GI/GU Flashcards by Natalie Kuhn

Bilious is a surgical emergency and warrants what?

An UGI w/ contrast immediately

Worried about Volvulus/acute malrotation

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Bradley is a newborn w/ Trisomy 21. He has not passed meconium and it’s been 24 hours since birth. He has no stool in his rectal vault and her abdomen is distended. He has a palpable fecal mass in her LL abdominal quadrant. What diagnostic test would you order?

Suction rectal biopsy

Worried about Hirschprung disease.

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Treatment for Hirschprung’s prior to surgery….

Decompress abdomen w/ NGT

Rectal irrigations

Surgery: Bowel resection

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What is a lethal side effect of Hirschprung Disease?

Enterocolitis

Fever, abdominal pain, diarrhea

ENTEROCOLITIS UNTIL PROVEN OTHERWISE

Most occur within 2 years of surgery.

T21 more at risk

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Susie is an 8 month old female. Mother brings her into your ED. You palpate a sausage-shaped mass in RUQ. Mother states that she’s been having currant jelly stools and has been intermittently colicky, bringing her knees to her chest. What is your next step?

Barium or Air Contrast enema

NO X-RAY, NO ULTRASOUND

Risk of re-intussussception highest in 1st 24 hours

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Henry is a 4 week old male who p/w nonbilious projectile vomiting. He is hungry after feeds and you palpate a 2cm olive-shaped mass in the mid epigastric area. You also notice +gastric peristaltic waves. What electrolyte imbalance are you most concerned about and how would you treat it?

Hypochloremic metabolic alkalosis

pH=7.5, CO2=35, BiCarb=10, Cl=80

Correct alkalosis w/ NSS bolus (20ml/kg) and start on 1.5 maintenance IVF with NaCL and add K when they pee

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If we suspect pyloric stenosis, what would we find on US?

The pylorus is >4mms

Common in 1st born males

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Mcburney point tenderness

RLQ pain with rebound tenderness (appendicitis)

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Obturator sign

Pain on flexion and internal rotation of right hip, patient is lying on their back (appendicitis)

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Psoas sign

Pain on extension of right hip, patient is lying on left side (appendicitis)

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Rovig’s sign

Pain in RLQ when you palpate the left. (appendicitis)

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Jenny is 13 years old and comes in with nausea, back pain and anorexia. She has a positive Psoas sign. What imaging would you order?

Abdominal CT is choice imaging (but US is often effective)

Not ruptured: Urgent surgery

Infection prevention if ruptured – broad spectrum abx – ceftriaxone, Flagyl, Zosyn

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What is the electrolyte disturbance we would expect in a patient w/ toxic megacolon?

Hypokalemia
Hypoalbuminemia
Leukocytosis

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What is toxic megacolon?

Children/adolescents w/ IBD, associated w/ infection, antidiarrheal agents, electrolyte disturbances. Marked dilation of the colon.

X-ray, CBC

Tx: Abx, fluid and electrolyte management

Surgery: Colectomy

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Catherine comes in w/ acute abdominal pain. She is hemodynamically unstable and acidotic. Abdominal x-ray reveals air in the abdominal cavity. Abdomen is rigid and tender on exam. She just spiked a fever. What do you think?

Bowel perforation.

MEDICAL EMERGENCY

Treatment: Bleeding, infection, abscess, broad spectrum abx, fluid/metabolic stabilization.

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Richard (Dick) is a 2 year old male. Mom says he is complaining of painless rectal bleeding. What test would you order?

Meckles scan

Treatment: Resection. Surgical reanastamosis

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You have a patient who you suspect has IBD, how do you diagnose?

Endoscopy

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Management for IBD

Salicylates, abx, steroids, hospital admission for severe exacerbation, bowel rest w/ IV nutrition/diagnostic procedures.

Flagyl/Cipro

Crohn Disease??

Involves any segment of GI tract, mouth to anus, malabsorption of Fe, Zn, Folate, Vit B12

Clinical findings: abd pain, diarrhea, rectal bleeding, fissures/tags, fisgulas, anorexia, weight loss

Ulcerative Colitis

nocolonstillrollin

Limited to the colon. Starts in rectum and ascends continuously

Findings: *****bloody mucoid diarrhea, urgency to defecate

Pancreatitis presentation

Sharp epigastric pain. Radiates to left side and back. +Nausea and vomiting.

