GI-Lecture part 5 Flashcards
What is IBS?
Dysregulated immune response of intestinal mucosa to microbes in genetically susceptible persons
- Crohn disease (CD)
- Ulcerative colitis (UC)
- Unclassified IBD (IBDU)
Crohn disease
- Any part of GI tract; terminal ileum/colon most common
- Esophageal disease in 20%; perianal disease common
- Inflammation usually transmural – fissures and fistulas occur
- “Skip” areas are unaffected areas of intestine
- Environmental exposure may trigger abnormal immune reaction in genetically susceptible individual
What condition has “Skip” areas are unaffected areas of intestine?
Chrons
What should be included in the history of Chron’s disease?
- Fever, weigh loss
- Delayed growth velocity, short stature, delayed bone age
- Arthralgias/arthritis in large joints
- Obstructive symptoms associated with meals
- Pain in umbilical region and RLQ
- Anorexia
- Malabsorption/lactose intolerance
- Diarrhea, pain with stooling
- Jaundice
- Oral aphthous ulcers
What should be included on physical exam of Chron’s Disease?
- Growth parameters
- Abdominal exam – RLQ tenderness, inflammation
- Perianal skin tags, deep anal fissures, perianal fistulas
- Clubbing of digits may be present
- Erythema nodosum common
Diagnostic studies – Chron Disease?
- Inflammatory markers
- Nutritional labs
- CBC, liver enzymes
- Stool O&P, culture, fecal alpha 1-antitrypsin, fecal calprotectin assay
- Bone age, bone density, abdominal films
- Ileocolonoscopy, esophagoscopy
Differential diagnosis- Chron Disease?
- RA, SLE, hypopituitarism, appendicitis, PUD, obstruction, lymphoma, anorexia, chronic granulomatous disease, sarcoidosis, growth failure
Management – Chron Disease?
- Control disease
- Prevent relapse
- Achieve normal nutrition, growth, lifestyle
- Pharmacologic, nutritional, surgical, psychosocial
- Refer to pediatric gastroenterologist for colonoscopy, endoscopy, diagnosis, consultation
- Corticosteroid management most common in U.S
Management – Crohn Disease (Cont.)
- Medications – prescribed by Pediatric GI
- Corticosteroids
- 5-Aminosalicylates
- Immunomodulator agents
- Biologic agents
- Antibiotics for acute infections
- Adjunctive therapy – growth hormone
- Hospitalization, TPN, surgery when severe
- Monitor growth, pubertal changes
- Ophthalmologic exam
- Nutritional counseling
- Encourage participation in social activities
What are the complications of Crohn Disease?
- Intestinal obstruction/scarring
- Growth failure
- Fistula/abscess
- Primary sclerosing cholangitis, pancreatitis, pericarditis, arthritis, peripheral neuropathy
- Increased risk of lymphoma/colon cancer
- Increased risk for opportunistic infections
Prevention and prognosis – Chron Disease
- Follow therapy to prevent sequelae
- Progressive; no cure, with remissions
- Child-onset disease more severe
Ulcerative Colitis?
- Chronic disease; diffuse inflammation of rectal/colonic mucosa
- Involves rectum in 95% of cases
- Multifactorial basis – heredity, diet, environment, immunologic, ineffective mucosal integrity
- Incidence increased in developing nations
History – Ulcerative colitis?
- Fever
- Anorexia / Weight loss
- Delayed growth/sexual maturation
- Diarrhea
- Lower abdominal cramping
- Pain increased before stooling/flatus
- Bright red blood/mucus in stool
- Nocturnal stooling
- Oral aphthous ulcers
- Skin lesions – erythema nodosum, pyoderma gangrenosum, diffuse papulonecrotic eruptions
Physical examination - Ulcerative Colitis
- Growth parameters
- Complete physical exam
- Abdominal rebound tenderness if severe
Diagnostic studies – Ulcerative colitis?
- CBC, iron-binding capacity, total protein, albumin, ESR, CRP
- Stool for WBC, blood, culture
- Bone age
- Colonoscopy
- Perinuclear neutrophil cytoplasmic antigen
- Fecal calprotectin assay
Differential diagnosis – Ulcerative Colitis?
- Shigella, Salmonella, Yersinia, Campylobacter, E. coli, C. difficile, IBS, self-limited colitis, Crohn disease
Management – Ulcerative Colitis?
- Control disease
- Prevent relapses
- Achieve normal nutrition, growth, lifestyle
- Refer for colonoscopy
Pharmacologic treatment options – individualized –
Ulcerative Colitis?
