Ped GI Disorders - Exam 3 Flashcards
What does true emesis look like? What if severe? What does it indicate?
true emesis: slightly yellow tinge due small amounts of bile
severe: greenish to lighter yellow if severe
small bowel obstruction
What is GER? How common is it? What is the tx?
infant or newborn with postprandial spitting and/or vomiting that resolves spontaneously by 12 months of age in over 85% cases.
Lifestyle changes help, no meds needed
no tx needed
What are infant risk factors for GER/GERD?
Small stomach capacity
Large volume feeds
Short esophageal length
Supine positioning
Slow swallowing response to refluxed material
Spitting up formula after feeds which worsens over time
Excessive belching or gas
Cyanosis or choking
Persistent congestion, cough or wheezing
Arching of the back while feeding
What am I?
What will it present like in children/adolescent?
What is important to note?
GERD
abdominal pain/chest pain/burning
EFFORTLESS spitting up is fine! but when they have to try for it, thats a problem
What are the risk factors for GERD?
asthma
CF
developmental delays
Tracheoesophageal Fistula
Apneic spells in newborns are typically caused by _____ especially if occurs with ______
reflux
positional change
What are the behavioral tx options for GERD/GER in infants? What are the medications options?
Smaller, more frequent feeds
Upright 45 min after feeds
Thickened feeds if needed or pre thickened formula
Breastfed - eliminate milk and eggs for 2 - 4 weeks
trial of famotidine or omeprazole
_____ is the sx procedure for GERD and is especially used in cerebral palsy
NISSEN fundoplication
for life threatening (think apneic spells)
Vomiting, fever, anorexia, headache, cramps and myalgia with an exposure to ____, ____ or _____. What is the peak timing?
gastroenteritits
viral
parasitic
bacterial
peak in the winter
What is the #1 cause of viral gastroenteritis? What are some parasitic causes? What are some bacterial causes?
Norovirus (#1)
Cryptosporidium, Giardia
Campylobacter, Clostridium, Salmonella, E. Coli
How is viral gastroenteritis transmitted? What is the incubation period? What age range is the MC?
fecal-oral route
12 hours – 4 days lasting 4 -7 days
More than 95% admissions under age 5 yo
What are concerning features of gastroenteritis?
Presence of blood or mucous
Weight loss
Prolonged cap refill, loss of turgor
Diminished BP, sunken fontanelle, dry mucous membranes
What lab studies would you want to order in gastroenteritis?
CBC
CMP
stool studies
UA- check for dehydration
What is the tx for gastroenteritis?
tx the symptoms
IV fluids!!
treat the underlying cause
______ is the MC indications for emergency surgery in peds. What is the MC underlying cause?
Acute Appendicitis
Obstruction by fecalith
What is the order of vomiting and pain in acute appendicitis? What is the order for gastroenteritis?
pain THEN vomiting
P then V= surgery
vomiting then pain is the order for gastro
What score on the pediatric appendicitis scale is likely for appendicitis?
7+ appendicitis is HIGHLY likely
What are the lab values in AA? What imaging studies should you order?
WBC >15,000
Elevated ANC >7500
US then CT abdomen
What is the abx of choice for AA?
1 dose of cefoxitin (Mefoxin) OR cefotetan (Cefotan) to prevent infection at least 30 - 60 min prior to incision for appendectomy
_____ is projectile vomiting associated with hypertrophy of the pylorus with elongation and thickening leading to near complete obstruction. What will the vomit look like?
pyloric stenosis
Non-bilious vomiting, dehydration, alkalosis in infants < 12 weeks old
What gender is MC for pyloric stenosis? What are 3 additional risk factors?
male
First born child
twins
Family history in 13%
In pyloric stenosis, when does the postprandial vomiting begin? How would the parents describe their eating pattern?
usually around 2-4 weeks old
Hungry and avid nurser “hungry vomiter”
What medication increases risk of pyloric stenosis?
Using erythromycin / azithromycin use is risk in children , specifically under age of 2 weeks of age
**What is the PE finding associated with pyloric stenosis?
**“Olive sign” – palpable oval mass RUQ at lateral edge of rectus abdominis muscle
pt will also be very dehydrated!
What acid/base disorder can be seen in pyloric stenosis? What diagnostic study should you order?
Hypochloremic hypokalemic metabolic alkalosis
US
What is the “string sign?” What is the dx?
a radiographic finding where a thin, string-like appearance of barium passes through a narrowed pyloric canal on an upper GI series
pyloric stenosis
What is the tx for pyloric stenosis?
