GI Flashcards
1
Q
Jaundice
- when check newborn
A
- at birth
- 2-5 days
2
Q
Jaundice
- 2 main physiologic causes
A
- increased production fo bilirubin
- decreased ability to metabolize/excrete bilirubin
3
Q
Jaundice
- 5 types
A
- physiologic
- Rh/ABO incompatibility
- Breastmilk jaundice
- Breastfeeding jaundice
- Extravasated blood
4
Q
Jaundice
- physiologic jaundice
A
- MC
- inability of immature liver to metal and excrete bilirubin
- usually benign
- usually resolves in 1-2 weeks
5
Q
Jaundice
- Rh/ABO incompatibility
A
- increased bd of fetal RBCs overwhelm liver
- Rh incompatibility: sensitized Rh- mother vs. Rh+ child
- ABO: maternal blood type O has predominantly IgG antibodies that cross the placenta and cause harm to the baby (non type O)
6
Q
Jaundice
- Breastmilk jaundice
A
- towards end of first week of life
- chemicals in breast milk thought to be responsible
- usually harmless and resolves spontaneously
- moms can keep breastfeeding
7
Q
Jaundice
- Breastfeeding jaundice
A
- inadequate milk production
- dehydration
- fewer bowel movements of baby
- decreased bilirubin excretion from body
8
Q
Jaundice
- extravasated blood
A
- cephalohematoma
- peripheral ecchymosis
9
Q
Jaundice
- W/u
A
- bili measurements in hospital and at newborn office visit
- newborn screening
- ABO typing
10
Q
Jaundice
- tx
A
- sunlight if <15
- phototherapy if >15
- feeding/supplementation: ensure adequate food supply
11
Q
Jaundice
- complications
A
Kernicterus (bilirubin encephalopathy) from high levels of indirect bilirubin (>20 in term infant)
- can occur at lower levels of bilirubin in presence of acidosis, hypoalbuminemia, certain drugs
12
Q
Gastroenteritis
- how common? why a big deal?
A
- one of the MC problems in peds
- still major cause of morbidity and mortality
13
Q
Gastroenteritis
- w/u
A
- history!!! onset, duration, frequency of BM/vomiting, etc. etc
- PE: VITALS, saliva/tears for dehydration, feel the belly for rigidity
- always look for other causes of vomiting like strep throat!
14
Q
Gastroenteritis
- stool studies: when to use, what is covered
A
- if ill >7 days or severe illness
- rotavirus
- c. diff
- fecal leukocyte stain to ID bacterial etiology
- culture: salmonella, shigella, yersinia
- e. coli
- campylobacter
- ova and parasite: giardiasis and cryptosporidium
15
Q
C. diff
- sx
A
- frequent, water diarrhea
- mucus
- sig odor
- weight loss
- abd pain and cramping
16
Q
c. diff
- predisposing factors
A
- previous c diff infection
- multiple abx
- hospitalizations
- PPIs
17
Q
c. diff
- tx
A
- if asx, no tx
- Metronidazole
- 2nd occurrence: PO vanc
18
Q
E. coli
- two types
A
- enterohemorrhagic (shiga toxin): more severe. Severe stomach cramps, diarrhea (bloody often), vomiting
- Enterotoxogenic: profuse watery diarrhea, abd cramping, fever, nausea, +/- vomiting, chills, muscle aches, bloating
19
Q
Campylobacter
A
diarrhea, cramping, abd pain, fever, +/- n/v
1 week
20
Q
Giardia
A
- cyclical diarrhea
- cramping, bloating, abd pain, dehydration
21
Q
Gastroenteritis
- tx
A
- zofran
- phenergen gel for tiny babies
- BRATT diet
- pedialyte
- NO anti-diarrheal (salicylate)
- FOLLOW UP
22
Q
Dehydration
- impact
- causes
A
- dehydration 2nd to diarrheal illness is leading cause of infant and child mortality worldwide
- Fluid loss
- Deficient intake
- Fluid shift (ascites, effusion, cap leak from burn or sepsis)
23
Q
stages of dehydration
A
chart in the lecture. she specifically mentioned checking fontanel and cap refill
24
Q
Three types of dehydration (list)
A
- Isonatremic (isotonic)
- Hyponatremic (hypotonic)
- Hypernatremic (hypertonic)
25
Isonatremic dehydration
- lost fluid is similar in sodium concentration to blood
| - least dangerous, MC
26
Hyponatremic dehydration
- lost fluid contains more sodium than blood
| - low serum sodium = fluid shift into extravascular space, exaggerating intravascular volume depletion
27
Hypernatremic dehydration
- lost fluid contains less sodium than the blood
- serum sodium is high, fluid shifts to intravascular space
- intravascular volume depletion is minimized for given amount of body water lost
28
Neuro complications of hyponatremia
- intractable seizures
| - if correct too fast = central pontine myelinolysis
29
Neuro complications of hypernatremia
- if correct too fast = cerebral edema
(when fluid leaves cells for intravascular space, creates osmotically active pressure in cells which can pull too much water in during rehydration)
**slowly rehydrate over 48 hours
30
Dehydration
| - non pharm tx
- No anti-diarrheal meds
- Oral rehydration: vomiting is not a CI, give frequent small amounts of fluid with correct Na and glucose proportions (pedialyte, infalyte, etc.)
