GI/nutritional system Flashcards
a 14-year-old boy with nausea, vomiting, constipation, and periumbilical pain that has settled in the lower right quadrant. The patient’s mom gave him a piece of toast and some water about 5 hours ago but he vomited 30 minutes after eating. On physical exam, he has tenderness and guarding in the lower right quadrant, pain upon flexion and internal rotation of right lower extremity, RLQ pain with right hip extension, and RLQ pain with palpation of the LLQ. Blood tests reveal leukocytosis with a shift to the left.
What is the most likely diagnoses?
Appendicitis
When someone is having appendicitis, will they have an appetite? will they be nauseas?
They will not have an appetite and most likely be nauseas with a low grade fever or vomiting
What is the rovsing sign?
RLQ pain with palpation of LLQ
What is obturator sign?
RLQ pain with internal rotation of the hip
What is psoas sign?
RLQ pain with hip extension
What type of imaging would you get of appendicitis if clinical dx is difficult?
ultrasound or abdominal CT
What on a CBC would support the Dx of appendicitis?
neutrophilia
a 23 day old newborn that is brought to the emergency department with a chief complaint of extreme fussiness. His parents think he has abdominal pain as he is “gassy” and pulls his legs up as if he is trying to stool. He passes a lot of gas from his rectum and his parents can hear his stomach gurgling a lot. Tonight’s episode has lasted for 4 hours with intractable crying, and his parents are very distraught. They have tried feeding, a pacifier, rocking, burping, changing the diaper, and inserting a rectal suppository but nothing has relieved the crying. He is currently feeding a standard cow’s milk formula with iron without vomiting or diarrhea. Further questioning reveals this is the fourth day in a row that this has happened on a daily basis, usually in the evening, but the baby usually cries for about 2 to 3 hours.
This child would be diagnosed with what?
Colic
What is the rule of 3’s for colic?
Cry 3hr/day, 3day/wk, for 3 weeks
When does colic in a child peak? when does it usually resolve?
peaks around 2-3 months of age, usually resolves around 4 months
What description would make you think of colic?
unexplained paroxysms of irritability, fussing, crying that my develop into agonized screaming, infant may also draw up knees to abdomen
Tx for colic?
Do not shake the baby
a 5-year-old boy with no significant medical history. His mother explains to you that since starting kindergarten earlier in the year, he has been having progressively worse periodic abdominal pain. When he has this pain he is cranky, refuses to eat, and has even vomited on a few occasions. She also explains that since starting school he has been having regular soiling accidents despite successfully potty training over a year ago.
What is the likely Dx
Constipation
What is encopresis?
poop in the rectum, loose stool leaks
What classifies as constipation?
<2 bowel movements per week
>episode of encopresis
What are some of the Rome III diagnostic criteria for functional constipation in a child with a developmental age less than 4?
- two or fewer bowl movements a week
- at least one episode of incontinence per week after toileting skills
- history of excessive stool retention
- history of painful or hard bowel movements
- presence of large fecal mass in rectum
- history of large diameter stools that may obstruct toilet
Will need at least 2 of these
how bout the rome III criteria for child with developmental age greater than 4
- two or fewer bowl movements a week
- at least one episode of incontinence per week
- history of retentive posturing or excessive voluntary stool retention
- history of painful or hard bowel movements
- presence of large fecal mass in rectum
- history of large diameter stools that may obstruct toilet
What is the imaging of choice to Dx constipation?
abdominal x-ray
What is the treatment of constipation in children?
- increase fiber to 11-24g/day
- Mineral oil 15 to 30ml per year of age per day
- miralax 1.5g per kg per day
- lactulose 1ml per kg per day once or twice a day
a previously healthy 11-year-old boy presents to the emergency department with a 3-day history of nausea, anorexia, weakness, abdominal pain, and an episode of vomiting. He has no history of fever, diarrhea, constipation, respiratory or urinary symptoms, or use of laxatives or diuretics. Physical examination reveals a thinly built boy with signs of sunken eyes, slightly dry mucous membranes, and generalized skin hyperpigmentation. He is afebrile, with a capillary refill time of less than 2 seconds, blood pressure of 94/68 mm Hg, and a heart rate of 116 beats/min. His weight is 32 kg (70.5 lb) (weight loss of 6% in the previous 3 days).
