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Gen Med: GI > Pediatric GI Disorders > Flashcards

Pediatric GI Disorders Flashcards

1
Q

What are the general characteristics of GER in children?

A
  1. Common in healthy infants
  2. ↓ w/ increasing age
  3. Regurgitation or vomiting ↓ toward end of 1st yr of life
  4. Unusual > 18 mo old
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2
Q

What complications can go along with GERD infants?

A
  1. Esophagitis
  2. . Poor weight gain
  3. Respiratory complications
  4. Occ. esophageal strictures or Barrett’s esophagus
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3
Q

How is GER differentiated from GERD?

A
  1. Focused H & P to determine GER vs GERD
  2. No warning signs: Uncomplicated GER
    A. Good weight gain
    B. Feeds well
    C. Not unusually irritable
    -Rarely requires intervention
  3. (+) warning signs: Complicated GERD
    A. Further evaluation required
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4
Q

what are GERD warning signs in infants?

A
  1. Bilious vomiting
  2. Hematemesis
  3. Hematochezia
  4. Consistently forceful vomiting
  5. Onset of vomiting after six months old
  6. Constipation
  7. Diarrhea
  8. Abdominal tenderness
  9. Abdominal distension
  10. Failure to thrive
  11. Recurrent pneumonia
    A. R/O tracheoesophageal fistula
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5
Q

How is GER treated in infants non-medically?

A
  1. Behavioral changes: don;t lay the baby down after eating
  2. Change in formula
  3. Thickening of feedings
    A. 1 Tbs oat cereal/oz of formula
  4. Stop breast-feeding (mom d/c milk & beef)
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6
Q

How is uncomplicated GER treated?

A
  1. “Happy spitters“
  2. Educate & reassure parents
    A. 2 wk trial of combined lifestyle changes
    B. Smaller feedings
    C. Milk-free diet (food protein intol)
    -Occult blood in stool, eczema, or FH of atopy
    D. Thickened feedings
    E. Anti-reflux positioning
    F. Tobacco smoke avoidance: 2nd hand smoke may affect LES relaxation
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7
Q

What is the first line treatment for GERD in infants?

A
  1. Soy based formula
  2. Thickened cow’s milk formula
  3. Thickened soy based formula
  4. Non-soy, non-dairy formula
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8
Q

What is the second line treatment for GERD in infants?

A
  1. If first line rx unsuccessful → 2 wk trial of acid suppression
    A. PPI (esomeprazole/Nexium)
    i. Improved → cont. x 3-6 mo
    ii. Ø improved → endoscopy
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9
Q

What increases the risk for pyloric stenosis?

A

Smoking during pregnancy ↑ risk

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10
Q

What is pyloric stenosis caused by?

A
  1. Caused by hypertrophy of the pylorus

2. Can progress to near-complete obstruction of gastric outlet

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11
Q

What are the general characteristics of pyloric stenosis?

A
  1. Characterized by forceful vomiting in young infants
  2. 3-6 wk-old infant who develops immediate postprandial vomiting
    A. Non-bilious & forceful (“projectile”)
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12
Q

What are the sxs of pyloric stenosis?

A
  1. Demands to be re-fed soon afterwards
    A. “Hungry vomiter”
  2. Pyloric “olive”
    A. Hypertrophied pylorus palpable in 50 - 90% w/ IHPS
    B. Pathognomonic
  3. 3-6 wk-old infant who develops immediate postprandial vomiting
    A. Non-bilious & forceful (“projectile”)
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13
Q

What are the ddx for pyloric stenosis?

A
  1. GE reflux
  2. Cow’s milk protein intolerance
  3. Adrenal crisis
  4. A. Malrotation, Hirschsprung Dz, Intussusception
  5. Liver disease
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14
Q

What are the dx studies for pyloric stenosis?

A
  1. Labs if ill appearing
  2. CBC, Lytes
    A. R/O dehydration & electolyte imb. (↓Cl, ↓ K), metabolic alkalosis
  3. USN
    A. Procedure of choice
    B. Classic “target” sign
  4. UGI
    A. Only done if PE & USN are nondiagnostic
  5. Upper endoscopy
    A. Only if other studies are inconclusive
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15
Q

What are the treatment for pyloric stenosis?

A
  1. Pyloromyotomy
    A.Longitudinal incision of pylorus w/blunt dissection to level of submucosa
    B. Relieves constriction
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16
Q

What is intussusception?

