Pediatric Gastrointestinal Disorders Flashcards
- how should true emesis look like?
- green coloration would indicate what?
- slightly yellow tinge due to small amounts of bile in the stomach
- greenish-lighter yellow: increasing amounts of bile
Bile in emesis can be a sign of ?
SBO
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
GER
persistent symptoms with adult-like symptoms of regurgitation into mouth, heartburn or dysphagia. Medications warranted. Intractable symptoms with life-threatening complications.
GERD
RF for GER/GERD
- Small stomach capacity
- Large volume feeds
- Short esophageal length
- Supine positioning
- Slow swallowing response to refluxed material
s/s GERD
infants
- 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
children/adolescents
- Abdominal pain and chest pain or burning
- Throwing up food into mouth / regurgitation / sour burps
RF/conditions for GERD
Asthma
Cystic Fibrosis
Developmental Delays
Tracheoesophageal Fistula
Apneic spells in newborns are typically caused by ? - esp if occurs with position change
reflux
how to dx Ger/GERd?
Diagnosis confirmed on UGI after clinical presentation
tx for GER/GERD in infants?
- Behavior modifications - Smaller, more frequent feeds; Upright 45 min after feeds; Thickened feeds; Breastfed - eliminate milk and eggs x 2-4 wks
- Trial of famotidine (Pepcid)
- Prilosec or Nexium
tx of GER/GERD for older children?
- Avoid caffeine and spicy foods; Avoid overfilling and late night eating
- Wt loss and trial of no milk products
- famotidine (Pepcid) or omeprazole (Prilosec)
signs of NISSEN fundoplication for persistent or life-threatening GERD
- FTT
- Esophagitis
- Apneic spells
- Life-threatening
s/s of Gastroenteritis
Vomiting, fever, anorexia, headache, cramps and myalgia
causes of Gastroenteritis
- Viral - Norovirus (#1), Adenovirus, Enterovirus, Rotavirus
- Parasitic - Cryptosporidium, Giardia
- Bacterial - Campylobacter, Clostridium, Salmonella, E. Coli
Viral Gastroenteritis MC when and in who?
- Peak in the winter
- Fecal - Oral transmission
- 12 hours – 4 days lasting 4 -7 days
- < 5y/o
concerning signs of gastroenteritis
- Presence of blood or mucous
- Weight loss
- Prolonged cap refill, loss of turgor
- Abnl respiratory pattern, elevated temp, ↑ pulse
- Diminished BP, sunken fontanelle, dry mucous membranes
- Decreased UOP
exposures that are suspicious for gatroenteritis
- Foreign travel
- Playing in creek
- Daycare
- Poultry or other farm animals, turtles , reptiles , ducks
w/u for gastroenteritis
- CBC - WBCs, bands
- BMP / CMP - carbon dioxide, BUN / Cr
- Stool studies - SSYC, O&P, viruses (GE panel)
- UA - dehydration
tx for gastroenteritis
- Symptomatic
- IVF
- Treat causative agent
Most common indication for emergency surgery in Pediatrics
Acute Appendicitis
MCC of Acute Appendicitis
Obstruction by fecalith
what differentiates appendicitis from gastroenteritis
Vomiting usually follows onset of pain in appendicitis as opposed to gastroenteritis
s/s of acute appendicitis
- Fever, periumbilical pain localizing to RLL with peritoneal irritation
- Anorexia, vomiting, constipation and diarrhea
- Tenderness, rebound, guarding, “bumps in road” or jumping off exam table
- Rovsing Sign, Obturator Sign ( flexion / extension of right hip), Iliopsoas Sign( pain with flfexion of right hip against examiners hand
pefiatric appendicitis scoring?
- anorexia - 1
- N/V - 1
- migration of pain - 1
- fever - 1
- pain with cough, percussion or hopping - 2
- RLQ tenderness - 2
- WBC >10k -1
- NEUT + bands >7.5k - 1
total 10 pts, >=6 likely dx
w/u for appendicitis
- WBC >15,000, pyuria, fecal leukocytes, hemoccult positive stools sometimes
- Elevated ANC >7500
- Elevated CRP with leukocytosis is a 92% indicator of appendicitis
- AAS – fecalith
- US - 93% sensitive followed by CT abdomen
- CT abdomen - with positive U/S, may be diagnostic
tx for appendicitis
- surgery asap
- close observation
- cefoxitin / cefotetan preop
Projectile vomiting associated with hypertrophy of the pylorus with elongation and thickening leading to near complete obstruction
Non-bilious vomiting, dehydration, alkalosis in infants < 12 weeks old
Pyloric Stenosis
RF for pyloric stenosis
- male
- first born
- twins
- FHx
s/s of pyloric stenosis
- Postprandial vomiting begins at 2-4 weeks of age
- Hungry and avid nurser “hungry vomiter”
- “Olive sign” – palpable oval mass RUQ at lateral edge of rectus abdominis muscle
- Dehydration or emaciation
use of what abx are risk in children , specifically under age of 2 weeks of age for Pyloric Stenosis?
