GI

Question 1

upper GI tract pedi considerations

Answer 1

• decreased saliva in infants
• decreased stomach capacity
• stomach positioning (horizontal in infants) & shape (round)
• reverse peristaltic waves may occur in infancy
• decreased hydrochloric acid until school age

Question 2

lower GI tract pedi considerations

Answer 2

increased propulsion w/ fever (= diarrhea/ loose stool)
immature liver
short large intestine

Question 3

sequence of abdominal exam

Answer 3

inspect, auscultate, percuss, palpate (alternative way to palpate ticklish kid, your hand over theirs)

Question 4

GERD def/ etiology/ diagnosis

Answer 4

def- symptoms and complications from chronic gastro reflux. etiology- relaxation of the lower esophageal sphincter (peaks at 3 mos of age); aggravated by overeating, recumbent position, caffeine (mom breast milk) high fat diet, exposure to second hand smoke
diagnosis- good H&P- mom will say the baby is spitting up a lot, miserable after eating

Question 5

GERD treatment first line

Answer 5

conservative measures first- smaller, more frequent feeds, elevate HOB after feeds, thickened feedings (if you have to- careful not to give kids too many calories- could lead to obesity)

Question 6

GERD meds (if first line interventions not working)

Answer 6

H2 receptors- Ranitidine (Zantac) 2- 4mg/kg/ day Q12hours- comes in oral solution of 15mg/ 1ml (usually used first) OR
Cimetidine (Tagamet) 10- 20mg/kg/day Q 6- 12hours- comes in oral solution 300mg/ 5ml
OTC- Maalox or Mylanta 1ml of each
No PPI’s approved for infants
If no relief, loss of weight, FTT, refer to gastro

Question 7

umbilical ring

Answer 7

palpate it- should be free of bulges, nodules, granulation. potential for herniation- see if hernia is easily reducable, if it is- don’t worry about it unless it doesn’t go away by 1 year

Question 8

pyloric stenosis patho/ prevalence

Answer 8

patho- diffuse hypertrophy of smooth stomach muscle/ thickened pylorus
prevalence- s/s appear at about 4 weeks, peaks at 6- 8 weeks, more in males.

Question 9

pyloric stenosis s/s

Answer 9

need good history taking! vomiting with increasing force and amount (propulsive/ projectile vomiting), appears hungry, “olive is palpable”

Question 10

diagnostics for pyloric stenosis

Answer 10

diagnostic standard is US- if +, need surgical intervention ASAP

Question 11

Acute gastroenteritis (AGE)

Answer 11

can be d/t bacterial or viral causes, common causes rotavirus, bacterial- salmonella, campylobacter, shigella, E.coli

Question 12

AGE s/s

Answer 12

includes N/V/D. big concern is for rapid dehydration and electrolyte imbalances- need to assess degree of dehydration (mild/ moderate/ severe) to make a decision related to oral rehydration protocols

Question 13

gold standard for mild to moderate dehydration

Answer 13

oral rehydration. pay attention to age of child, the younger the child, the faster they get dehydrated. Palpate the frontal fontanelle (would be sunken in if dehydrated) and assess mucous membranes. Use pedialite to supplement water, NO gatorade for kids under 6/7 yrs old.

Question 14

Rotavirus

Answer 14

most often effects infants and young kids 3mos to 2 years- is one of the most common causes of diarrhea. In US outbreaks during winter and spring months. Problem particularly in child- care centers and children’s hospitals. Severe infection- leading cause of severe, dehydrating diarrhea in infants and young kids

Question 15

1 question to ask mom to assess baby’s hydration

Answer 15

when was the last time they had a wet diaper? If 6 hours or longer- BAD

Question 16

1st line tx for mild to moderate dehydration

Answer 16

oral rehydration

Question 17

functional abdominal pain AKA recurrent abdominal pain

Answer 17

patho- stress response- can be familial/ genetic
need careful hx taking- assess pain behaviors, pain at night or with sleep?
- stomach prob won’t hurt at time of office visit
- could tell them to keep diary for 1 month
- discuss with parents options for testing

Question 18

assessments to r/o appendicitis

Answer 18

Obturator- bend knee at hip/ rotate internally
Psoas sign- raise thigh against hand
Cutaneous hypersthesia- pinch skin folds, will be hyperresponsive
Rebound tenderness- suggests peritoneal inflammation, press deeply and evenly in LLQ- watch facial expression
- can also tell them to hop off exam table by themselves, see if that hurts

