Pediatric GI disorders

Question 1

Most tracheo-esophageal fistulas are…

Answer 1

blind upper esophageal pouch

lower esophagus attached to the trachea

Question 2

TE fistula H and P

Answer 2

coughing and cyanosis during feeding
abdominal distention
aspiration pneumonia

CXR following NG tube insertion demonstrating the malformation

Treatment: surgical repair

Question 3

Pyloric stenosis

Answer 3

hypertrophy of sphincter, obstructing gastric outlet; projectile vomiting

Labs: metabolic alkalosis due to vomiting because you are getting rid of hydrochloric acid

Hydrogen out of cells and potassium into cells, leading to hypokalemia

Overall, hypochloremic, hypokalemic metabolic acidosis

Radiology:
barium swallow- string sign
US- pyloric muscle thickness

Treatment: pyloromyotomy
reconnect stomach to duodenum

Question 4

Necrotizing enterocolitis

Answer 4

idiopathic necrosis of the intestinal mucosa with epithelial cell sloughing

main risk factors: low birthweight, premature birth
(immature gut)

start tube feeds very slowly
and give IV TPN as you titrate up

H and P:
bilious vomiting
lethargy
poor feeding
diarrhea
hematochezia
abdominal distention
abdominal tenderness
signs of shock in severe cases

Labs:
metabolic acidosis
decreased sodium
bowel distention
air in the bowel wall- necrosis and gangrene (pneumotosis intestinalis)

free air if perforation

Treatment: 
TPN
IV broad-spectrum antibiotics
NG suction
surgical resection of affected bowel (if necrosis)

Question 5

Hirschprung disease

Answer 5

absence of autonomic innervation of the colon leading to bowel spasms and obstruction

H and P:
vomiting
obstipation (Severe constipation to the point of intestinal obstruction)
failure to pass stool (think about CF too)
“blast sign”- rectal exam leads to blast of stool

Labs-
biopsy- absence of ganglia
radiology- xray shows dilated bowel

Treatment: colostomy and resection of the affected area

Question 6

obstipation

Answer 6

Severe constipation to the point of intestinal obstruction

Question 7

Intussusception

Answer 7

mcc bowel obstruction in the first 2 years of life

telescoping of bowel into itself, more likely if there is a lead point

RF
adenovirus (inflammed peyer's patches)
CF
Meckel
cancer if in an adult

H and P:
-sudden abdominal pain that lasts

Question 8

Meckel diverticulum

Answer 8

remnant of the vitelline duct, that is an outpouching of the ileum

2x more common in males
within 2 feet of the ileocecal valve
2 main types of ectopic tissue (gastric or pancreatic)
2% of the population
most complications occur before 2 years of age

typically asx
RF for intussesception
abscess formation

Radiology: Meckel scan, with injected radionucleotide that highlights acid- secreting gastric mucosa

Question 9

Neonatal jaundice- what are the various types?

Answer 9

1. Physiologic jaundice
2. Breastfeeding jaundice
   immune-related: ABO incompatibility
   or Rh (or other antigen) incompatibility (erythroblastosis fetalis)
3. Truama, cephalohematoma, bruising
4. infection, sepsis
5. polycythemia
6. hereditary (G6PD deficiency, hereditary spherocytosis, dubin- johnson- direct/conjugated bilirubin elevation), Rotor syndrome (direct/conjugated bilirubin elevation), Bylar disease (direct/conjugated bilirubin elevation)
7. biliary atresia- hallmark is high percentage of direct bilirubin refer to peds for biopsy and imaging (cirrhosis risk)

Question 10

Physiologic jaundice

Answer 10

Physiologic jaundice (50% of newborns) due to lack of UDP-GT enzyme, starting around day 3, and peaking at

Question 11

Breastfeeding jaundice

Answer 11

exaggerated physiologic jaundice
breastfed babies whose milk letdown has not fully started; baby is dehydrated
occurs in the first week of life
peak at 12-15 bili level
starts around days 4-14

Question 12

Breast milk jaundice

Answer 12

starts after the first week, continues for weeks to months while breastfeeding
due to substances found in the breastmilk
improvement with formula for 48-72 hrs is diagnostic

ok as long as there is no kernicteris

Question 13

What antibiotic is contraindicated in neonates with hyperbilirubinemia and why?

Answer 13

ceftriaxone

it displaces bilirubin from albumin, which increases the likelihood of kernicterus or encephalopathy

Question 14

What characteristics of neonatal jaundice are pathological until proven otherwise?

Answer 14

Any jaundice in the first 24 hours
Rise in total bilirubin by more than 0.5 mg/dL/hr
Rise in total bilirubin more than 5 mg/dL/day
Direct (conjugated) bilirubin greater than 20% of the total bilirubin or >1.5 mg/dL
Total bilirubin higher than 13 mg/dL in term neonates
Jaundice appearing after 2-3 weeks of age

Question 15

Hypercarotenemia

Answer 15

no scleral icterus

due to beta carotene deposition

Question 16

Kernicterus

Answer 16

unconjugated bilirubin crosses BBB and deposits in the basal ganglia and hippocampus

causes permanent damage

Question 17

Treat neonatal jaundice

Answer 17

phototherapy

IVIG may reduce the need for exchange transfution in cases of maternal- fetal blood type incompatability

Question 18

Failure to thrive

Answer 18

below the 2nd percentile for weight for age given sex and age

weight 1 occasion

weight crosses 2 major percentiles downward on a standardized growth chart over time

weight for length ratio