erythromycin / azithromycin
w/u for pyloric stenosis
- CMP - Hypochloremic hypokalemic metabolic alkalosis BUN and Cr; mild hyperbilirubinemia
- CBC - r/o infectious cause
- US vs UGI
tx for pyloric stenosis?
Pyloromyotomy laparoscopically
- Acute, non inflammatory encephalopathy with a fatty, degenerative liver
- Occurs during or after a viral illness (3-5 days after onset) - typically influenza, varicella, or GE
- > 80% had taken ASA within 3 weeks of illness
reye’s
Reye’s Syndrome MC in who?
- < 18y; peak 5 - 14 y/o; rare in newborns
- Male = Female
- 93% Caucasian; 5% African American; other % equally distributed among other ethnic groups
pathophys of reye’s syndrome
- Viral infected host + salicylates/other toxin = injures mitochondria = inhibits oxidative phosphorylation and fatty-acid beta-oxidation
- cells have swollen, less mitochondria + glycogen depletion and minimal tissue inflammation.
- Hepatic mitochondrial dysfunction = hyperammonemia = cerebral edema and ICP
- also leads to edema and fatty degeneration of proximal lobules in kidneys
s/s of reye’s syndrome
- 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
w/u for reye’s syndrome
- Eval any child with vomiting and AMS
- ALL should be tested for Inborn errors of Meatabolism
- labs: CBC, CMP, ammonia, LP, Liver bx, CT or MRI, Skin bx (fatty acid oxidation disorders and metabolic disorders)
tx for reye’s syndrome
- IVF
- Diuretics - dec ICP and inc fluid loss through urination
- Meds to prevent bleeding - Vit K, plasma and platelets
MCC of death in reye’s syndrome?
- cerebral edema or ICP
- CV collapse, resp failure, renal failure, GI bleeding, status epilepticus, or sepsis
Factors that increased risk of mortality in reye’s syndrome
- < 5 y/o
- Rapid progression of illness
- CVP < 6 mm H2O
- Ammonia level > 45
- Glucose < 60
- hypoproteinemia unresponsive to Vit K and plasma
- Muscle involvement
- Atopic inflammatory disease of both proximal and distal esophagus
- In children - driven by food allergen exposure in which skin prick testing is positive for food allergies
- In adolescents and adults - allergic rhinitis, atopic dermatitis (eczema) is associated with approx 60% of cases
Eosinophilic Esophagitis
pathogenesis of Eosinophilic Esophagitis
Esophageal mucosa is infiltrated by T-cells, B-cells, eosinophils and IgE expressing mast cells
Eosinophilic Esophagitis MC in who?
- Mainly in developed countries
- All ethnic groups equal
- Affects children and adults
- Male predominance 3:1
- GER symptoms unresponsive to PPIs
- Incidence 1 - 4 / 10,000 annual diagnoses
s/s of Eosinophilic Esophagitis
- Vomiting
- Dysphagia - infants refusing to feed; adults with solid foods
- Abdominal pain
- Feeding disorder / Food intolerance
- Heartburn
- Food impaction
- Vague chest pain - retrosternal
- Diarrhea
w/u for Eosinophilic Esophagitis
- Allergy hx
- Labs: peripheral eosinophilia; Elevated total IgE levels
-
Upper endoscopy: Active inflammation, diminished vascular pattern, mucosal abnormalities, transient rings, fixed rings, and strictures
- dx: multiple esophageal bx w/ >15 eosinophils per hpf
tx for eosinophilic esophagitis
- remove antigenic foods
- Inhaled steroids are puffed, then swallowed from a MDI
- fluticasone or budesonide; Do not rinse mouth or eat for 30 min to max effectiveness - Esophageal dilation - for strictures
MC age of presentation with peanut allergy?