A
  1. Invagination of a part of the intestine into itself
    A. Most often near iliocecal junction
  2. Idiopathic
  3. ↑ incidence w/seasonal viral gastroenteritis
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17
Q

Who most commonly gets intussesception?

A
  1. Most common abdominal emergency in early childhood
  2. Most commonly between 3 mo – 5 yr of age
    A. Most common cause of intestinal obstruction 6mo -3 yr
  3. M > F
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18
Q

What is the pathophys of intussusception?

A
  1. A proximal segment of bowel, telescopes into a distal segment, dragging the associated mesentery with it
  2. Leads to venous & lymphatic congestion w/intestinal edema → ischemia, perforation, peritonitis
19
Q

What are the sxs of intussusception?

A
  1. Sudden onset of intermittent, severe, crampy, abdominal pain
    A. 15 to 20 minute intervals
    B. ↑ frequency & severity over time
  2. Inconsolable crying
    3.Vomiting may follow pain episodes
    A. Becomes bilious as obstruction develops
  3. Drawing up of the legs toward the abdomen
  4. Normal behavior & pain free between episodes
  5. +/- palpable sausage-shaped right abdominal mass
  6. +/- stool w/ hematochezia + mucous (currant jelly)
20
Q

What is the triad associated with intussusception?

A
  1. Seen in < 15 % of pts at presentation
    A. Pain
    B. Palpable sausage-shaped abdominal mass
    C. Currant-jelly stool
21
Q

What is ta common atypical presentation of intussusception?

A
  1. Lethargy or altered consciousness alone

2. Often confused w/ sepsis

22
Q

What is the dx study of choice for intussusception? What is seen?

A
  1. USN
    A. “Target sign” (“bull’s eye” or “coiled spring”)
    B. Layers of the intestine w/in intestine
23
Q

What other dx studies can be used?

A
  1. X-Ray
    A. Intestinal obstruction
    B. Distended loops of bowel w/out air fluid levels
24
Q

What is the rx for intussusception?

A
  1. Reduction using hydrostatic (contrast or saline) or pneumatic (air) enema
    A. Done w/USN guidance
    B. Procedure is both diagnostic & therapeutic
    C. Before reduction by enema, stomach should be decompressed w/ NG tube & IV hydration
  2. Surgery if reduction unsuccessful or suspected bowel perforation
25
Q

What is Meckel’s diverticulum?

A
  1. Diverticulum, containing all layers of small bowel wall
    A. Results from incomplete obliteration of vitelline duct → forming a true diverticulum of small intestine
  2. Uncommon & usually clinically silent
  3. Found incidentally
    A. M > F
26
Q

What causes Meckel’s diverticulum?

A
  1. Most common congenital anomaly of GI tract

A. ↑ incidence w/congenital malformation of the umbilicus, alimentary tract, nervous system, or CV system

27
Q

What is the rule of twos in regard to meckel’s diverticulum?

A
  1. M > F 2:1
  2. Occurs in 2% of population
  3. Occurs w/in 2 ft from ileocecal valve
  4. Can be 2” in length
  5. 2 to 4 % of pts develop a complication over lifetime
28
Q

What are the sxs of meckel’s diverticulum?

A
  1. Generally normal exam
  2. Sx’s of diverticulitis
    A. Midline abdominal tenderness
    B. Distention
  3. Sx’s of bowel obstruction
    A. Abdominal distention
    B. N/V
  4. GI bleeding
    A. SB ulcer distal to tic 2° to acid secreted by ectopic gastric mucosa w/in the tic
29
Q

What raises clinical suspicion of meckel’s diverticulum?

A
  1. Children w/ painless lower GI bleeding
  2. Pt w/ features of acute appendicitis but appendix has already been removed
  3. Adults w/ obscure GI bleeding (ie, no source identified)
30
Q

What are the dx studies for Meckel’s diverticulum?

A
  1. Meckel’s scan (Nuclear)
    A. Sensitivity in children (85-97%) > adults (60%)
    B. Identifies ectopic gastric mucosa w/in tic
  2. Mesenteric Arteriography
  3. Double balloon enteroscopy
  4. Capsule endoscopy
  5. Abdominal exploration
31
Q

What are the tx options for Meckel’s diverticulum?

