatment of GER in children
- Smaller, more frequent meals
- Thickened feedings/formulas
- H2 blockers/PPIs reduce discomfort NOT frequency of reflux
- Surgery if severe
Describe eosinophilic esophagitis
- Vague symptoms c/w GERD including dysphagia
- MC in boys than girls
Diagnosis of eosinophilic esophagitis?
- Symptoms unresponsive to antacid
- Endoscopy shows white exudate with eosinophils, hypertrophied mucosal rings
- Skin testing may show specific allergens
Treatment of eosinophilic esophagitis
- Exclusion/elimination diet
- Swallowed “inhaled” steroids or systemic steroids
- Esophageal dilation for strictures
Who is MC affected by achalasia of the esophagus?
Children over 5 yo
Treatment of achalasia of the esophagus
- Botulism toxin injection in LES (relapse is over 50% though)
- Pneumatic dilation of LES
- Surgical myotomy
Describe caustic burns of the esophagus based on pH
- pH under 2 causes less injury due to sore taste
- pH over 12 larger volume of ingestion, deeper injury w/liquefactive necrosis
Role of endoscopy in caustic burns of the esophagus
- Performed under 48 hrs may underestimate injury
- Performed over 72 hrs may risk perforation
What type of caustic burn to the esophagus MC leads to strictures?
Full thickness necrosis with circumferential lesions
MC FB in the GI tract?
Coins
pins/screws/nails with blunt end heavier than sharp end usually pass w/o problem
Foreign bodies in the GI tract
- 80-90% pass
- Pins/screws/nails with blunt end heavier than sharp end usually pass w/o problem
- Removal recommended
Who is MC affected by pyloric stenosis?
4:1 males
13% with family history
Clinical presentation of pyloric stenosis
- Symptoms 2-4 wks, up to 12 wks
- Postprandial nonbilious vomiting (occasionally projectile)
- Ravenous after vomiting
Treatment of pyloric stenosis
- Fluid resuscitation prior to surgery
- Pyloromyotomy
Who is MC affected by gastric and duodenal ulcers?
Males
Any age!
Symptoms of gastric/duodenal ulcers
- Pain and bleeding MC
- Obstruction
- Anemia
MC causes of gastric/duodenal ulcers
- Underlying severe illness (US)
- H pylori infection (world)
- Toxins (US)
Treatment of gastric/duodenal ulcers
- Acid suppression/neutralization
- Limit caffeine, aspirin, ETOH, NSAIDs
- H pylori treatment
Which type of hernia occurs through the foramen of Bochdalek?
Congenital diaphragmatic hernia (posterolateral)
What improves survival in infants with congenital diaphragmatic hernia?
Extracorporeal membrane oxygenation with NO, high frequency oscillatory ventilation
Types of intestinal atresia
50% are jejunoileal
45% are duodenal
Double bubble on x-ray indicates:
Intestinal atresia
Describe short bowel syndrome
Malabsorption disorder caused by the removal of over 50% of small intestine
Etiology of short bowel syndrome
- Necrotized enterocolitis (45%)
- Intestinal atresia (23%)
- Gastroschisis (15%)
- Volvulus (15%)
Treatment of short bowel syndrome
- Parenteral or enteral nutrition
- Bowel lengthening procedures
MC cause of intestinal obstruction in the 1st 2 years of life?
Intussusception
Define intussusception and where it typically occurs
- Inversion of one portion of the intestine within another
- Typically occurs just proximal to ileocecal valve telescoping into the colon
Causes of intussusception
- Unknown in 85%
- In children over 6 yo, lymphoma is leading cause
Treatment of intussusception
- Barium and air enemas are diagnostic/therapeutic
- Surgery if toxic, unsuccessful, signs of bowel perforation
What is the MC cause of intussusception in children over 6 yo?
Lymphoma
What is the MC form of inguinal hernia in children?
Indirect (follows the processus vaginalis)
Clinical presentation of inguinal hernias in children
- Males 9:1, premature
- Painless mass
- History is often enough for surgical referral
Clinical presentation of umbilical hernias in children
- MC blacks, preterm
- Most regress spontaneously if fascial defect less than 1 cm
Which type of hernia in children is more likely to spontaneously regress?
Umbilical
Describe Meckel diverticulum
- Slight bulge in the small intestine present at birth and a vestigial remnant of the omphalomesenteric duct
- Most complications occur under 2 yo
- 40-60% have rectal bleeding d/t heterotopic gastric mucosa
40-60% of children with Meckel diverticulum have:
Rectal bleeding due to heterotopic gastric mucosa
Diagnosis of Meckel diverticulum
99mTc nuclear scan
Treatment of Meckel diverticulum
Surgical resection
Define chronic constipation in children
2 or more of:
- Less than 3 BM/wk
- 1 or more episode of soiling per wk
- Impaction of rectum w/stool
- Passage of toilet obstructing stool
- Retentive posturing and fecal withholding
- Tenesmus, hematochezia common due to anal fissures
Diagnosis of chronic constipation
- HISTORY
- KUB can be helpful
Clinical presentation of appendicitis in children
- Peak age 15-30 yo but not uncommon in toddlers
- Positive CRP and leukocytosis have PPV of 92%
- US
- Negative abd CT has NPV of 99%
What has a 99% negative predictive value of appendicitis?
Negative abd CT (with non-visualized appendix)
What has a 92% positive predictive value of appendicitis?
Positive CRP and leukocytosis
How does anterior displacement of the anus present?
- Constipation w/straining
- Severe displacement may be a form of imperforate anus
Severe anterior displacement of the anus may be a form of:
Imperforate anus
How does anal stenosis present?
