GI Lecture Flashcards
What is included in a history for GI disorders?
- fam h/o GI disorders (celiac disease, gallbladder, ulcers, H. Pylori
- past medical history of GI tract (illness surgery, celiac, IBS, cleft lip palate, esophageal problems.
- feeding habits
- appetite/thrist
- pain OLDCARTs
- bowel habits- constipation vs. diarrhea
- food intolerance/allergy
- nausea, vomitting, belching flatulance, heartburn
- apnea, asthma, odorous breath
Pain characteristics for GI can be?
-Pain characteristics (OLD CARTS)
- Epigastric
- Periumbilical
- Colonic,
- Suprapubic
Referred (shoulder, back, neck, groin)
Acute, Secondary ANS stimulation can cause s/s N/V, diaphoresis, pallor, anxiety
GI history good to?
Develop a rapport between parent & child
assess general appearance sick vs not sick appearing
What is included for a physical Exam for GI assessment?
Head to toe examination Height/Weight/BMI on growth charts General appearance
HEENT, Neck CV/Resp
Abdominal:
Inspect for visible peristalsis, rash/lesions, asymmetry, masses, pulsations
Auscultate BSs, abdominal bruits Percuss for masses, HSM
Palpate lightly then deeply for masses, HSM, CVA tenderness, rebound tenderness/Rosving’s sign, guarding, obturator/psoas signs Rectal exam when indicated
Gynecological exam when indicated (usually referred)
Skin: inspect hydration status
Have the child jump on one foot
DX Testing for GI?
Performed as indicated: Urinalysis
CBC w/ diff
CMP (includes LFTs), lipid profile, ESR, CRP, TSH, Free T4, H.Pylori IgG/IgM, EBV Panel Food intolerance/allergy testing
Stool Studies (O&P, WBC, culture, cryptosporidium, giardia, rotavirus, c. diff) Fecal fat collection
Pregnancy test Urine PCR for STIs
DX for GI radiology?
Radiological evaluation: Abdominal X-ray (KUB) Upper/Lower GI series Air contrast enema Bone Age
CXR
Ultrasound HIDA scan CT scan MRI
Think about things that can be
done in the office such as UA, blood glucose, CBC
DX testing for GI
For GI DX testing?
Special testing: barium swallow, pH probe, endoscopy, breath hydrogen test, sweat chloride test
What can be done to manage GI disorders?
Antibiotics Antifungals
Anthelmintics Antiemetics
Antidiarrheals (rarely used)
Stool softeners/laxatives
Antispasmodics
Corticosteroids
Reduction of pain Reduction of acidity Probiotics/Prebiotics Diet changes
Anti-reflux measures
What are some GI disorders?
- Dysphagia
- Vomiting/Dehydration
- Cyclic Vomiting Syndrome
- GERD
- PUD
- Colic
- Appendicitis
- Intussusception
- Abdominal Pain/Migraine
- IBS/Cohn’s/Ulcerative colitis
What are some types of malabsorption syndromes?
- Malabsorption syndrome (Celiac disease, Lactose intolerance, Cow’s milk protein intolerance/allergy)
- Polyps
- Anal Fissure
- Failure to Thrive (FTT)
- Acute/Chronic Diarrhea
- Parasite infection
- H. Pylori infection
- Constipation (w/ or w/o encopresis)
What is the most common cause of abdominal pain in children?
(Know!)
- Abd pain of unknown cause
- Gastroenteritis
- Appendicitis
- Constipation
- UTI
- Viral infection
- Strep Pharyngitis
- Sinusitis/Pharyngitis
- Pneumonia
What is the most common GI complaint?
Constipation
- Second most commonly referred condition in pediatric gastroenterology ?
Constipation
What is the rest common pediatric gastroenterology complaint?
generalized abd pain
What is constipation?
- Decreased frequency of bowel movements or difficulty having a bowel movement for more than two weeks with associated distress the child.
Difficult to define by actual frequency of BMs alone because of factors such as?
passage of stool, consistency of stool, and volume of stool
What is some history info for constipation?
- Age/Circumstance of onset
- Meconium passage
- Bowel pattern
- Pain/bleeding with defecation
- Withholding behaviors
- Soiling
- Abdominal pain
- Diet
- Weight loss
- Vomiting
- Medications
- Toilet training history
- Neurological problems
- Urinary problems
Know the Bristol stool chart!
What should the physical exam be like to assess for constipation?
- General Exam: growth and development
- Neurological Assessment: tone, strength, DTR’s
- Abdominal Exam: palpable stool, percussion
- Perianal Exam: anal position, fissures, skin tags, hemorrhoids, anal wink, rash
- Digital Rectal Exam: tone, size of rectum, fecal mass, stool occult
- Spine: sacral dimple, tuft
What are some red flags of constipation?