Pyloromyotomy laparoscopically
_____ is an acute, non inflammatory encephalopathy with a fatty, degenerative liver. When does it occur after? What medication is it associated with?
reye’s syndrome
Occurs during or after a VIRAL illness (3-5 days after onset) - typically influenza, varicella, or GE
taken aspirin (salicylate) within 3 weeks of illness
What is the MC age range of Reye’s syndrome?
Affects children up to 18 years of age with peak 5 - 14 years of age; rare in newborns
MC in white
What is the pathopsy behind Reye’s syndrome?
ASA which injures the mitochondria of the cell. This injured mitochondria inhibits the oxidative phosphorylation and fatty-acid beta-oxidation in the host
What will the cells infected with Reye’s syndrome look like? Why is it super bad?
All cells have swollen, reduced number of mitochondria, along with glycogen depletion and minimal tissue inflammation.
Hepatic mitochondrial dysfunction results in hyperammonemia, resulting in cerebral edema and ICP
aka liver is damaged which leads to high ammonia which leads to encephalopathy. Can also harm the kidneys
Persistent and continuous vomiting and diarrhea after a viral illness .
Lethargy
Tachypnea
Confusion, disorientation, hallucinations
Seizures
Weakness or paralysis in arms and legs
Decreased LOC
What am I?
How do you dx?
What should you do next?
Reye’s syndrome aka lots of puking will be present
dx of exclusion
order tests for inborn errors of metabolism
Any child with _____ and _____ ddx of _____ should be considered
vomiting and AMS
Reye’s syndrome
What is the tx for Reye’s Syndrome?
tx the symptoms!!
IV fluids and diuretics
meds to prevent bleeding: Vit K, plasma and platelets
Why do you give diuretics in Reye’s syndrome? Why do you give Vit K, plasma and platelets?
Decrease ICP and increase fluid loss through urination
need to prevent bleeding because the liver is NOT working well
What is the prognosis for Reye’s Syndrome? Why?
Death usually due to cerebral edema or ICP, but may be due to CV collapse, resp failure, renal failure, GI bleeding, status epilepticus, or sepsis
What factors increase the risk of mortality in Reye’s Syndrome?
Age younger than 5
Rapid progression of illness
CVP < 6 mm H2O
Ammonia level > 45
Glucose < 60
hypoproteinemia unresponsive to Vit K and plasma
Muscle involvement
What is the underlying cause of eosinophilic esophagitis?
ATOPIC inflammatory disease of both proximal and distal esophagus
eosinophil-rich inflammation inhabits the esophagus
In children, what is eosinophilic esophagitis associated with? What should you do next?
driven by food allergen exposure in which skin prick testing is positive for food allergies
What is the imaging of choice eosiniophilic esophagitis?
EGD and will see abnormal esophageal mucosa: Active inflammation, diminished vascular pattern, mucosal abnormalities, transient rings, fixed rings, and strictures
aka the esophagus does NOT look smooth
What is the MC pt with eosinophilic esophagitis?
developed countries, male, all ethnic groups equal
**What is one hx finding that would make you think potential eosinophilic esophagitis?
**GER symptoms unresponsive to PPIs
Vomiting
Dysphagia - infants refusing to feed; adults with solid foods
Abdominal pain
Feeding disorder / Food intolerance
Heartburn
Food impaction
Vague chest pain - retrosternal
Diarrhea
What am I?
What would be in the pts hx?
eosinophilic esophagitis
food allergy, asthma, eczema or chronic rhinitis
What will a pts lab show in EE? **What is the histologic confirmation needed to dx EE?
May show peripheral eosinophilia
Elevated total IgE levels in about 70%
**Histologic confirmation via multiple esophageal bx revealing 15 or more eosinophils per hpf is diagnostic
What is the tx for EE? What if strictures are present?
avoid food allergies!
Inhaled steroids are puffed, then swallowed from a MDI
fluticasone (Flovent) or budesonide (Pulmicort)
Esophageal dilation may be needed to treat strictures
What is the pt education for fluticasone (Flovent) or budesonide (Pulmicort) when treating EE?
Inhaled steroids are puffed, then swallowed from a MDI
Do not rinse mouth or eat for 30 min to max effectiveness
_____ is a food allergy that kiddos do NOT tend to outgrow. What age range?
peanut alllergy
around 24 months old
What is the difference between a peanut and treenut?
peanuts are beans that grow in the ground
treenuts: are fruit that grow on trees
When do s/s of a peanut allergy tend to show up? What 3 organs systems do they involve the most?