- Mild-moderate: topical mesalamine, oral 5-ASAs, or topical steroids
- Moderate-severe: systemic steroids
- Thiopurines -immunosuppressive drugs; fight inflammation
- Biologic agents
- Hydrocortisone rectal for tenesmus (cramping rectal pain)
- Cyclosporin monotherapy
- Probiotics as adjunctive therapy
- Curcumin to maintain inactive disease – Antioxidant/ anti-inflammatory
- Iron supplementation to correct anemia
Management – Ulcerative Colitis
- Nutrition
- High in protein/carbohydrate, normal fat, decreased roughage
- Lactose poorly tolerated
- Parenteral/enteral supplements
- Refer for nutritional therapy
- Monitor growth
- Surgery – complete proctocolectomy curative
- Ophthalmologic examination
- Psychosocial therapy
- Immunization status
Complications – Ulcerative colitis
- Growth failure, toxic megacolon, intestinal perforation, liver disease, sepsis, colon cancer
- Arthritis, uveitis, malnutrition, behavior problems
Causes of Failure to
Thrive
Endo/Metabolic
- Hypothyroidism
- Diabetes mellitus
- Adrenal insufficiency or excess
- Parathyroid disorders
- Pituitary disorders
- Growth hormone deficiency
- Inborn errors of metabolism
Prevention and prognosis – Ulcerative Colitis
- Follow therapy to optimize remission
- Prognosis good - mild disease/those responding well to initial therapy
Failure to Thrive
- Lack of weight gain proportional to age
- Disruptions in biologic, psychosocial, environmental factors contributing to growth and development
Three basic causes:
1. Inadequate caloric intake
2. Inadequate caloric absorption
3. Excessive caloric expenditure
* Onset between 2-4 months – usually congenital disorders
* Onset between 4-8 months – associated with feeding problems
Causes of Failure to
Thrive
Gastrointestinal
- GER
- Crohn disease
- Pyloric stenosis
- Cleft palate / lip
- Lactose intolerance
- Hirschsprung disease
- Hepatitis
- Cirrhosis
- Pancreatic insufficiency
- Biliary disease
- IBD
- Malabsorption
Pulmonary Failure to Thrive
- Asthma
- Bronchopulmonary dysplasia
- CF
- anatomic abnormalities of upper airway
- OSA
- Recurrent infected adenoids and tonsils
Neurologic failure to thrive?
- Mental retardation
- Cerebral hemorrhage
- Degenerative disorders
- Cerebral palsy
Cardiac failure to thrive?
Cardiac: Cardiac diseases leading to CHF
Failure to Thrive
Clinical findings and risk factors
- Poor weight gain associated with poor intake
- Vomiting, food refusal, food fixation, abnormal feeding practices, anticipatory gagging, irritability
- Chronic physical problems, psychosocial problems
- Distinguish non-organic from organic etiology
- Prenatal – maternal health, obstetric complications
- Perinatal – birth weight, congenital anomalies, neurologic insults, NB screening results, weight for gestational age
- Neonatal –intraventricular hemorrhage ( IVH), seizures, hypoxia, extreme hyperbilirubinemia, infection
- Postnatal health – illness, hospitalization, chronic health, stooling/voiding history,
ROS - Developmental trajectory/temperament
- Family/psychosocial history
Renal: failure to thrive?
- UTI
- Renal tubular acidosis
- Diabetes insipidus
- CKD
Failure to Thrive
Diagnostic studies
- Basic metabolic profile, vitamin D (calcidiol), lead, zinc, iron screening, albumin for protein status (severe FTT)
- CBC/ESR, BMP, serum electrolytes (include total CO2 to rule out renal tubular acidosis), UA and culture, sweat test, stool studies for fat, reducing substances, O&P, and culture
- Review of newborn metabolic screening tests
- Extremity radiographs if indicated (e.g., rickets)
- TSH, Chest radiograph, Renal ultrasound and voiding cystourethrography
- HIV screening, Karyotype (especially in small girls for Turner syndrome), Bone age, Developmental testing, Growth hormone (expensive, often done later in workup)
Causes of Failure to
Thrive
Infectious
* GI parasitic or bacterial infections
* TB
* HIV
Congenital - Many genetic abnormalities
Malignancy/immune
* Cancers of childhood
* Collagen-vascular disease
* JIRA
Nutritional - Lack of calories/micronutrients: Vit A, Zn, Fe
Causes of Failure to
Thrive
Hematologic - Sickle cell disease and others
Prenatal - Small for gestational age, perinatal infection
Psychosocial
* Depression
* Anorexia nervosa, bulimia
* Maternal depression
* Child abuse or neglect
* ADHD
* Autism
* Chronic pain
Environmental - toxins
Failure to Thrive
Physical examination
- Weight, height, BMI, head circumference
- Skinfold measurements
- Vital signs
- Hydration status
- Dysmorphic features
- Skin, hair, nails, mucous membranes
- Evidence of abuse/neglect
- Oral findings
- Respiratory, cardiovascular, abdominal, endocrine, neurologic exam
Failure to Thrive
Diagnostic studies
- Feeding assessment
- Developmental assessment
- Laboratory/imaging
- Failure to Thrive Evaluation
- Complete dietary history
- Complete psychosocial evaluation
Failure to Thrive
Management??
- Interdisciplinary team
- Manage treatable causes
- Restore nutritional intake
- Provide nutritional rehabilitation
- Parent education/support
- Treat underlying chronic condition
- Evaluate for weight gain every 1-3 weeks
- Hospitalize if needed
Failure to Thrive
Prognosis?