- Anal stenosis
- Blood mixed in stool/bloody diarrhea
- Failure to thrive
- Tight empty rectum
- Sacral dimple
- Atypical perianal exam
- Prolapse of rectum
When is functional constipation most commonly seen?
between 6 months and 4 years of age
Functional constipation?
- > 2 weeks of < 2 bowel movement s per week with hard, large or small stools in the absence of:
structural, endocrine, or metabolic abnormalities.
Functional constipation?
- Normal meconium passage
- Onset during transition periods
- No overtly distended abdomen
- Normal growth
- Overflow soiling
- Improved with medical therapy
Encopresis
Encopresis
What is the treatment for encopresis?
- Diet: fiber and water!
- Fiber
- Whole grains, fruits, and vegetables
- Rule of Thumb: age in years + 5 = goal of number of grams of fiber needed each day.
- Water/fluid intake
- About 2 oz per gram of fiber
- Liquids add fluid to the colon and bulk to stools, making bowel movements softer and easier to pass
Rule of Thumb: age in years + 5 = goal of number of grams of fiber needed each day.
treatment for encopresis
Encopresis treatment?
- Clean out (2-3 days)
- Maintenance medication (6 months-2 years)
- Sitting on toilet regularly – reward system
- Diet
- Keys to success: adequate clean-out, consistent use of medications, regularly scheduled toileting and improved diet.
Encopresis
Treatment continued (Medications)?
- Stool softeners:
- Miralax
- Lactulose
- Milk of magnesia
- Colace
- Stimulant Laxatives:
- Senna syrup, tablets
- Ex lax
- Dulcolax
- Enemas:
- Milk and Molasses
- Saline
- Soap suds
Hypertrophied Pyloric
Stenosis
What is it?
Caused from hypertrophy of the pylorus
muscle
- The lumen becomes obstructed by mucosa, resulting in a blockage of the lumen that extends from the stomach to the duodenum
Hypertrophied Pyloric Stenosis
- Unknown cause, associated with a failure of nitric oxide synthetase and decrease nitric oxide and an inability of the smooth muscle of the pylorus to relax
Hypertrophied Pyloric Stenosis
Leads to several metabolic abnormalities, including metabolic alkalosis, hypochloremia and hypokalemia
Hypertrophied Pyloric Stenosis
Hypertrophied Pyloric
Stenosis?
- Occurs between1.4 and 4 per 10000 live births
- More common in males than females
- Possible genetic predisposition
- Typical case is a first born male presenting with recurrent vomiting between 3-5 weeks of age
- Infant between 2-8 weeks
- Presents with nonbilious projectile vomiting
- Infant remains hungry after feedings
- Generally not febrile or ill appearing unless the onset of dehydration produces lethargy
What is this clinical condition? (Know)
Hypertrophied Pyloric
Stenosis
Hypertrophied Pyloric
Stenosis
- Physical Examination?
- Peristaltic wave in the RUQ
- Pylorus palpable as a small, hard mass or “olive”
- Weight loss and possible dehydration
- Characteristic facies with furrowed brow, wrinkled appearance and prominent sucking pattern
Hypertrophied Pyloric
Stenosis
- Diagnosis?
- Abdominal ultrasound has become the gold standard for diagnosis
- Upper GI barium study can also be useful
Treatment for Hypertrophied pyloric stenosis?
- Treatment is correction of metabolic alkalosis and dehydration and then surgical correction
Upper Gastrointestinal Disorder?
Dysphagia?
- Difficulty or discomfort in swallowing
Symptoms of Dysphagia may be?
be oral, pharyngeal or esophageal
- Structural Defects:? for dysphagia?
- Esophageal narrowing
- Extrinsic obstruction
What are some nonstructural causes of dysphagia?
- Motility disorders of oropharynx/esophagus
- Prematurity/neurologic impairment from CP or other disorders
- Mucosal injury – GERD, eosinophilic, esophagitis
What history should you do for dysphagia?
- Progressive dysfunction
- Persistent drooling/cough
- Pain
- Picky or food refusal
- Heartburn
- Halitosis
- Weight loss
- Regurgitation
What physical exam should you do for dysphagia?
- Observe feeding
- PE may appear normal
- Diagnostic Studies
- Lateral neck films
- Barium swallow
- Fiberoptic endoscopy/videofluroscopy
- Manometry – measure of esophageal tone
- MRI
- Electromyography – evaluates sphincter tone
- Electromyography
evaluates sphincter tone
- Manometry
- Manometry – measure of esophageal tone
In dysphagia the physical exam may appear?
normal
What are some differential dx for dysphagia?
- Obstructive/compressive lesions – difficulty with solids
- Physiologic dysfunction – systemic disorder
- Psychological – dysfunctional feeding relationship
- Management
- Multidisciplinary Approach
- Depends on source of disorder:
- Physical
- Cognitive
- Developmental
- Behavioral