This child is suffering from what?
Dehydration
What percent of weight loss is mild dehydration? moderate? severe?
3-5% for mild
6-9% for moderate
>10% for severe
What are the most accurate signs of moderate to severe dehydration in children?
prolonged capillary refill
poor skin turgor
abnormal breathing
a 2-day-old preterm (33 weeks), weighing 1.3 kg neonate with upper abdominal fullness. A nasogastric tube drains bilious aspirate. The external genitalia and anal opening are normal. Further evaluation by X-ray flat plate abdomen shows a “double-bubble appearance” with total absence of distal bowel gas
what is the Dx?
duodenal atresia
What is duodenal atresia?
this is a congenital absence or complete closure of a portion of the lumen of the duodenum
What causes duodenal atresia?
caused by increased levels of amniotic fluid during pregnancy and intestinal obstruction in newborn babies
what could be a sign of duodenal atresia?
early biliary vomiting
What other condition is duodenal atresia commonly associated with?
Down syndrome
What will you see on X-ray with duodenal atresia?
double bubble
What will you see with malrotation
Corkscrew appearance
What are the Txs for duodenal atresia?
- suction/drain secretions, respiratory
- elevate head, iv glucose and fluid, abx
Definitive is surgery
a 6-year-old boy whose mom reports “my son keeps having accidents in his underwear. He’s 6 years old. Shouldn’t he be old enough to know better by now?”
What is the likely cause?
Encopresis
Describe encopresis?
he repetitive, voluntary or involuntary, passage of stool in inappropriate places by children four years of age and older
How would you Dx encopresis?
rectal exam or imaging of choice is KUB
Tx for acute encopresis?
Peg/Miralax
Glycerin suppository for infants up to 3d
Tx for chronic encopresis?
Elimination of all cows milk 1-2 wk trial
Maintenance laxatives for 6 mo-1 yr
High fiber diet and increase fluids
Toilet sitting: same time 5-10 min after meals
a 5-year-old boy is brought into the emergency department after he was found at home by his father possibly drinking bleach stored in the laundry room. The child consumed an unknown amount and appears generally well. The child has an unremarkable past medical history and is not currently taking any medications. Physical exam reveals a normal cardiopulmonary and abdominal exam. The neurological exam is within normal limits and the patient is cooperative and frightened. The parents state that the ingestion happened less than 30 minutes ago
What is the likely Dx?
foreign body
What is indicated for all patients with a suspected foreign body?
Bronchoscopy
If a foreign body is thought to be in the esophagus based on imaging/clinical presentation what is your plan of action?
- observe for 24 hours with serial radiographs
- remove endoscopically if the object dose not pass through ass within 24 hours
If the object causes symptoms or time-point of ingestion is unknown then immediate endoscopic removal
If the object is distal to esophagus what is your plan?
- if symptomatic remove immediately
- small blunt object then follow with serial radiographs, remove endoscopically if does not advance past pylorus in 3-4 weeks
- Large object >3cm beyond pylorus then monitor with serial imaging in the stomach then remove endoscopically
a 4-year-old boy is brought to the urgent care for 48 hours of watery diarrhea. He had been attending daycare 3 times a week, and several other kids have also experienced similar symptoms. He has had 4-5 bowel movements per day and has had a decreased appetite. His parents have been encouraging him to drink electrolyte solution. On physical exam, he is noted to have sunken eyes, poor skin turgor, and increased capillary refill time
What is the diagnoses?
Gastroenteritis
What is another name for gastroenteritis?
infectious diarrhea, it involves the stomach and small bowel
If someone is experiencing bloody stool, is the cause more likely to be viral or bacterial?
bacterial
What kind of virus in children is the most common cause of gastroenteritis?
Rotavirus
How would you diagnose gastroenteritis?
this is typically done based on persons signs and symptoms. Dont really need to know the cause as most are self limiting within 2 weeks
When should stool cultures for gastroenteritis be considered?
for pts with blood in the stool, possible food poisoning exposure and those who have traveled to developing world
Also children younger than 5, old people and those with poor immune function
What labs should be check in pts with gastroenteritis?