Question 19

history w/ appendicitis

Answer 19

diffuse periumbilical pain, often with anorexia (if anorexia and then all of a sudden very hungry- may have burst)
N/V after the onset of pain
after several hours, pain more localized and continuous
afebrile or low grade temp (if high- may have burst)
- Refer to ER

Question 20

Intussesception

Answer 20

telescoping of one portion of intestine to another (“SS”- stinky sock analogy) occurs most frequently at the ileocecal valve, males 2 times more frequent than females, usually occurs between 3- 12 mos of age, cause is unknown

Question 21

clinical manifestations of intussesception

Answer 21

healthy well nourished baby with severe abdominal pain evidenced by kicking and drawing legs up to abdomen, one or 2 normal stools, then bloody mucus stool aka “currant jelly- like stools”- is a classic sign, palpation of sausage- shaped mass, signs of intestinal obstruction

Question 22

treatment of Intussesception

Answer 22

medical reduction by hydrostatic pressure (aka barium enema) newer water- soluble contrast with air pressure. if this doesn’t work- surgical; manual reduction, sometimes with intestinal resection.
- we know its fixed when baby starts having normal BMs again

Question 23

constipation

Answer 23

stool withholding- common during toilet training. Encopresis, enuresis also common.
- should encourage “p” fruits- peaches, pears, prunes. Avoid bananas and also educate that MILK can be very binding- should not have more than 16- 20 ounces/ day. could do bowel training, could use OTC laxatives if necessary, and probiotics

Question 24

encopresis

Answer 24

fancy word for poop in pants.

overflow of incontinent stool causing soiling, often d/t fecal retention or impaction.

Question 25

encopresis clinical findings

Answer 25

soiled clothing or fecal odor without apparent awareness, social withdrawal, increased incidence of urinary tract infections

Question 26

enterobiasis, what is it? s/s? how to tx?

Answer 26

roundworm, pinworm- adult nematode (parasite) lives in the rectum or colon and emerges onto perianal skin to lay eggs while child sleeps.
very puritic, especially at night
entire fam needs to be treated- anyone living in the house, with Vermox (Mebendazole) one tablet (100mg), may need to repeat in 2 weeks, cannot be given to pregnant women or kids under 2yrs

Question 27

Crohn’s disease

Answer 27

-inflammation of mucosal lining of GI tract, autoimmune response, chronic inflammation can lead to abscesses, fistulas, strictures, inherited susceptibility/ seen in families

Question 28

Crohn’s disease s/s, how to tx

Answer 28

abdominal pain, weight loss, fever, delayed growth and pubertal development. to treat refer to GI, they will likely scope/ get a biopsy

Question 29

irritable bowel disease

Answer 29

diarrhea or constipation or alternation between the 2, chronic bloating/ abdominal pain

• very common in adolescents
• chronic condition
• treatment- avoid foods that aggravate sx, adequate fiber intake, mind/ body relationships- therapist for stress related issues may help

Question 30

Celiac disease

Answer 30

• inherited autoimmune disorder
• chronic intestinal malabsorption and inability to digest gluten (protein found mostly in barley, wheat, rye, oats)
• identified after several months after gluten is introduced into the diet (usually between ages of 1 and 5 years)

Question 31

celiac patho

Answer 31

accumulation of glutamine produces a toxic effect on mucosal cells causing atrophy of villi. Malabsorption occurs causing deficiencies of essential vitamins and nutrients.

Question 32

clinical findings of celiac disease

Answer 32

fat absorption affected in early stage
protein, carbs, mineral, and electrolyte absorption then later affected
progressive malnutrition: anorexia, muscle wasting, distended abdomen
secondary deficiencies: anemia & rickets (vit D)
behavioral changes: irritability, fretfulness, apathy
watery, pale, foul smelling stool

Question 33

celiac crisis

Answer 33

severe episodes of dehydration and acidosis from diarrhea

Question 34

celiac treatment

Answer 34

primarily dietary- low in gluten (no wheat, rye, barley or oats), high in calories and protein & low in fat, small/ frequent feedings, adequate fluids, vitamin supplements- all in water- miscible form; supplemental iron.
Assess parent/ child knowledge of dietary regimen, nutritional status
Outcomes- parent/ child verbalizes understanding, consumption of adequate calories for growth and development, establish normal growth and development milestones, normal bowel function, adequate hydration, comfort