Pediatric Gastrointestinal Disorders Flashcards
1
Q
- how should true emesis look like?
- green coloration would indicate what?
A
- slightly yellow tinge due to small amounts of bile in the stomach
- greenish-lighter yellow: increasing amounts of bile
2
Q
Bile in emesis can be a sign of ?
A
SBO
3
Q
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
A
GER
4
Q
persistent symptoms with adult-like symptoms of regurgitation into mouth, heartburn or dysphagia. Medications warranted. Intractable symptoms with life-threatening complications.
A
GERD
5
Q
RF for GER/GERD
A
- Small stomach capacity
- Large volume feeds
- Short esophageal length
- Supine positioning
- Slow swallowing response to refluxed material
6
Q
s/s GERD
A
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
7
Q
RF/conditions for GERD
A
Asthma
Cystic Fibrosis
Developmental Delays
Tracheoesophageal Fistula
8
Q
Apneic spells in newborns are typically caused by ? - esp if occurs with position change
A
reflux
9
Q
how to dx Ger/GERd?
A
Diagnosis confirmed on UGI after clinical presentation
10
Q
tx for GER/GERD in infants?
A
- 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
11
Q
tx of GER/GERD for older children?
A
- Avoid caffeine and spicy foods; Avoid overfilling and late night eating
- Wt loss and trial of no milk products
- famotidine (Pepcid) or omeprazole (Prilosec)
12
Q
signs of NISSEN fundoplication for persistent or life-threatening GERD
A
- FTT
- Esophagitis
- Apneic spells
- Life-threatening
13
Q
s/s of Gastroenteritis
A
Vomiting, fever, anorexia, headache, cramps and myalgia
14
Q
causes of Gastroenteritis
A
- Viral - Norovirus (#1), Adenovirus, Enterovirus, Rotavirus
- Parasitic - Cryptosporidium, Giardia
- Bacterial - Campylobacter, Clostridium, Salmonella, E. Coli
15
Q
Viral Gastroenteritis MC when and in who?
A
- Peak in the winter
- Fecal - Oral transmission
- 12 hours – 4 days lasting 4 -7 days
- < 5y/o
16
Q
concerning signs of gastroenteritis
A
- 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
17
Q
exposures that are suspicious for gatroenteritis
A
- Foreign travel
- Playing in creek
- Daycare
- Poultry or other farm animals, turtles , reptiles , ducks
18
Q
w/u for gastroenteritis
A
- CBC - WBCs, bands
- BMP / CMP - carbon dioxide, BUN / Cr
- Stool studies - SSYC, O&P, viruses (GE panel)
- UA - dehydration
19
Q
tx for gastroenteritis
A
- Symptomatic
- IVF
- Treat causative agent
20
Q
Most common indication for emergency surgery in Pediatrics
A
Acute Appendicitis
21
Q
MCC of Acute Appendicitis
A
Obstruction by fecalith
22
Q
what differentiates appendicitis from gastroenteritis
A
Vomiting usually follows onset of pain in appendicitis as opposed to gastroenteritis
23
Q
s/s of acute appendicitis
A
- 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
24
Q
pefiatric appendicitis scoring?
A
- 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
25
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
26
tx for appendicitis
1. surgery asap
2. close observation
3. cefoxitin / cefotetan preop
27
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
28
RF for pyloric stenosis
1. male
2. first born
3. twins
4. FHx
29
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
30
use of what abx are risk in children , specifically under age of 2 weeks of age for Pyloric Stenosis?
erythromycin / azithromycin
31
w/u for pyloric stenosis
* CMP - Hypochloremic hypokalemic metabolic alkalosis BUN and Cr; mild hyperbilirubinemia
* CBC - r/o infectious cause
* **_US_ vs UGI**
32
tx for pyloric stenosis?
Pyloromyotomy laparoscopically
33
* 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
34
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
35
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**
36
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
37
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)
38
tx for reye's syndrome
* IVF
* Diuretics - dec ICP and inc fluid loss through urination
* Meds to prevent bleeding - Vit K, plasma and platelets
39
MCC of death in reye's syndrome?