Should check on electrolytes and kidney function with CMP
And a UA for dehydration concern
Can also do CBC for bloody diarrhea and stool culture
For a pedi with low BP, sunken fontanelle and dry mucus membranes what do you want to know about them.
Want to know if they are crying or peeing.
What kind of arthritis can occur in pt who have had infection with campylobacter?
Reactive arthritis
What is the Tx for gastroenteritis?
primarily replenishing fluids. For mild or moderate it can be done via oral fluids with like salts and sugars added
Are antibiotics recommended for children with fever and bloody diarrhea?
yep, can choose from Doxy Cipro Azithro Bactrim
3-month-old who presents with his mother for a WCC. The patient consumes 4 ounces of cow’s milk formula every three hours. He stools once per day, and urinates up to five to six times per day. His mother reports that he regurgitates a moderate amount of formula through his nose and mouth after most feeds. He does not seem interested in additional feeding after these episodes, and he has become progressively more irritable around meal times. The patient is starting to refuse some feeds. The patient’s weight was in the 75th percentile for weight throughout the first month of life. Four weeks ago, he was in the 62nd percentile, and he is now in the 48th percentile. His height and head circumference have followed similar trends.
What is the Dx?
GERD
Complications of GERD include what?
ailure to thrive, aspiration pneumonia, esophagitis, choking or apneic episodes, hematemesis, anemia, and fussiness
What is one of the most common causes of GERD in children?
overfeeding
If emesis is independent of meals, is it likely to be GERD?
no
If severe reflux or projectile emesis is present what kind of studies should be considered?
abdominal US and barium swallow
Is a CBC in gerd usually normal?
yes
What might a CMP in a pt with GERD show?
hypochloremic, hypokalemic metabolic alkalosis
a 3-month-old girl with jaundice and clay-colored stools x 15 days. She was born full-term, and there were no antenatal or postnatal complications. Her milestones were normal for age. On examination, weight is 4.3 kg (<3rd percentile), length is 54 cm (<3rd percentile), and head circumference is 39.5 cm (1oth percentile). You note icterus and hepatosplenomegaly.
What is the likely Dx?
hepatitis
What can some of the symptoms of neonatal hepatitis be?
may range from transient jaundice and acholic stools to liver failure, cirrhosis, and portal hypertension
What are the presenting features of neonatal hepatitis that occur during the first week of life?
Presenting features in the first week of life include jaundice and hepatomegaly in 50% of patients
Is neonatal hepatits generally self limiting?
Yeah, 70% will have full recovery during infancy
How do you Dx neonatal hepatitis?
Based on clinical presentation, results of liver biopsy, and exclusion of other causes of cholestasis
What fat soluble vitamins should be checked and possibly added to diet in neonatal hepatitis?
vitamins A, D, E and K
TPN may be needed if growth is still problematic
What kind of acid can be used to enhance bile flow and to reduce bile viscosity?
Ursodeoxycholic acid
What is the majority of viral hepatitis in children?
hepatitis A and B
The presence of what antibody confirms Hep A?
anti-HAV IgM
How soon can HCV RNA be detected in someone who is infected?
within 1 week
HBsAg if positive indicates what?
for active disease. It is the antigen used in the hepatitis B vaccine.
HBsAB is what?
is protective and can result from vaccination or natural infection.
HBcAb results from what?
results from natural infection (not vaccination) and persists lifelong.
HBeAg rises….
very early in active infection and is therefore useful in diagnosing acute infection.
when does HBeAb rise? late or early too?
late in infection
what can HBV PCR be used for?
may be used for both diagnosis and assessing the response to therapy
a 2-week-old boy with constipation. His mother reports that he has not had a bowel movement for over 5 days and is quite concerned. On further examination, you discover that the boy is in the 5th percentile for weight. Physical examination shows a distended abdomen. Rectal examination shows an absence of stool in the rectal vault. A contrast enema reveals dilated loops of bowel and megacolon.
What is the likely Dx?
Hirschsprung disease
what causes Hirschsprung disease, or congenital aganglionic bowel disease
caused by a lack of caudal migration of the ganglion cells from the neural crest. It produces contraction of a distal segment of colon, causing obstruction with proximal dilatation.