- do not give apple juice, ginger ale, milk, cx broth
- IV rehydration
31
Dehydration
| - pharm tx
- avoid empiric abx (c.diff!)
| - Ondansetron or phenergen gel for nausea
32
Dehydration
| - diet to return to food
- start feeding as soon as tolerated
- BRATT diet
- no dairy until 24 hours after diarrhea/vomiting free
- foods with complex carbs
- avoid fatty foods an simple carbs
- probiotics
33
Constipation
| - criteria for dx
- Rome III
- 2 of the follow sx over preceding 3 months:
* fewer than 3 BM/week
* straining
* lumpy/hard stool
* sensation of anorectal obstruction
* manual maneuvering required to defecate
34
Constipation
| - may be asx except for the following sx
- abd bloating
- pain on defecation
- rectal bleeding
- spurious diarrhea
- low back pain
35
Constipation
| - Overview of types
```
Primary:
- functional
Secondary
- dietary
- structural
- systemic dz
- medication
- psychologic
```
36
Constipation
| - Primary/functional
- withholding dt fear of pain, "too busy", scared of public bathroom, etc.
- often a consequence of a single episode fo painful defecation...
37
Constipation
| - secondary causes: dietary
- inadequate fiber/water
- overuse of coffee/tea/alcohol (???)
- diet change: nursing/formula to cow milk
38
Constipation
| - secondary causes: structural
- colon obstruction
- stricture
- volvulus
- outlet obstruction
39
Two types of outlet obstruction that cause constipation
- Anatomic: intussusception, recital prolapse, rectocele
| - Functional: puborectalis/external sphincter spasm, short-segment Hirschsprung, prudential nerve damage
40
Constipation
| - secondary causes: systemic dz
- endocrinology and metabolic disorders (hypercalcemia, hyperparathyroidism, etc.)
- Neurologic (stroke, Hirschsprung, Parkinsons, MS, spinal cord lesion, etc.)
- CT disorders: scleroderma, amyloidosis
41
Constipation
| - secondary causes: meds
- antidepressants
- anticholinergics (SLUD)
- metals like iron
- Antacids
- CCB
- Opioids
- NSAIDS
- Sympathomimetics
- etcccccc
42
Constipation
| - secondary causes: psychologic
- depression
- anxiety
- somatization
43
Constipation
| - workup
- HPI and PE
- Imaging: xray
- DRE
- Labs: TSH/T4, CMP
- GI: lower GI endoscopy, colonic transit (Sitzmarker study), Anorectal manometry
44
Constipation
| - tx 4 types
- Behavioral
- Pharm
- Education
- F/u
45
Constipation
| - Behavioral tx
- toileting habits
- diet (increase fiber, fluids, decrease constipating foods)
- exercise
46
Constipation
| - Pharm tx
- bulk-forming agents (psyllium)
- emollient stool softeners (docusate), best for short term prophylaxis
- Rapidly acting lubricants (mineral oil) for acute and subacute
- Prokinetics (Linzess): DO NOT USE
- Stimulant laxatives (senna, ex-lax): not for chronic use
- Osmotic laxative: miralax, fleet enema, lactulose, MOM
47
Constipation
| - education tx
- bristol stool chart
- what is normal, what is not normal
- mechanical aids
48
Constipation
| - complications
- hemorrhoids
- fissures
- pelvic floor damage in women
- megacolon
- volvulus
- rectal prolapse
- rectal ulcers
- urinary urgency or incontinence
49
Constipation
| - special thought for newborns
- Meconium >24 hours, consider Hirschsprung's
- Anatomical defects in the spinal cord
- Anorectal anomalies (anal atresia/stenosis)
- Meconium plug: CF
- endocrine, metabolic, neuromuscular dz
50
Encopresis
- MC results from functional constipation
- with constipation: overflowing diarrhea
- without constipation: colitis/enteritis, not yet potty trained, neuro issues
51
Encopresis
| - w/u
- check for constipation
- Hx/sx indiating gastroenteritis, intestinal malabsorption, etc.