24 months
s/s of peanut allergy
within minutes of exposure; delayed up to 2 hrs possible
3 MC, and may include more than one system: Skin, rsp, GI
w/u for peanut allergy
-
Skin prick vs serological testing
- ImmunoCAP - peanut specific IgE level
- If either of these positive - no need for oral food challenge - Oral food challenge
- Food elimination diet
peanut allergy mgmt/prevention
- pt ed
- mild-mod reaction - Benadryl or cetirizine (Zyrtec)
- Early signs of anaphylaxis
- Severe: EpiPen; Transport to ER for further management
future mgmt for penaut allergy
- Food Oral Immunotherapy (OIT) - most effective
- Food Sublingual Immunotherapy
- Epicutaneous Immunotherapy
peanut allergy recommendations for babies with eczema
- Babies with severe eczema and/or egg allergy - Introduce peanut products between 4-6 months of age
- Babies with mild to moderate eczema - Introduce peanut products at 6 months of age
- Babies w/o eczema - Not important to introduce early, but ok if parents do so
MCC of Gastric and Duodenal Ulcers
H. pylori
w/u and tx for Gastric and Duodenal Ulcers
- UGI, endoscopy and bx
- triple therapy: amoxicillin + clarithromycin + omeprazole
difference between acute diarrhea vs chronic diarrhea?
- acute: 5 - 14 d; No fever, non-bloody – virall; F, bloody, mucous – stool cx; Probiotics sometimes helpful; Dehydration
- chronic: > 1 mo; abx use; Fruit juices, starch; Milk protein allergy; Toddler’s diarrhea
which virus is responsible for a longer course of diarrhea?
Adenoviruses
Vomiting (80-90%), followed 24 hours by low grade fever, watery diarrhea
Diarrhea 4-8 days or longer
dx?
w/u?
tx?
- viral diarrhea
- Stool cx – virus identified. No blood or WBCs seen in stool; Labs – WBC normal, BMP, UA
- Supportive / Dehydration, bicarb loss, metabolic acidosis
- MCC of intestinal obstruction first 2 years of life
- 6-12 months of age most common (almost always < 2 years old)
- 86% idiopathic
Intussusception
- Sudden onset of severe, crampy, colicky pain
- Inconsolable crying and drawing up legs
- Vomiting (90%), Bloody diarrhea (50%)
- “Currant, jelly stool”
- Sausage-shaped abdominal mass mid-right abdomen
dx?
w/u?
tx?
- Intussusception
- Barium enema – Gold Standard
- Surgery in some cases
- 1-14 d after abx therapy and up to 30 d after abx use
- Fever, abdominal distension, tenesmus, abd pain
- Neutrophils and gross blood in stool – dx by stool cx
dx?
tx?
- Pseudomembranous Enterocolitis
- D/C abx; metronidazole or vancomycin
- Chronic, non-specific
- Most common cause of loose stools in otherwise healthy kids 6-20 months old
- 3-6 loose stools/day, waking hours only, no blood
- Grow normally, all tests negative
- Excessive fruit juice worsens
- Resolved by 3-4 years old
dx?
Toddler’s Diarrhea
- Non-allergic food sensitivity (non-IgE mediated)
- Males > Females
- Infants with family history
- Healthy infants with flecks of bright red blood in stool (heme positive)
- Disappears by 8-12 months of age
dx? tx?
- milk protein allergy (MPA)
- eliminate source of protein (cow’s milk - 60% of cases or soy-based milk) and maternal avoidance of milk protein in nursing mothers
- Immune mediated enteropathy triggered by gluten
- Diarrhea, abdominal distention, fatty stools, FTT, irritability, constipation
- Clinically improves on a gluten-free diet
- Occurs at 6-24 months of age after gluten introduced
dx?
w/u?
tx?
- Celiac Disease
- tTG; DX: Endoscopy with small intestinal bx
- Gluten restriction for life (wheat, rye, barley and some oats completely eliminated)
Other causes of Diarrhea that resolve spontaneously without treatment
- Giardia
- Salmonella
- Yersinia
- Shigella
- Campylobacter
- IBD - ab pain, diarrhea, bloody stools, fever, wt loss
- IBS
Most common problem throughout childhood
constipation
criteria for constipation for peds
Must be present 1 month in infants and toddlers, 2 months in older children
definition of constipation
- Less than 3 bowel movements per week
- More than one episode of encopresis per week
- Impacted rectum with stool
- Large bulk stool
- Withholding
- Painful, hard stools
3 main transitions of constipation
- Introduction to solid foods or cow’s milk
- Toilet Training
- School entry
how to improve constipation thru diet?
when introducing to solid foods:
- Ensure adequate fiber intake
- more fluids
- < 2 y/o – 5 g fiber/day
- Pureed veggies, fruits and fiber infant cereal
- cow’s milk < 24 oz/day, 16 oz ideal
complications during toilet training that contribute to constipation
- Stool withholding - Painful stools, using adult toilets
-
Inadequate fiber
- Child’s age + 5-10 grams fiber/day
- (7-15 grams in kids 2-5 years old is avg) -
cow’s milk
- Slows intestinal motility
- Satiates child
- < 24 oz/day (16 oz preferably)
what may help with constipation when it comes to school entry?
