GI Flashcards
What is esophageal atresia?
blind esophageal pouch w/ or w/o a fistulous connection between the proximal or distal esophagus & trachea
Clinical presentation of esophageal atresia?
Polyhydramnios (excess amniotic fluid)
only sxs within hrs of birth : infants in the 1st few hrs of life w/ copious secretions, choking, cyanosis & respiratory distress
Can esophageal FBs pass spontaneously?
yes, 80-90%
What is the MC FB ingested?
coin
management for coin ingestion?
Plain neck, chest, &/or abdominal radiographs
Esophageal coin on AP CXR
Tracheal coin - tends to be on its edge
Protect the airway
Give continuous oropharyngeal suction
Tx for coin ingestion?
Retrieval if:
Not passed into stomach
button battery
multiple magnets
What FB ingestion is a medical emergency?
button battery
may have perforation in 2 hrs
Tx for button battery?
Requires endoscopic retrieval if lodged in the esophagus:
If in stomach, watch for 24-48 hours to see if it passes, if not, must be removed endoscopically
Gastroesophageal reflux (GER) v GERD?
GER: uncomplicated recurrent spitting & vomiting
resolves spontaneously
GERD:
present when reflux causes secondary sx or complications
What is GER?
Reflux of gastric contents into the esophagus
occurs during relaxation of LE sphincter
common in young infants
sxs of GER?
infants: postprandial regurgitation from effortless to forceful
Tx of GER?
Usually benign
expected to resolve by 12-18mo of life
When infants develop sx like FTT, food refusal, pain, GI bleeding, upper or lower airway sx, etc. GER becomes GERD
sxs of GERD?
Older children = heartburn, dysphagia
Who is at risk for GERD?
asthmatics, Cystic Fibrosis, Developmental handicaps, Hiatal hernia, repaired TE fistula
complications of GERD?
esophagitits
recurrent pneumonia
recurrent cough
dental erosions
warning signs for GERD?
bile stained emesis (intestinal obstruction)
GI bleeding
Onset of vomiting after 6mo
Failure to thrive (FTT)
diarrhea, fever, hepatosplenomegaly
abdominal tenderness or distension or neuro changes
Need further work up!
Tx for GERD?
thickened feeds with oat cereal
milk free diet for 2 wks
H2 blocker v. PPI
Surg: Nissen Fundoplication
Epidemiology of eosinophillic esophagitis? EOE
all ages, M >F
What are the 2 MC comps of EOE?
1) esophageal food impactions
2) esophageal stricture
s/s of EOE?
feeding dysfunction, vague non specific sx of GERD
long meal times (washing down food w/ liquids)
avoidance of highly textured foods
No response to medical/ surg GERD tx
FH or PMH of atopy, asthma, dysphagia or food impaction
Dx of EOE?
Endoscopy:
esophageal mucosa w/ thickening, mucosal fissures, strictures & rings
esophagus sprinkled w/ pinpoint white exudates (resembles candida)
white spots composed of eosinophils
Need to r/o other causes
Tx of EOE?
elimination of food allergens
swallowed topical steroids (MDI)
-2 puffs of Fluticasone BID
What is Pica?
Persistent eating of nonnutritive substances
ex. Animal feces, Clay, Dirt, Hairballs, Ice, Paint, Sand
At least 1 month
Inappropriate to developmental level
Pica may be assoc. with…
iron and zinc deficiency
What is rumination?
Repeated regurgitation and re-chewing of food
At least 1 mo
More common 3 to 12 months
Less common in older children
Presentation of rumination?
Malnutrition
Failure to thrive
Weight loss
Bad breath
Tooth caries
Presentation of malabsorption?
Weight loss Malnutrition Diarrhea/steatorrhea (fat malabsorption) N/V Abd pain
Assessment of malabsorption?
Stool sample
Substance removal and challenge
Work up for celiac disease or cystic fibrosis
What is PhenylketonuriaPKU?
Most common inborn error of amino acid metabolism
Decreased activity of phenylalanine hydroxylase (enzyme that converts phenylalanine to tyrosine)
Presentation of PKU?