- Must perform DRE
52
Encopresis
| - tx
- tx underlying cause!
53
Hirschsprung Disease
| - MC first sign
- dx suggested by delay in first meconium
| - 95% HD delayed meconium, only 1% normal infants don't pass meconium in first 48 hours
54
Hirschsprung Disease
| - describe
- motor disorder of colon
- failure of embryonic cells to migrate completely during colonic development
- affected portion of colon can't relax, causes functional obstruction
55
Hirschsprung Disease
| - tx
- surgical: remove segment w/o innervation, anastomose areas with normal nerves
56
Phenylketonuria (PKU)
- MC inborn error of amino acid metabolism
| - deficiency of phenylalanine hydrolase enzyme (PAH) = accumulation of phenylalanine in body
57
Phenylketonuria (PKU)
| - sx
Cutaneous
- light skin and hair
- eczema, light sensitivity, pyogenic infections/KP
- decreased # pigmented nevi
- eye abnl (hypopigmentation)
Neuro
- reduced cog functioning
- developmental delay
- epilepsy
- extrapyramidal manifestations (parkinsonism)
Other
** Musty/mousy odor
58
Phenylketonuria (PKU)
| - w/u
Labs
- routine to screen newborns
- consider in adoptions, unknown birth hx, home delivery, etc.
Imaging
- MRI: older pts
- check for areas of demyelination
- volume loss in brain (cerebrum, corpus callosum, hippocampus, pons)
59
Phenylketonuria (PKU)
| - Tx via diet
- Phenylalanine restriction: low protein, limit starch, limit aspartame
- supplement for other essential amino acids, minerals, vitamins
- Breastfeeding ok in most cases
60
Phenylketonuria (PKU)
| - Pharm tx
- large neutral amino acids which block phenylalanine at BBB - mainly when refuse diet changes
- Sapropterin
- injectable phenylalanine ammonium lyase (substitute for PAH)
61
Phenylketonuria (PKU)
| - monitoring
- check 2x/week in newborn
- weekly in infant
- 2-3 weeks in toddlers
- monthly for life
62
GERD
- some is normal, need to understand frequency and amount
| - ensure not malabsorption (gassy, constipated, diarrhea)
63
GERD
| - etiology
- incompetent LES: will improve by year 1
- Excess acid production: H. pylori
- delayed gastric emptying, can be 2nd to constipation
- poor esophageal peristalsis
64
GERD
| - sx
- infant: spit up, arch back, cry excessively esp. after feeding or when flat, red throat
- child: epigastric pain, "chest pain", tasting acid
- atypical: chronic congestion, cough, wheezing, hoarse, sore throat, otitis media, n/v
65
GERD
| - workup
- empiric tx
| - UGI
66
GERD
| - tx non pharm
- Infant: keep upright after feeding, burp frequently, sleep on incline
- Child: avoid chocolate, tomato, citrus, peppermint, coffee. Eat small meals, don't eat before bed, elevate head of bed, weight loss if obese
67
GERD
| - med tx
- H2 blockers: ranitidine, etc
| - PPIs: omeprazole, lansoprazole, etc.
68
Lactose intolerance
- lactase enzyme activity declines with age
| - milk intolerance: determine if lactose intolerant, milk protein allergic, or malabsorption syndrome
69
Lactose intolerance
| - cause
- congenital: rare, AR
- premature: decreased lactase activity, will improve with ingestion of lactose
- temporary: gastroenteritis, inflammation
70
Lactose intolerance
| - sx
- GI: abd pain, bloating, flatulence, fussy
- stool: loose, watery, acidic, blood
- food avoidance of milk
- borborygmi
71
Lactose intolerance
| - tx
- dietary mod
- special formula
- start with lactose > milk protein > total elimination diet and progress
- Mom's diet if breastfeeding
- dont go to soy: 40% of lactose sensitive infants are also intolerant of soy
72
Colic
- inconsolable infant btwn 4-8 weeks (6 week peak)
- cry between 6 and midnight
- rule out other causes
- don't shake
- gerber soothe colic drops
- Levsin
- support system!!
