GI Problems in Pediatrics

Question 1

A 16 year old boy presents to clinic and complains of food sticking in his chest when he eats. It is worst when eating meats. He has asthma and is allergic to cats. He is otherwise healthy. Father has esophageal strictures requiring dilatation. What is at the top of your differential diagnosis?

Answer 1

Eosinophilic Esophagitis

DDx: GERD, structural, motility issue, FB, psychogenic (“globus”)

Question 2

A 16 year old boy presents to clinic and complains of food sticking in his chest when he eats. It is worst when eating meats. He has asthma and is allergic to cats. He is otherwise healthy. Father has esophageal strictures requiring dilatation. What investigations would you pursue?

Answer 2

Investigations: CXR (air fluid levels, FB), barium swallow (R/O stricture, look at motility), consider a trial of GERD treatment (PPI), endoscopy

*Most patients with true dysphagia should have a referral to a gastroenterologist.

Question 3

What is the management for EoE?

Answer 3

Elemental diet (consult with allergist, 6 food elimination diet)
Steroids: swallowed fluticasone, viscous budesonide and in rare serious cases systemic steroids
PPI trail: 10-30% improve with PPI alone

Question 4

How is EoE diagnosed?

Answer 4

Endoscopy with biopsy. Histologic diagnosis: increased eosinophils in esophageal biopsies (>15/HPF). Other features: white plaques (eosinophil clumps), furrowing, ringed esophagus, stricture if chronic.

Question 5

A 9 year old girl presents with a 2 year history of abdominal pain. The pain is vague: periumbilical, intermittent, with no radiation and is a 4/10. She has no constipation, diarrhea or vomiting. Her growth is appropriate. What is your DDx?

Answer 5

DDx: functional abdominal pain, celiac disease, GERD, constipation.

Question 6

What investigations do you order to confirm your suspicions of celiac disease?

Answer 6

Tissue transglutaminase (TTG) (+ in 95% of cases)
Biopsy completed on non-gluten free diet. Biopsy shows scalloping of tissue (blunted villi).

Question 7

What is the treatment of celiac disease?

Answer 7

Gluten free diet FOR LIFE. Repeat celiac serology should be negative after 1 year of strict gluten free diet.

Question 8

First time parents present to the emergency department after 2 weeks of streaks of bright red blood and mucous in their daughter’s stool. Their daughter, Emma, is 2 months old. The bright red streaks are increasing in frequency and are now present with every stool. Emma is otherwise well. No fever, diarrhea, irritability, vomiting and is gaining weight appropriately and is breastfed. PMHx is unremarkable. What is at the top of your differential diagnosis?

Answer 8

Food Protein Induced Colitis

DDx: anal fissure, NEC, infection, intussusception, colitis

Question 9

What is the management of food protein induced colitis?

Answer 9

For breastfed infants mom must remove all cow’s milk protein from her diet as well as soy. Formula fed infants must start a protein hydrosylate formula.