- Most achieve expected growth/development
- Severe effects on development and social/emotional health because of effects on brain in first 6 months
Acute-Chronic Diarrhea
- Altered intestinal mechanisms as result of:
- Nonabsorbable solutes in GI tract; fluids exceed transport capacity
- Invasion, inflammation, release of toxins by bacteria/viruses
- Mutations in ion transport proteins
- Altered anatomy of intestinal surface
- Change in intestinal motility
- Altered immune function
Acute Diarrhea
- Disruption of normal intestinal net absorption versus secretory mechanisms
- Excessive loss of fluids into intestinal lumen
- Dehydration, electrolyte imbalance, death may occur
- Viruses, viral enterotoxin (rotavirus)
- Bacteria, parasites, bacterial endotoxins, cytotoxins
- 20% of child deaths worldwide
Acute Diarrhea Organisms
- Nontyphoidal Salmonella, Shigella, Campylobacter, E. coli, rotavirus, norovirus, enteric adenovirus, Giardia, Cryptosporidium, Strongyloides cause most disease
- Dysentery – specific strains of Salmonella, Shigella
- Cryptosporidium, E. coli O157:H7, Giardia, Listeria, Salmonella, Shigella, V. cholerae must be reported to CDC
Acute Diarrhea
History
- Pattern of diarrhea: onset, volume, frequency
- Appearance of stool
- Associated symptoms: pain, fever, vomiting
- Number of wet diapers/voids in past 24 hours
- Diet/changes in diet
- Response to ORT
- Food allergies
Acute Diarrhea
History continued:
- Family members/friends with similar symptoms
- Day care, school, other exposure
- Travel history, picnics
- Recent weight/growth
- Medications
- Chemotherapy
- Surgeries
Acute Diarrhea
Physical examination?
- Complete physical examination
- Assess for dehydration
Diagnostic studies for diarrhea?
- Stool examination
- Stool pH, reducing substances
- Stool cultures for bloody/prolonged diarrhea
- Electrolytes if indicated
- CBC for serious disease
Acute Diarrhea
Differential diagnosis
- Gastroenteritis, antibiotic use most common
- Systemic infection in infants/children
- Food poisoning in older children/adolescents
- Primary disaccharidase deficiency, Hirschsprung toxic colitis, adrenogenital syndrome, neonate opiate withdrawal, toxins
Acute Diarrhea
Management
- Maintain nutrition
- Prescribe antibiotics prudently
- Treat related conditions
- Antidiarrheals – not recommended generally
- Probiotics – treat acute diarrhea and ameliorate the risk of antibiotic-associated diarrhea
- Oral enteric peppermint oil may cause smooth muscle relaxation
Acute Diarrhea Complications?
dehydration, electrolyte imbalance, chronic diarrhea, etc
Prevention of Diarrhea?
- Good handwashing
- Good sanitation/removal of soiled clothing and diapers
- Avoid contaminated sources
- Exclusive breastfeeding first 6 months
- Vitamin A/zinc (used in developing nations)
- Avoid unnecessary antibiotic usage
- Rotavirus vaccine
Chronic Diarrhea?
- Loose stools of >10 mL/kg/day in infants; >200 g/day in older children
- Result of intraluminal/mucosal factors affecting cellular mechanisms of GI tract
What is the history for chronic diarrhea?
- > 3 watery stools/day > 2 weeks
- “Toddler’s diarrhea” – 10/day
- Dietary history
- Stool consistency, blood, mucus, food particles
- Stool incontinence
- Exposure to illness
- Teething
- Prior treatments for diarrhea
- Recent travel
What are the red flags for chronic diarrhea?
hematochezia/melena, persistent fever, weight loss, anemia
What is the physical exam for chronic diarrhea?
- Hydration status
- Weight/height/growth retardation
- Skin and hair
- Vital signs
- Thyroid enlargement
- Respiratory symptoms
- Clubbing of fingers
- Abdominal examination/rectal examination
Chronic Diarrhea Diagnostic Evaluation?
- Stool – culture, O&P, pH, reducing substances, occult blood, leukocytes, fat/fecal elastase
- CBC, electrolytes, albumin
- UA, culture
- ESR, CRP
- Hormonal studies if secretory tumors suspected
- Breath hydrogen test for lactose intolerance
- Viral serologies
- Sweat chloride test
- Endoscopy, barium studies
Chronic Diarrhea
Management
- Treat underlying cause
- Toddler’s diarrhea: normalize diet, remove offending
fluids/foods, eliminate sorbitol, fructose, reduce fluid intake to
<90 mL/kg/day - Treat carbohydrate malabsorption
- Predigested formula for infants with post-gastroenteritis malabsorption syndrome
- Refer: newborns with diarrhea in first hours of life; patients with growth delay or failure abnormal physical findings, or those with severe illness
What are the complications of chronic diarrhea?
- Malnutrition, growth failure