73
Pyloric stenosis
- MC in boys
- genetic link
- first 2 months of life
- possibly predisposed by bottle feeding and macrolides
74
Pyloric stenosis
| - sx
- projective vomiting** (no bile) soon after feeding
- very hungry soon after feeding
- decreased weight, little weight gain
- epigastric olive shaped mass **
- constipation
75
Pyloric stenosis
| - workup
- H and P
- rehydrate before investigating
- Test feed to try to feel olive mass (spasm of muscle)
- US**
76
Pyloric stenosis
| - labs
- dehydration: electrolytes, pH, BUN, Cr
77
Pyloric stenosis
| - tx
- med emergency!!
- correct fluid loss, electrolytes, pH imbalance
- Surgery: Ramstedt pyloromyotomy (standard of care)
- Atropine is non surgical option
78
Intussusception
- ileum telescopes into ascending colon
| - obstructs passage of intestinal contents
79
Intussusception
| - signs and sx
- vomiting: non-bilious to bilious
- abd pain
- currant jelly stool **
- maybe just diarrhea
- lethargy
- sausage-shaped mass
80
Intussusception
| - w/u
- Xray
- US: target sign or pseudo kidney sign
- Contrast enema: most reliable, look for crab claw sign**
81
Intussusception
| - treatment
- therapeutic enema
| - surgical: incision and manual reduction
82
Volvulus
- long mesentery with narrow attachment at retroperitoneum
- malrotation of colon
- MC sigmoid, also cecal, transverse colon, splenic flexure
- rare in kids, MC 8th decade
83
Volvulus
| - w/u
* CBC (left shift indicates bowel ischemia, peritoneal infection, systemic sepsis), CMP
* imaging:
- Xray best for sigmoidal
- CT if XR inconclusive,: upward displacement of appendix and large-bowel obstruction = cecal volvulus
- Barium enema: birds beak at base of volvulus
- sigmoid- and colonoscopy
84
Volvulus
| - sx
- bloody or dark red stool
- constipation/difficulty releasing stool
- distended abd
- pain/tender abd
- n/v
- shock
- vomiting green
85
Volvulus
| - tx
- endoscopic decompression
| - surgical resection
86
Volvulus
| - prognosis
- even with quick intervention, mortality is still ~25% for emergent procedures!
87
Duodenal atresia
- complete intrinsic intestinal obstruction
- Intestine can be separated by: apposition, fibrous cord, a gap
- proximal segment is dilated
- distal segment is empty
- MC location: vicinity of ampulla of vater
- common in trisomy 21
88
Duodenal atresia
| - signs and sx
- vomit w/in hours of birth
- scaphoid abdomen (sunken)
- epigastric fullness?
- will pass meconium in 24 hours
89
Duodenal atresia
| - risk if lack of fast intervention
- weight loss
- dehydration
- electrolyte imbalance
90
Duodenal atresia
| - dx
Double bubble sign on prenatal US - see stomach and post-pyloric dilated duodenal loop
91
Duodenal atresia
| - tx
duodenoduedenostomy in newborn
92
Foreign body
| - what children at increased risk
- speech delay/abnl
- Very young
- tracheoesophageal fistula
- stenosing lesions
- previous GI sx
93
Foreign body
| - w/u
- 2 view xray
| - endoscopy
94
Foreign body
| - signs and sx
- child tells you
- lodged: inflammation, pain, bleeding, scarring, obstruction
- eroding: mediastinitis (via esophagus), peritonitis (via lower GI tract)
95
Foreign body
| - when is it a problem
- esophageal impaction
- too long (>6 cm) or too wide (>2 cm), bigger than a quarter
- made of zinc: ulcerations in stomach acid
- 2+ magnets
- button/disc batteries
- other known GI abnl
96
Foreign body
| - tx
- endoscopy
- Bougienage (push it through)
- if in stomach/lower GI, MC spontaneous passage (follow with X-rays)
- sharp, lodged, or dangerous objects should be removed endoscopically