What are the first signs of hirschsprung disease
baby’s inability to pass meconium, 48 hours postpartum
Other clinical features include constipation, vomiting, and abdominal distension
How is Dx of hirschsprung disease made?
rectal suction biopsy, revealing the absence or paucity of ganglion cells
Can also do barium assisted radiography or digital rectal exam
Tx for hirschsprung disease?
resection of the affected segment or colostomy
a 25-day old boy presenting for his well-child checkup. He was born at 39+6 to a 28- year-old mom who had been followed by this clinic for her prenatal care. Prenatal history was unremarkable. During his first few weeks of life, he has been exclusively breastfed and is now well above his birth weight. Mom has no major concerns and appears to be doing well but did notice a bulge in her son’s right inguinal area when changing his diaper yesterday. Your exam was unremarkable except for a notable bulge in the patient’s right scrotum and inguinal area.
What is the likely Dx?
inguinal hernia
an indirect inguinal hernia passes through where?
Passage of intestine through the internal inguinal ring down the inguinal canal, may pass into the scrotum. Often congenital and will present before age one
Remember: Indirect goes through the Internal Inguinal Ring (an “I” for an “I”)
a direct inguinal hernia passes through?
Passage of intestine through the external inguinal ring at Hesselbach triangle, rarely enters the scrotum
What kind of imaging may be helpful for inguinal hernias?
ultrasound
Tx for inguinal hernias?
referral for elective repair
Optimal timing is debatable: a waiting time less than 14 days is advisable for asymptomatic inguinal hernias in this pediatric age group
An emergent referral is necessary if evidence of bowel incarceration is noted (erythema of overlying skin, pain, and tenderness)
a young mother who brings her 12-month-old daughter to your office reporting that she has had recurrent “belly aches” for the past two weeks. The child experiences sudden, colicky abdominal pain that recurs every 15 to 20 min, often with vomiting. These episodes are interspersed with periods of no complaints. The mother also reports that she has seen her squatting with her knees to her chest, which seems to relieve her of her symptoms. She describes her stool as bloody with mucus, almost as though it were a currant jelly. On physical examination, you note abdominal distention and tenderness along with a sausage-shaped abdominal mass in the RUQ.
What is the likely Dx?
intussusception
What is the Tx for intussusception?
barium enema
what shape is felt with intussusception?
sausage shaped mass
what signs will you see on xray with intussusception?
will reveal a “Crescent sign” or a “Bull’s eye/target sign/coiled spring lesion” representing layers of the intestine within the abdomen
can intussusception affect children after a viral infection?
yes
a 3-day old baby boy is brought by his mother for his first postnatal visit. He was born via vaginal delivery at 39.2 weeks with Apgar scores of 7 and 9 at 1 and 5 minutes, respectively. The mother’s pregnancy was uncomplicated. He stayed in the well-baby nursery for two nights and was discharged without incident. On physical exam, the neonate appears lethargic with a soft, open fontanelle and soft abdomen. His skin is notable for a yellowish tinge. Mom is exclusively feeding him breastmilk for 5-10 minutes every 4 hours. At birth his weight was 7lbs 6oz and his current weight is down to 6lbs 8oz.
What is likely Dx?
Jaundice
At what total bilirubin level does neonatal jaundice appear?
above 2 mg/dl
when is neonatal jaundice considered physiologic?
If there’s isolated unconjugated hyperbilirubinemia appearing 24 hours after birth in an infant with no symptoms or signs of a serious illness.
total bilirubin rises slower than 0.2 mg/dL per hour or 5 mg/dl per day, remains lower than 18/mg/dl, and resolves within 1 week in full-term infants or 2 weeks in preterm infants
When is neonatal jaundice considered pathologic?
If unconjugated hyperbilirubinemia appears within the first 24 hours after birth or the infant shows symptoms or signs of a serious illness, or if total bilirubin rises faster than 0.2 mg/dL per hour or 5 mg/dl per day or becomes greater than 18/mg/dl or lasts more than 1 week in term infants or 2 weeks in preterm infants
How do you Dx neonatal jaundice?