Intellectual disability *MC
Fair skin and hair (impairment of melanin synthesis)
Atopic dermatitis
hyperactivity
seizures
Musty or mousy odor to body & urine
Epilepsy (50%)
When do we check for PKU?
newborn screen
autosomal recessive trait
What are some common allergies?
cow’s milk, fruits, egg, fish, nuts, cereal
Skin presentation for food allergies?
Urticaria and angioedema
dx of food allergies?
In vivo IgE against a specific food (skin testing)
In vitro for specific IgE
RAST (radioallergosorbent testing )
fluorescent-enzyme immunoassay
Removal + re-challenge
Clinical reactivity vs IgE antibodies
Tx of food allergies?
Avoidance and re-introduction annually
Epinephrine
H1 blockers
What is celiac disease?
Immune mediated enteropathy triggered by gluten
1 in 100
Gluten = protein in wheat, rye & barley
s/s of celiac disease?
abd pain, V/D
abdominal bloating or distention
constipation
othersL oral ulcers, pruritic rash, growth/puberty delay, iron def. anemia, decreased BMD
risk factors for celiac disease
T1DM Down syndrome Turner syndrome Autoimmune thyroidititis Family hx of CD
Dx of celiac disease?
serology &/or duodenal biopsy (villous atrophy w/ increased intraepithelial lymphocytes)
Tx of celiac disease?
gluten restriction for life (wheat, rye & barley)
intestinal mucosa improves by 6 to 12mo
supplemental calories, vitamins, & minerals (only in acute phase)
What are some abdominal wall defects?
Gastroschisis & Omphalocele
Complications of abdominal wall defects?
GERD
Volvulus
Malabsorption
dx of abdominal wall defects?
maternal elevated AFP
Discovered on prenatal u/s (usually 1st trimester)
Delivered via c-section w/ surgical correction
What is a omphalocele?
Membrane covered herniation of the abdominal contents into the base of the umbilical cord
sac may contain liver, spleen, intestine
What is gastroscisis?
Uncovered (no sac) intestine through small abdominal wall defect to the right of the umbilical cord
no sac
Intestinal atresia in approximately 10-20% of infants
Prevalence for gastroschisis, why?
illicit drugs like meth & cocaine
possible link w/ aspirin & ibuprofen use during pregnancy
young maternal age
When are diaphragmatic hernias usually diagnosed?
8-10 wks gestation
dx of prenatal US
Polyhydramnios (50%) (excess amniotic fluid)
Tx of diaphragmatic hernia?
intubation, mechanical ventilation & decompression of the GI tract w/ OG tube
Surg to reduce abdominal contents & close diaphragmatic defect
complications of diaphragmatic hernias?
pulmonary hypertension
severe GER/GERD
at risk for behavior problems
hearing loss, poor growth
umbilical hernias are MC in?
full term, African American infants
most regress spontaneously, esp if fascial defect has a diameter of <1cm
When should you consider repairing umbilical hernias?
if persist beyond 4 years of age
What is pyloric stenosis?
Postnatal muscular hypertrophy of the pylorus
Progressive gastric outlet obstruction
Epidemiology of pyloric stenosis?
30-40% are first born
M> F 4:1
more common in whites
s/s pf pyloric stenosis?
projectile postprandial vomiting
sx usually begin between 3-6wks of age, may start as late as 12wks (rare)
infants are usually hungry and nurse avidly (“hungry vomiter”)
PE findings in pyloric stenosis?
Some upper abd distention after feeding
prominent gastric peristaltic waves (possibly seen)
Hallmark sign: olive mass (5-15mm mass in RUQ esp. after vomiting)
Dx of pyloric stenosis?
pyloric US
barium upper GI: string sign
Tx of pyloric stenosis?
surg repair:
- pyloromyotomy
- good px but 3-4x risk for chronic abd pain in childhood
Apple core or String sign on US indicates…
pyloric stenosis
indicating the elongated narrowed pyloric canal (short arrow).
duodenal atresia is assoc. with..
down syndrome
X-ray findings seen in duodenal atresia?
double bubble sign
presentation of duodenal atresia?
bilious vomiting hours after birth
Tx of duodenal atresia?
surg correction
What is short bowel syndrome?