Usually develop within minutes of exposure but may be delayed up to 2 hours
Skin
Respiratory
GI
What lab test can you order for a peanut allergy? What can you do if either are positive?
Skin prick vs serological testing
ImmunoCAP - peanut specific IgE level
either are positive NO need to for oral food challenge
What is the tx for mild/moderate peanut allergy reaction? severe?
mild/moderate: Benadryl or cetirizine (Zyrtec)
severe: epinephrine via EpiPen at home then immediately go to ED
What is the recommendation for a baby with severe eczema and/or egg allergy to be introduced to peanuts?
Introduce peanut products between 4-6 months of age
What is the recommendation for a baby with mild/moderate eczema to be introduced to peanuts? babies without eczema?
Introduce peanut products at 6 months of age
Not important to introduce early, but ok if parents do so
____ is the MC pathogen associated with gastric ulcers. How do you test for it?
H. pylori
stool for H pylori
What is the dx test for gastric ulcers? What is the tx?
UGI, endoscopy and biopsy
amoxicillin, clarithromycin and omeprazole
What is considered diarrhea?
passage of 3 or more loose/watery stools
What is considered acute diarrhea? chronic?
acute: 5-14 days
chronic: longer than 1 month
How long does the diarrhea caused by viruses last? What is the MC virus? What age range?
Diarrhea can last 2-3 weeks
norovirus is the MC
3-15 months is most common age range
Vomiting (80-90%), followed 24 hours by low grade fever, watery diarrhea
Diarrhea 4-8 days or longer
What am I?
What dx are needed?
What is the tx?
viral diarrhea
stool culture: to identify the virus, no blood or WBC will be seen
tx: supportive care with fluids, may need to replace bicarb
_____ is the MC cause of intestinal obstruction for the first 2 years of life. What specific age range is MC?
intussusception
6-12 months old
Sudden onset of severe, crampy, colicky pain
Inconsolable crying and drawing up legs
Vomiting (90%), Bloody diarrhea (50%)
What am I?
What is the PE stool finding?
What is the PE finding?
intusseusception
“Currant, jelly stool”
Sausage-shaped abdominal mass mid-right abdomen
What is the gold standard dx for intusseusception? If that does not work, move on to _____
barium enema: usually dx and tx
then sx if barium enema does not work
What is a volvulus? What are some precipitating causes?
when the intestine twists on itself
severe constipation
hirschsprung’s dz
adhesions from a former sx
Abdominal pain
Bloating
Vomiting
Constipation
BLoody stools
complication: loss of blood supply and bowel ischemia
What am I?
How do you dx?
What is the tx?
volvulus
abdominal xray
tx: surgery to untwist bowel
_______ is abx associated diarrhea and usually starts 1-14 days after abx therapy and up to 30 days after abx use. How do you dx?
Pseudomembranous Enterocolitis
stool culture: Neutrophils and gross blood in stool
What is the tx for pseudomembranous enterocolitis?
d/c abx use
metro or vanc
____ is the MC cause of loose stools in otherwise healthy kids 6-20 months old. What are the defining characteristics?
toddler’s diarrhea
3-6 loose stools/day
waking hours only!!!
no blood
When does toddler’s diarrhea tend to resolve? What will the dx tests show?
Resolved by 3-4 years old
normal growing toddlers and all tests are negative!!
_______ is a NON-allergic food sensitivity. Is it mediated by IgE? What gender?
milk protein allergy
non-IgE mediated
MC in males with a family hx
A milk protein allergy will present in a healthy infant with ________. What is the tx? When will it go away?
flecks of bright red blood in stool (heme positive)
Treatment is to eliminate source of protein (cow’s milk - 60% of cases or soy-based milk) and maternal avoidance of milk protein in nursing mothers
need to give hydrolyzed formula to the baby
Disappears by 8-12 months of age
Diarrhea, abdominal distention, fatty stools, FTT, irritability, constipation
What am I?
When will s/s start to appear?
celiac dz
Occurs at 6-24 months of age after gluten introduced
**What is the lab you should order for celiac dz? What is diagnostic?
tTG (tissue transglutaminase
Endoscopy with small intestinal biopsy is diagnostic
_____ is the MC problem throughout childhood and must be present ____ month in infants/toddlers and _____ in older children
constipation
Must be present 1 month in infants and toddlers, 2 months in older children
What is defined as constipation?