- Ribbon like stools
- Blood, mucus at rectum
- Fecal impaction
- Abd distention
MC anorectal abnormality in children?
Imperforate anus
Clinical presentation of imperforate anus
- Infants fail to pass meconium
- Anal musculature development may be nonexistent
Complication of imperforate anus
Anal musculature may not be developed
What is pseudomembranous enterocolitis?
- AKA C. diff colitis
- Colitis develops after abx use
- Treated by stopping abx with observation
____ may be normal flora in up to 50% of newborns
C. diff
Conditions associated with celiac disease in children
- DM type 1
- Down syndrome
- Turner syndrome
- IgA deficiency
- Autoimmune thyroiditis
- FH of celiac disease
Classic presentation of celiac disease in children?
GI manifestations
- Symptoms start when gluten is introduced (6-24 mo)
- Chronic diarrhea, distention, anorexia, vomiting, irritability
Non-GI manifestations of celiac disease in children?
- Delayed puberty/short stature
- Iron deficiency anemia
- Osteopenia/porosis
- Elevated LFTs
Diagnosis of celiac disease
- Biopsy with and w/o gluten exposure (initially the gold standard)
- IgA anti-tissue transglutaminase Ab (most sensitive and specific)
What is the most sensitive and specific test for celiac disease?
IgA anti-tissue transglutaminase Ab
What is the initial gold standard for testing celiac disease?
Biopsy with and w/o gluten exposure
Treatment of celiac disease
Gluten free diet for life
Describe congenital lactase deficiency
- RARE
- Genetic forms appear after 5 yo (Asian/Native American 100%, AAs 70%, caucasians 30-60%)
Treatment of congenital lactase deficiency
Lactose restriction and/or lactase supplementation
Clinical presentation of cow’s milk protein intolerance
- Flecks of blood in stool
- Occurs w/introduction of milk protein
- Skin testing is UNRELIABLE (esp under 6 mo)
Skin testing for cow’s milk protein intolerance
Unreliable especially under 6 mo
Prognosis of cow’s milk protein intolerance
- Allergic colitis in infants self-limited (resolve by 8-12 mo)
- In older children, may induce eosinophilic gastroenteritis
Etiology of IBD
Multifactorial - leads to maladaptive immune response to bowel flora
Clinical presentation of IBD
- Younger presentation is more severe
- Abd pain, diarrhea, bloody stools
- Anorexia, wt loss
- Extra-intestinal signs
Extra-intestinal signs of IBD
- Uveitis
- Arthritis
- Growth delay
- Rash
- Anemia
Where does Crohn’s affect the GI tract?
ANY part of GI with skip areas (most often the ileum)
Where does UC affect the GI tract?
Proctitis extending to proximal colon
Complications of Crohn’s
- Malnutrition
- Side effects of corticosteroids
- Increased potential for carcinomas of the colon
Complications of UC
- 3-5% end up diagnosed as Crohn’s
- Arthritis
- Growth failure
- Increased potential for carcinomas of the colon
What is a potential complication of either UC and Crohn’s?
Increased potential for carcinomas of the colon
Treatment of IBD
- Diet
- Aminosalicylates (ASA)
- Corticosteroids
- Immunomodulators
- Abx
- Infliximab
- Surgery (NOT curative for Crohns)
Is surgery curative for Crohn’s or UC?
UC
Clinical presentation of rotovirus
- MC in 3-15 mo, winter/spring
- Incubation 1-3 days then vomiting (80-90%)
- Then profuse watery diarrhea lasting 4-8 days
Treatment of rotovirus
Supportive
- IV fluids
- Refeeding with regular diet when tolerated
- Antidiarrheals are ineffective and potentially dangerous
Antidiarrheal use in rotovirus?
Ineffective and potentially dangerous
Causes of chronic diarrhea
- Abx (eradicates normal flora)
- Extra intestinal infections (UTI, URI)
- Malnutrition
- Diet (overfeeding, fruit juices)
- Meds (laxative abuse)
Describe allergic diarrhea
- Cow’s milk often implicated but uncommon!
- Older children may present similarly to celiac disease
- IgE mediated reactions to foods may lead to vomiting, diarrhea, pallor, shock
How may older children with allergic diarrhea present?
Similar to celiac disease
What is toddler’s diarrhea?
- Chronic nonspecific diarrhea
- Healthy thriving 6-20 mo (resolves by 3.5 yo)
- Diarrhea is worse on low residue, low fat, high carb diet
Treatment of toddler’s diarrhea
- Change of dietary fiber (either up or down in amount based on current diet)
- Slight increase in dietary fat
- Restriction of osmotically active carbs (fruit juices)
Parasites/bacteria that cause chronic diarrhea?
Giardia, salmonella, yersinia
Describe post-infectious diarrhea
- Prolonged diarrhea following enteritis
- Often improves with resuming more normal, varied diet
Causes of vomiting in children
- Viral gastroenteritis (MC)
- Obstruction and acute/chronic inflammation of GI tract
- CNS inflammation, tumor
- Metabolic derangements (including inborn errors)
- Vestibular responses (motion sickness)
Describe cyclic vomiting syndrome
- Vomiting lasting up to 72 hrs or more
- Typically occurs over 1 yo
- 50-70% have fam hx of migraines
Majority of patients with cyclic vomiting syndrome have:
Family history of migraines
Treatment of cyclic vomiting syndrome
- Avoidance of triggers
- Antihistamines/benzodiazapines
- Migraine meds (sumatriptan)