- Reluctant to use at school - Asking to go; Modesty
- Schedule - Time between classes
-
Increase fiber to 11 – 24 g/d
- Bran, whole wheat, fruits, veggies with peelings
- Increase fluids
presentations that are dx to constipation?
- Stool withholding behavior, pain with defecation, rectal bleeding or anal fissure
- Hard stool in rectum, laxity of anal sphincter
- Stool impaction on KUB
mgmt for constipation
- PEG (Miralax) – 1 – 1.5 gram/kg/day or Lactulose 1 - 2 grams/kg/day
- Fiber, decrease milk, increase fluids
- Enema
- Bathroom training
what is Encopresis
- Fecal incontinence or soiling
- Stool accumulates in rectum
- Hard, painful stools to pass
- Rectal enlargement
- Loss of sensation
- Internal and external sphincters relax – semi-solid stool leaks onto perianal skin and clothing
causes of Encopresis
- Functional - Chronic constipation
- Emotional - School, divorce, etc.
s/s of Encopresis
- Abdominal pain, fecal mass, dilated rectum packed with stool
- May cause enuresis or urinary frequency
how to dx encopresis
- Rectal exam
- KUB
goals of 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
acute tx for encopresis
- PEG / Miralax – 1-1.5 g/kg/day – >6 months old
- Fleets enema – children 2 and older
- Dulcolax supp
- Glycerin supp for infants
- Rectal stimulation
everything x 3 days
chronic tx for encopresis
- Maintenance laxatives for at least 6 months – 1 year
- High fiber diet
- Increased fluid intake
- Toilet sitting – same time daily 5-10 minutes after meals - Timed by stopwatch; Reward for effort, not success
- Parental monitoring
- Rescue plan if > 3 days without a BM
general mgmt, f/u for encopresis
- Elimination of all cow’s milk 1-2 wk trial
- F/u - Monthly, then q 3-4m
- Newborns with severe constipation – r/o Hirschsprung’s or CF
- GI referral if persists
Most tx for Encopresis fail because of?
inadequate meds and/or discontinuing meds too soon
Absence of ganglion cells in mucosal and muscular layers of colon
Hirschsprung’s Disease
- Failure to pass meconium in first 24-48 hours
- Vomiting - bilious emesis
- Abdominal distention
- Reluctance to feed
- Up to 50% can have – fever, diarrhea, foul-smelling or ribbon-like stools
- Tight anal sphincter and anal canal
dx?
w/u?
tx?
- Hirschsprung’s Disease
- KUB - Dilated proximal colon and absence of gas in pelvic colon; Rectum void of stool despite impaction on KUB
- rectal bx: ganglion cells absent in both submucosal and muscular layers of involved bowel.
- surgery - diverting colostomy or ileostomy
Slit-like tear in squamous epithelium of anus
Cries with defecation and holds stool
Bright red blood on toilet tissue
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
Anal stenosis
3 types of dehydration based on their severity?
- Mild – 3-5% volume loss
- Moderate – 6-9% volume loss
- Severe - >10% volume loss
correlation of volume depletion to wt/fluid loss?
Volume depletion = 2 kg weight loss = 2 Liters of fluid loss
s/s of dehydration?
w/u?
- inc pulse rate, dec skin turgor, dec BP, increased thirst, lethargy, dec UOP, sunken eyes
- CBC, BMP, UA
- serum bicarb most useful lab to assess degree of dehydration in children (< 17 mEq/L BUN is increased
- inc urine specific gravity w/ excretion of protein
how to administer oral rehydration in dehydrated pt?
- Pedialyte
- Frequent, small amounts by syringe
- 5 ml q 2-4 min x 4 h - Mild dehydration – 50 ml/kg; Moderate – 100 ml/kg - Trial of Zofran 4 mg ODT
how to administer IV rehydration to dehydrated pt?
- Isotonic solution = NS
- Give 20 ml/kg over 1 hour and repeat up to 2 boluses
- Zofran
- Start oral rehydration
- Recheck bicarb level
- What dx is 75% of all rectal anomalies
- males > females
- GI and GU involvement
- fail to pass meconium at all
Imperforate anus