* **cerebral edema or ICP**
* CV collapse, resp failure, renal failure, GI bleeding, status epilepticus, or sepsis
40
Factors that increased risk of mortality in reye's syndrome
1. < 5 y/o
1. Rapid progression of illness
1. CVP < 6 mm H2O
1. Ammonia level > 45
1. Glucose < 60
1. hypoproteinemia unresponsive to Vit K and plasma
1. Muscle involvement
41
* **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
42
pathogenesis of Eosinophilic Esophagitis
Esophageal mucosa is infiltrated by T-cells, B-cells, eosinophils and IgE expressing mast cells
43
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
44
s/s of Eosinophilic Esophagitis
1. Vomiting
1. Dysphagia - infants refusing to feed; adults with solid foods
1. Abdominal pain
1. Feeding disorder / Food intolerance
1. Heartburn
1. Food impaction
1. Vague chest pain - retrosternal
1. Diarrhea
45
w/u for Eosinophilic Esophagitis
1. Allergy hx
1. Labs: peripheral eosinophilia; Elevated total IgE levels
1. **Upper endoscopy**: Active inflammation, diminished vascular pattern, mucosal abnormalities, transient rings, fixed rings, and strictures
- **_dx_: multiple esophageal bx w/ >15 eosinophils per hpf**
46
tx for eosinophilic esophagitis
1. **remove antigenic foods**
1. Inhaled steroids are puffed, then swallowed from a MDI
- **fluticasone or budesonide**; Do not rinse mouth or eat for 30 min to max effectiveness
1. **Esophageal dilation** - for strictures
47
MC age of presentation with peanut allergy?
24 months
48
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
49
w/u for peanut allergy
1. **Skin prick vs serological testing**
- **ImmunoCAP - peanut specific IgE level**
- If either of these positive - no need for oral food challenge
1. Oral food challenge
1. Food elimination diet
50
peanut allergy mgmt/prevention
1. pt ed
2. mild-mod reaction - Benadryl or cetirizine (Zyrtec)
3. Early signs of anaphylaxis
- Severe: EpiPen; Transport to ER for further management
51
future mgmt for penaut allergy
1. Food Oral Immunotherapy (OIT) - most effective
1. Food Sublingual Immunotherapy
1. Epicutaneous Immunotherapy
52
peanut allergy recommendations for babies with eczema
1. Babies with severe eczema and/or egg allergy - Introduce peanut products between 4-6 months of age
1. Babies with mild to moderate eczema - Introduce peanut products at 6 months of age
1. Babies w/o eczema - Not important to introduce early, but ok if parents do so
53
MCC of Gastric and Duodenal Ulcers
H. pylori
54
w/u and tx for Gastric and Duodenal Ulcers
* UGI, endoscopy and bx
* triple therapy: amoxicillin + clarithromycin + omeprazole
55
difference between acute diarrhea vs chronic diarrhea?
1. acute: 5 - 14 d; No fever, non-bloody – virall; F, bloody, mucous – stool cx; Probiotics sometimes helpful; Dehydration
1. chronic: > 1 mo; abx use; Fruit juices, starch; Milk protein allergy; Toddler’s diarrhea
56
which virus is responsible for a longer course of diarrhea?
Adenoviruses
57
Vomiting (80-90%), followed 24 hours by low grade fever, watery diarrhea
Diarrhea 4-8 days or longer
dx?
w/u?
tx?
1. **viral diarrhea**
1. Stool cx – virus identified. No blood or WBCs seen in stool; Labs – WBC normal, BMP, UA
1. Supportive / Dehydration, bicarb loss, metabolic acidosis
58
* MCC of intestinal obstruction first 2 years of life
* 6-12 months of age most common (almost always < 2 years old)
* 86% idiopathic
Intussusception
59
* 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?