- direct coombs test- if positive then check Rh or ABO incompatibility
If negative then check levels of hemoglobin
low ⇒ hematomas
high ⇒ diabetic mother, twin- twin, maternal- fetal transfusion or delayed cord clamping.
normal ⇒ look for increased reticulocytes and LDH and decreased haptoglobin which point to hemolysis
If both total bilirubin and conjugated bilirubin levels are high then the jaundice could be caused by what?
hepatocellular and caused by genetic syndromes, like Dubin-Johnson and Rotor syndrome.
If alkaline phosphatase levels are would you think posthepatic or hepatocellular cause?
posthepatic, caused by obstruction of biliary tree
a 9-year old boy was brought to the clinic by his mother on account of 5-month history of abdominal cramps, bloating, diarrhea and flatulence that occur usually about 2 hours after ingesting milk.
Likely Dx?
lactose intolerance
What kind of symptoms might be associated with lactose intolerance?
abdominal bloating and cramps, flatulence, diarrhea, nausea, borborygmi (rumbling stomach), or vomiting after consuming significant amounts of lactose
What type of supplementation might pts with lactose intolerance need?
calcium
How do you Dx lactose intolerance?
lactose hydrogen breath
Positive if the post lactose breath hydrogen value rises greater than 20 ppm over the baseline measurement
Can also do stool acidity test (fecal Ph test)
a 12-year-old boy who is brought into your clinic by his father for sunburns that have not been healing. The father states that he easily gets sunburned. His father admits that he and his partner have never taken the child to see a doctor. The patient walks with a wide stance gait and appears unstable on his feet. He has an extensive erythematous, scaling, hyperkeratotic rash on his face, neck, arms and legs.
What is the likely Dx?
niacin deficiencies vitamin B3
What does a deficiency in B3 cause?
pellagra (meaning “raw skin), which is characterized by a photosensitive pigmented dermatitis
What are the recommended amounts of niacin? from children to women during lactation?
Children 9–13: 12mg
19+ male: 16mg; 19+ female: 14mg
Pregnancy: 18mg
Lactation: 14mg
What are the 4 D’s for B3 deficiency?
Dermatitis ⇒ Photosensitive, pigmented
Diarrhea ⇒ Potentially also vomiting
Dementia ⇒ Potentially also anxiety, disorientation
Death ⇒ Untreated pellagra potentially fatal
How can you assess niacin status?
by measuring urinary N-methylnicotinamide or by measuring the erythrocyte NAD: NADP (ratio).
a 6-week-old first-born baby boy with projectile vomiting after feedings over the last 24 hours. Mom says that he enjoys feeding, and even after he vomits, he appears eager and hungry. On physical exam, you palpate an olive-shaped mass in the epigastric region at the lateral edge right upper quadrant. Labs show blood pH 7.47 and potassium of 3.2 mmol/L. On a barium upper GI series report, the radiologist states a “string sign” is present.
What is the likely Dx?
Pyloric stenosis
What sequela can come from pyloric stenosis?
vomiting (that might be projectile), as well as dehydration and metabolic alkalosis
How is pyloric stenosis Dx?
ultrasound
What will you see on ultraound/ barium study with pyloric stenosis?
ultrasound will show double-track
barium studies will show “string sign” or “shoulder sign”
What will occur from pyloric stenosis? metabolic alkalosis or acidosis?
alkalosis
Tx for pyloric stenosis?
pyloromyotomy (Ramstedt’s procedure)
an otherwise-healthy 7-month old female infant brought to the clinic by her mother on account of a 3-month history of umbilical swelling which is usually more apparent when she cries. On examination, the swelling was reducible and a defect was felt through the umbilicus.
What is the liekly Dx?
umbilical hernia
What age is closure of umbilical ring usually completed?
by 5 years of age
When are umbilical hernias detected?
detected during the newborn abdominal examination, particularly when there is increased intraabdominal pressure from crying
When should a child get surgery for umbilical hernia?
if persists >2 years of life
a 3-year-old girl is brought to your office for a routine checkup. She was recently adopted and her past medical history is unknown. The patient’s parents state that she was very emaciated when they adopted her and noticed she has trouble seeing in the evening. They also note that she was experiencing profuse foul-smelling diarrhea as well, which is currently being worked up by a gastroenterologist. Her temperature is 98.3°F, blood pressure is 106/64 mmHg, pulse is 104/min, respirations are 17/min, and oxygen saturation is 99% on room air. The girl appears very thin. She has dry skin noted on physical exam.