Less than 3 bowel movements per week
impacted rectum with stool, large bulk stools or painful hard stools
When are the major 3 transitions in a child’s life that constipation is common?
Introduction to solid foods or cow’s milk
Toilet Training
School entry
What are ways to make sure your kiddo does not get constipation?
ensure adequate fiber intake
increase fluids
pureed veggies, fruits and fiber infant cereal
decrease cow’s milk to less than 24oz per day (16 oz is ideal)
What is the goal fiber intake for a kiddo less than 2 years old?
<2 years old – 5 grams fiber/day
What are common reasons that kiddos get constipated?
intentionally withholding stool because it is painful
using adult toilets, not wanting to go at school
inadequate fiber intake
cows milk
What is the tx for constipation in children?
miralax or lactulose
increase fiber, decrease milk and increase fluids
What is encopresis?
when soft poop comes out around the impacted hard stool
fecal incontinence or soiling
can lead to rectal enlargement and loss of sensation
Why does encopresis occur?
Internal and external sphincters relax – semi-solid stool leaks onto perianal skin and clothing
child holds in stool of pain and stretched out nerves and muscle does not work well
What are the underlying causes of encopresis?
functional due to chronic constipation
emotional: school, divorce etc etc
What are s/s of encopresis? How do you dx?
Abdominal pain, fecal mass, dilated rectum packed with stool
May cause enuresis or urinary frequency
rectal exam and KUB
What is the tx for encopresis?
Daily, soft stools without pain every 1-2 days without incontinence
Rebuild rectal muscles that control bowels
Stability on laxatives for 6 months to years
Having a rescue plan in place
GI referral if needed
What is the acute treatment for encopresis?
PEG/Miralax/fleets enema/dulcolax
rectal stimulation
What is the chronic treatment for encopresis?
Maintenance laxatives for at least 6 months – 1 year
eliminate cow’s milk 1-2 week trial
High fiber diet
Increased fluid intake
scheduled toilet time
parental monitoring and having a rescue plan in place in case the kiddo goes 3 days without a BM
How often does a kiddo need to follow up for encopresis? Why do most treatments fail?
Monthly, then every 3-4 months
Most treatment failures are caused by inadequate meds and/or discontinuing meds too soon
What do you need to r/o in a newborn with severe constipation?
r/o Hirschsprung’s or CF
What is Hirschsprung’s Dz? What is the key feature?
Absence of ganglion cells in mucosal and muscular layers of colon
Failure to pass meconium in first 24-48 hours
Vomiting - bilious emesis
Abdominal distention
Reluctance to feed
fever, diarrhea, foul-smelling or ribbon-like stools
Tight anal sphincter and anal canal
What am I?
What gender is more common?
Hirschsprung’s dz
males are 4 times more common than females
What am I?
What should you do next?
Hirschsprung’s Disease
KUB and rectal bx!!
What will a KUB show in a pt with Hirschsprung’s Disease?
Dilated proximal colon and absence of gas in pelvic colon
Rectum void of stool despite impaction on KUB
What is the gold standard diagnostic test for Hirschsprung’s dz? What is the tx?
Rectal biopsy – ganglion cells absent in both submucosal and muscular layers of involved bowel
Surgical – diverting colostomy or ileostomy
_____ is 75% of all rectal anomalies. What is the key finding?
Imperforate anus
failure to pass meconium at all
Slit-like tear in squamous epithelium of anus
Cries with defecation and holds stool
Bright red blood on toilet tissue
What am I?
anal fissure
Very small anus with a dot of meconium
Ribbon-like stools
Blood or mucus in rectum
Fecal impaction or abdominal distention
Tight ring in anal canal
Could be ____ or _____
How do you tell the difference?
anal stenosis or imperforate anus
imperforate anus will not have any meconium pass at all
What is considered mild, moderate and severe dehydration?
Mild – 3-5% volume loss
Moderate – 6-9% volume loss
Severe - >10% volume loss
What is considered volume depletion? What are some s/s?
Volume depletion = 2 kg weight loss = 2 Liters of fluid loss
Increased pulse rate, decreased skin turgor, decreased blood pressure, increased thirst, lethargy, decreased UOP, sunken eyes
**______ is the most useful lab to assess degree of dehydration in children. ____ will be increased
serum bicarb
BUN will be increased
What is the tx for dehydration if choosing to go oral rehydration?
What is the tx for dehydration if choosing the IV rehydration route?
What are the 2 MC oral fluids given for rehydration?
pedialyte or gatorade