1. Intussusception
2. Barium enema – Gold Standard
3. Surgery in some cases
60
* 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
61
* 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
62
* 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
63
* 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)
64
Other causes of Diarrhea that resolve spontaneously without treatment
* Giardia
* Salmonella
* Yersinia
* Shigella
* Campylobacter
* IBD - ab pain, diarrhea, bloody stools, fever, wt loss
* IBS
65
Most common problem throughout childhood
constipation
66
criteria for constipation for peds
Must be present 1 month in infants and toddlers, 2 months in older children
67
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
68
3 main transitions of constipation
* Introduction to solid foods or cow’s milk
* Toilet Training
* School entry
69
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
70
complications during toilet training that contribute to constipation
1. **Stool withholding** - Painful stools, using adult toilets
2. **Inadequate fiber**
- Child’s age + 5-10 grams fiber/day
- (7-15 grams in kids 2-5 years old is avg)
3. **cow’s milk**
- Slows intestinal motility
- Satiates child
- < 24 oz/day (16 oz preferably)
71
what may help with constipation when it comes to school entry?
1. **Reluctant to use at school** - Asking to go; Modesty
2. **Schedule** - Time between classes
3. **Increase fiber to 11 – 24 g/d**
- Bran, whole wheat, fruits, veggies with peelings
- Increase fluids
72
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
73
mgmt for constipation
1. **PEG (Miralax) – 1 – 1.5 gram/kg/day or Lactulose 1 - 2 grams/kg/day**
1. Fiber, decrease milk, increase fluids
1. Enema
1. Bathroom training
74
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
75
causes of Encopresis
1. **Functional** - Chronic constipation
1. **Emotional** - School, divorce, etc.
76
s/s of Encopresis
* Abdominal pain, fecal mass, dilated rectum packed with stool
* May cause enuresis or urinary frequency
77
how to dx encopresis
* Rectal exam
* KUB
78
goals of encopresis
1. Daily, soft stools without pain every 1-2 days without incontinence
1. Rebuild rectal muscles that control bowels
1. Stability on laxatives for 6 months to years
1. Having a rescue plan in place
1. GI referral if needed
79
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
80
chronic tx for encopresis
1. Maintenance laxatives for at least 6 months – 1 year
1. High fiber diet
1. Increased fluid intake
1. Toilet sitting – same time daily 5-10 minutes after meals - Timed by stopwatch; Reward for effort, not success
1. Parental monitoring
1. Rescue plan if > 3 days without a BM
81
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
82
Most tx for Encopresis fail because of?
inadequate meds and/or discontinuing meds too soon
83
Absence of ganglion cells in mucosal and muscular layers of colon
Hirschsprung's Disease
84
* 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?
1. **Hirschsprung's Disease**
1. KUB - Dilated proximal colon and absence of gas in pelvic colon; Rectum void of stool despite impaction on KUB
2. **rectal bx**: ganglion cells absent in both submucosal and muscular layers of involved bowel.
1. **surgery** - diverting colostomy or ileostomy
85
Slit-like tear in squamous epithelium of anus
Cries with defecation and holds stool
Bright red blood on toilet tissue
Anal fissure
86
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
87
3 types of dehydration based on their severity?
* Mild – 3-5% volume loss
* Moderate – 6-9% volume loss
* Severe - >10% volume loss
88
correlation of volume depletion to wt/fluid loss?
Volume depletion = 2 kg weight loss = 2 Liters of fluid loss
89
s/s of dehydration?
w/u?
1. inc pulse rate, dec skin turgor, dec BP, increased thirst, lethargy, dec UOP, sunken eyes
1. 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
90
how to administer oral rehydration in dehydrated pt?
1. Pedialyte
- Frequent, small amounts by syringe
- 5 ml q 2-4 min x 4 h - Mild dehydration – 50 ml/kg; Moderate – 100 ml/kg
2. Trial of Zofran 4 mg ODT
91
how to administer IV rehydration to dehydrated pt?
1. Isotonic solution = NS
- Give 20 ml/kg over 1 hour and repeat up to 2 boluses
- Zofran
- Start oral rehydration
- Recheck bicarb level
92
* What dx is **75% of all rectal anomalies**
* males > females
* GI and GU involvement
* **fail to pass meconium at all**
Imperforate anus