A
  1. Manage clinical manifestations that brought the Meckel’s diverticulum to clinical attention
    A. PPI for GI bleed
    B. IV fluids & lytes prn
    C. NG tube % bowel rest for obstruction
    D. abx prn: Flagyl, augmentin for kids, cipro for adults etc.
  2. Surgical resection if symptomatic
    A. Diverticulectomy
    B. Segmental small bowel
32
Q

Define Hirschsprung’s dz?

A
  1. Aka congenital aganglionic megacolon
  2. Assoc. w/chromosomal anomalies
  3. 1 in 5000births
  4. M > F
  5. Majority affect short segment of distal colon
33
Q

What is the pathophys of Hirschsprung’s dz?

A
  1. Motor disorder of the gut → functional obstruction
    A. Failure of neural crest cells (precursors of enteric ganglion cells) to migrate completely during intestinal development → aganglionic segment of colon fails to relax
34
Q

What are the sxs of Hirschsprung’s dz?

A
  1. Diagnosed as neonate
    A. 95 % fail to pass meconium in 1st 48 hr of life
  2. Sx’s of distal intestinal obstruction
    A. Bilious emesis
    B. Abdominal distension
    C. Failure to pass stool
  3. Explosive expulsion of gas & stool after the digital rectal examination
    A. “Squirt sign” or “blast sign”
    B. Temporary relief of obstruction
35
Q

What are the sxs of Hirschsprung’s dz in childhood?

A 
1. Mild case
A. Chronic constipation & failure to thrive
2. Enterocolitis (rare)
A. Fever 
B. Vomiting
C. Diarrhea
D. Abdominal distension
A. Can progress to toxic megacolon
36
Q

What are the dx studies Hirschsprung’s dz?

A
  1. X-Ray
    A. Decreased or absent air in the rectum & dilated bowel loops proximal to the aganglionic region
  2. Rectal Bx - gold standard for diagnosis
  3. Contrast enema
  4. Anorectal manometry
37
Q

What is the treatment for Hirschsprung’s dz?

A
  1. Surgical resection of aganglionic segment of bowel
2. Enterocolitis
A. IV fluids
B. IV antibiotic
C. Rectal irrigation
D. Emergency colostomy (rare)
E. Surgical resection when stable
38
Q

What is intestinal malrotation?

A
  1. Rotational anomaly of GI tract
    A. Proximal bowel grows faster than distal bowel
  2. Bowel twists 270° counterclockwise
    A. Occurs as a result of an arrest of normal rotation of the embryonic gut
    B. Often associated w/ other GI abnormalities
  3. Volvulus (torsion of the intestines)
    A. Most common presenting sx in infancy
    B. Can be life-threatening – emergency!
39
Q

What are the sxs of intestinal malrotation in infants?

A 
1. Signs of acute SBO in early infancy
A. Bilious vomiting
B. Mild distension
C. Diffuse tenderness 
D. +/- peritonitis
E. Bloody stool DRE
i. Worrisome sign
ii. Suggests bowel ischemia & possible necrosis
40
Q

What are the sxs of intestinal volvulus?

A
  1. High risk for systemic decompensation
  2. Hematemesis
  3. Hematochezia
  4. Abdominal distension
  5. Peritonitis
  6. Shock
41
Q

What are the sxs of intestinal malrotation in older children and adults?

A 
1. Most common
A. Insidious
B. Intermittent vomiting 
C. Abdominal pain
2. Less Common
A. Failure to thrive 
B, Solid food intolerance
C. Malabsorption 
D. Chronic diarrhea 
E. Pancreatitis
F. Peritonitis 
G. Biliary obstruction
H. Motility disorders
42
Q

What are the dx studies of intestinal malrotation?

A 
1. UGI series 
A. Best initial exam
B. Misplaced duodenum (ligament of Treitz on R) 
C. “Corkscrew" appearance
2. Bariumenema (rare) 
3. USN
4. CT
43
Q

What are the dx studies of intestinal volvulus?

A
  1. Volvulus (Clinical Dx)
    A. No additional evaluation needed
    B. IV resuscitation & immediate surgery for exploration
44
Q

What is the treatment for intestinal malrotation/volvulus?

A
  1. IV fluids
  2. NG tube
  3. Surgery
    A. Ladd procedure
    B. Reduction of volvulus (if present) & appendectomy

Gen Med: GI (16 decks)

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