What is likely Dx?
vitamin A deficiency
What can cause vit A defic
from inadequate intake, fat malabsorption, or liver disorders
What can vit A defic cause?
immunity and hematopoiesis and causes rashes (dry skin) and typical ocular effects (eg, xerophthalmia (dry eyes), night blindness)
How do you Dx Vitamin A defic?
measurement of serum retinol levels
levels less than 20 micrograms/dL [0.7 micromol/L] suggest deficiency
What is the Tx for vit A defic?
- Infants 6 to 12 months of age: 100,000 international units orally (30 mg retinol equivalent) – One dose
- Children 12 to 59 months of age: 200,000 international units orally (60 mg retinol equivalent) – Dose repeated every four to six months
- Routine supplementation is no longer recommended for neonates, infants one to five months of age, or to mothers during the postpartum period living in endemic areas
a 13-year-old boy who presents with a rash. He is accompanied by his mother who first noticed red dots on his skin last week that have been spreading over the last few days. The patient’s mother notes that his gums have begun to bleed after brushing his teeth and he has been sleeping more than usual. He has not been ill recently or received any vaccines. The boy had an unremarkable birth history and was diagnosed with autism spectrum disorder at age three. He is primarily nonverbal and attends a school for children with special needs. Exam reveals a thin boy who avoids eye contact and does not respond to verbal questions. Cardiopulmonary exams are unremarkable. The hair on his arms is coiled. The child’s leg shows diffuse petechiae on the leg and you note gingival hemorrhage.
Likely Dx?
Vitamin C defic
how do you diagnose vitamin C defic?
plasma and leukocyte vitamin C levels are the mainstay for assessment and are reasonably well correlated with vitamin C intake
The most specific symptoms of Vitamin C defic are?
occurring as early as three months after deficient intake) are follicular hyperkeratosis and perifollicular hemorrhage, with petechiae and coiled hairs
What are some other common symptoms of vitamin C defic (hint: related to mouth)
ecchymoses, gingivitis (with bleeding and receding gums and dental caries)
Tx for vitamin C deficiency?
For children, recommended doses are 100 mg ascorbic acid given three times daily (orally, intramuscularly or intravenously) for one week, then once daily for several weeks until the patient is fully recovered
Adults are usually treated with 300 to 1000 mg daily for one month
a 5-year-old who presents to your office for an initial visit. The child just immigrated from Africa and is now living in his new home. The patient is small for his age and is in the 5th percentile for height and 10th percentile for weight. His parents are concerned as the child has complained of leg pain and chest pain ever since he fell off the monkey bars at school. A radiograph of the chest demonstrates expansion of the anterior rib ends at the costochondral junctions and a radiograph of the legs demonstrates genu varum. The cardiac and pulmonary exam are within normal limits.
Likely Dx?
vitamin D deficiency
Severe deficiency of vitamin D causes?
rickets in infants and children, and osteomalacia in all age groups
signs and symptoms of rickets?
bowed legs, fractures, costochondral thickening (“rachitic rosary”), dental
Who is vitamin D deficiency more common in?
dark skin pigmentation and those who are exclusively breastfed beyond three to six months of age
What is a risk factor for low vitamin D in an infant?
If they were a premature birth
How do you Dx Vitamin D deficiency?
serum 25OHD levels
Vitamin D sufficiency– 20 to 100 ng/mL (50 to 250 nmol/L)
Vitamin D insufficiency– 12 to 20 ng/mL (30 to 50 nmol/L)
Vitamin D deficiency– <12 ng/mL (<30 nmol/L)
What level of vitamin D is recommended to maintain?
levels >20 ng/mL (50 nmol/L) in most population
What should all breastfeed infants be supplemented with?
400 international units (10 micrograms) daily of vitamin D supplements, beginning within a few days after birth
Children 1-18 should receive what dose of vitamin D to maintain a level above 20ng/ml?
600 international units (15 micrograms) daily