A condition resulting from reduced intestinal absorptive surface >
leads to alternation in intestinal function
compromises growth, fluid/electrolyte balance &/or hydration status
When does short bowel syndrome usually occur?
after surg resection of intestine
s/s of short bowel syndrome?
generally related to their malabsorptive state:
diarrhea
dehydration
electrolyte or micronutrient deficiency states
excessive gas, foul ambling stool
Tx of short bowel syndrome?
goal: promote growth
Diet
Total parenteral nutrition (TPN) - worry about liver issues w/ prolonged use
Enteral nutrition (g-tube)
Meds to slow motility
Antacids, H2 blockers, or PPI
Abx to prevent or treat bacterial overgrowth
Surgery (STEP)
Intestinal transplantation (last resort)
What is intussusception?
Telescoping of one segment of the intestine into another segment
MCC of bowel obstruction in the first 2yrs of life
MCly starts just proximal to the ileocecal valve
Epidemiology of intussusception?
3x more in Males
s/s of intussusception?
recurrent paroxysms of abdominal pain (screams, draws up knees)
int. severe, crampy abd pain
V/D Passage of rectal blood/mucous: “red currant jelly” pathonomonic
PE findings for intussusception?
Palpable right-sided sausage-shaped mass
hirschsprung disease is assoc. with..
downs
Tx of hirschsprung disease?
surg removal of aganglionic bowel: temporary colostomy
surg reconstruction
What is the rule of two’s?
Meckel’s diverticulum:
- 2% of the population
- Male-to-female 2:1
- 50% of complications occur in first 2yrs of life
- Within 2 feet from the ileocecal valve
- 2 inches in length
presentation of meckel’s diverticulum?
painless lower GI bleed
recurrent or atypical intussusception
Dx of meckel’s diverticulum?
arteriography or CT angiography
Tx of meckel’s diverticulum?
surg resection if sxs
What is Gilbert’s syndrome?
familial unconjugated hyperbilirubinemia
Epidemiology of Gilbert’s syndrome?
autosomal dominant
Dx of gilbert’s syndrome?
serum unconjugated bili usually <3-6
an increased of 1.4 of unconjugated bilirubin after a 2 day fast is dx
tx of Gilbert’s syndrome
no tx necessary
Cystic fibrosis primary affects which 4 areas?
Lung, pancreas, intestine and liver
When should you suspect CF? dx?
Suspect in any child with meconium ileus, cholestasis, recurrent URI/lung disease or malabsorption
Sweat chloride test
Newborn screening available
Tx of cystic fibrosis?
Oral supplementation of pancreatic enzymes improves digestion
Ursodiol can help to relieve the manifestations of cholestasis
What are pilonidal cysts?
Infx of the skin or subcutaneous tissue at or near the upper part of the natal cleft of the buttock
patho of pilonidal cysts?
Develop when ingrown hair forms in the skin>
Forms a cyst that becomes a sinus
Most sinuses become infected
risk factors for pilondal cysts?
overweight/obesity
local trauma or irritation
sedentary lifestyle or prolonged sitting
deep natal cleft
family hx
Tx of pilonidal cysts?
Soaking in warm water ease pain of pilonidal cysts
Surgical opening and draining of the infected sinus
What is Enterobiasis (Pinworms)?
Worms in the stool or eggs on perianal skin
intense anal pruritus
Dx of pinworms?
scotch tape test
Tx of pinworms
treat all household members at the same time to prevent reinfections
repeat tx in 2 weeks
Pyrantel pamoate 11mg/kg (max 1g)- OTC
keep nails short/clean
wash sheets freq.
What is encopresis?
Repeated passage of feces into inappropriate places (e.g., clothing or floor)
Involuntary or intentional
at least 3 mos
at least 4 yrs of age or equivalent developmental level
tx of encopresis?
behavioral-education tx
pharm: initally suppositories & enemas
Miralax
laxatives (mineral oil, high fiber diet, etc)
biofeedback therapy
What is considered constipation?
2 or more for 2 months:
1) < 3 BMs per wk
2) > 1 episode of encopresis per wk
3) impaction of the rectum w/ stool
4) passage of stool so large it obstructs the toilet
5) retentive posturing & fecal witholding
6) pain w/ defecation
What causes constipation?
dehydration, excessive milk, lack of fiber
meds
thyroid disease, CP
anal fissues
Tx of constipation?
diet changes to “p”
Miralax
Lactulose
Milk of Magnesia