Normal Amylase

28-85

Rises early, lasts 3-5 days

Normal Lipase

0-160

More sensitive

Diagnostic w/u for pancreatitis

Amylase levels rise early and last 3-5 days, lipase is more specific and elevated longer.
Increase in CRP (0-1 normal)- highest at 48 hours
Abdominal X-ray
CXR to r/o pleural effusion
Abd US (repeat Q3-4 days)

Management for pancreatitis

``` NG decompression IVF pain control (Dilaudid PCA, Morphine) IV nutrition Low fat diet (no cheese steaks)/NPO ```

What do we need to diagnose a UTI??

UA and culture Culture must be from catheterized specimen, at least 50,000 CFUs/mL UA will show +nitrates, white count >5, pyuria, leukoesterase (elevated WBC's)

Do we prophylactically treat a child after their first febrile UTI?

No Unless they have VUR or an anomoly

When is a VCUG indicated?

Not recommended after 1st UTI If US is abnormal we can get a VCUG VCUG performed if there is recurrent febrile UTI

Normal specific gravity of urine

1.003 (dilute) to 1.030 (concentrated, dehydrated)

Adam is a 6 year old male who complains of unilateral, acute scrotal pain. He has an absent crymesteric reflex. You know you must emergently consult what service?

SURGERY. Ochiopexy -- pin the opposite teste down so it doesn't twist.

What is Renal Tubular Acidosis

Defect in renal tubules Resulting in a METABOLIC ACIDOSIS with a NORMAL anion gap *Renal tubular acidosis (RTA) is a disease that occurs when the kidneys fail to excrete acids into the urine, which causes a person's blood to remain too acidic. Without proper treatment, chronic acidity of the blood leads to growth retardation, kidney stones, bone disease, chronic kidney disease, and possibly total kidney failure.

What is MUDPILES??

``` M-methanol U-Uremia (a raised level in the blood of urea and other nitrogenous waste compounds that are normally eliminated by the kidneys.) D- DKA P- Paraldeyhde I-Iron/Isonizde L-Lactic acidosis (volvulus) E-Ethylene glycol S-Salicylates (ASA) ``` Cause of metabolic acidosis with a HIGH anion gap (>12)

Causes of Metabolic acidosis w/ normal anion gap

``` Renal Tubular Acidosis Diarrhea GI fistula Post hyperventilation Post anion-gap acidosis ```

Causes of pre-renal failure

Most common form Decreased blood flow to the kidney through acute disease causing hypovolemia and some medications such as ACE inhibitors ``` Shock GI problems Diabetes Ketoacidosis Hypoproteinuria Hemorrhage Dehydration Volume depletion Poor perfusion ```

Renally toxic meds

intrinsic renal failure ``` Aminoglycosides (gent) Zantac NSAIDS Dyes Myoglobin ```

Pre Renal Failure LABS

``` decreased u.o. (oliguria) Normal sediment Sp.gr. > 1.020 *** (concentrated) Urine Na 15:1 FeNa(%) ```

Intrinsic Renal Failure (ATN) Labs

``` decreased/normal u.o. RBC casts, cellular debris Sp.gr. 30mEq/L Cr ratio(u:p) 2 Cr elevated and increasing BUN elevated and increasing ```

Indications for Dialysis

``` Acidosis High K Low Ca Azotemia (elevation in BUN >20) Confusion Bradycardia Tamponade ```

What is the treatment for nephrotic syndrome

*********Corticosteroids**************** No salt added Fluid restriction Suppression with cyclosproin

Nephrotic syndrome pearls

Etiology unknown Thought to be immune mediated Boys (2:1) ages 2-6 May follow recent URI Symptoms: Periorbital edema, pitting of lower extremities, weight gain, acities, pleural effusions ``` Diagnosis: UA w/ +3/+4 protein ****** Microscopic hematuria Normal or reduced renal fx Normal C3**** Protein excretion of >2g in 24hrs Elevated cholesterol and triglycerides Low albumin Low Ca ```

Post Strep Glomerulonephritis (PEARLS)

Follows Group A strep Low C3 Hematuria UA w/ RBCs and red casts Treatment: diuretics (high dose lasix), anti HTN, penicillin x10 days, manage electrolytes

HUS PEARLS

Hemolytic anemia RBC's break down, clog the kidney Low RBC, low platelet Caused by e.coli and shigella BLOODY DIARRHEA ***!!!!!!!!! Supportive care, replace RBCs, replace platelets, IVF Tears up the kidney, rips it up (good outcome though w/ supportive care)

ATN (phases)

Oliguric (don't pee) Diuretic (dumb kidney, pee alot) Recovery (months to years)

The metabolic acidosis that results from RTA may be caused either by failure to recover sufficient (alkaline) bicarbonate ions from the filtrate in the early portion of the nephron (proximal tubule) or by insufficient secretion of (acid) hydrogen ions into the latter portions of the nephron (distal tubule).

pearl You dont reabsorb Bicarb OR You dont excrete H ions ( acid)