Pediatric GU/Gi Disorders Flashcards
differentiate
pyleonephritis
cystitis
urethritis
three time periods when UTIs are common in children
Pylonephritis
- infection of the kidney
Cystitis
- infection of the bladder
Urethritis
- infection of the uretra (From outside to the bladder)
- “UTI”
UTIs in kids
- during infancy: their immune system is not functioning 100%
- during potty training: they tend to hold urine/stool and increased risk
- sexual activity: the bacteria ascend the tract after activity
- higher risk in girls > boys
Risk Factors for UTIs in Children
Anatomic Abnormalities
- VUr: vesiculoureteral reflux
- PUV: posterior Urethral Valve (boys only)
Immune System
- disruptions or defects
Habits/Bahaviors
- dysfunctional voiding: not fully emptyin
- constipation: a big RF for UTIs
Female/Male Sex
Foreskin: on males, increased risk for bacterial trapping significantly
anatomy: urethra closer to the anus in females: increased risk of infection
Pyelonephritis
symptoms
Pyeloneph. = kidney/ureter infection
Infant symptoms
- HIGH GRADE FEVER!!: #1 most commony symptom
- always be suspicious for a UTI in child under 2 months with high grade unexplaiend fever
- failure to thrive, irritabile
- vomiting & poor feeding
- fould smelling urine
Older Kids syptoms
- high grade fever
- flank pain/tenderness CVA
- vomiting
- they can usually tell you some symptoms
Cystitis
Symptoms
Cystitis: infection of the bladder
Symptoms
- dysuria: painful urination
- frequency and urgecy complaints
- malordorus
- enuresis: previous potty trained but now wetting the bed
- suprapubic pain
- can see gross hematuria
How can a UTI be diagnosed in children
- ways to collect specimen
UTI diagnosis = relies on a proper urine collection to get urinalysis and culutre
Infants & non-toilet trained = catheterization perferred
- bagged specimens not sutablie in febrile pt. need to ahve a clean sample
Toilet trained kids
- clean catch midstream specimen usually can be obtained
- girls: watch contamination from skin and vaginal
- boys: uncircumsized: need to retract foreskin to ensure proper collection
UTI in kids
- urinalysis results
- urine culutre
- pathogens
Urinalysis
- nitrites +
- leuk. esterase +
- > 5 WBCs
not all bacteria produce nitrites
Urine Culture: necessary for dx. you CANNOT dx. UTI on a urinalysis alone
- GOLD STANDARD: urine culutre…
- CFU > 100,000 in a clean catch
- CFU > 50,000 in a catheterized catch
you cannoy dx. a UTI on dipstick or urinalysis alone OR on prusumed symptoms !!!! need the culutre
pathogens
- E. coli!! = most common
- klebsiella
- proteus
- enterococcus
- citrobacter
- serratia
- pseudomonas
Treating Pyleonephritis
- infants under 2 months
- kids 2-24 moths + fever
Infants under 2 months
- youll be getting a fully septic workup anayway for understanding fever
- IV abx + admit begin abx. immediately after culutres then adjust sesitivity
- seems like IV abx (cefx, aminoglycoside)
- never nitrofurantoin
Kids 2-24 months + fever
- 7-10 days of oral or IV then oral
Kids with cystitis + NO FEVER (or superlow grade)
- treat after you obtain culutres; dont wait for results
- bactrum or cephalosporins
Treament Rules
- treat proptly - prevent urosepsis and renal scarring (cant increase future HTN risks)
what do you do for an infant/young kid with febrile UTI based on positive culture
FEVER
UTI
confirmed UTI with cultures
- consider prophylatic abx. for small babies: to prevent rucurrance while you infestiable any anatomical abnormalities
- radiologic stuides
- US recommended
- VCUG
- DMSA Renal scan (looking for scarring)
Imaging Studies for pediatric UTIs
Imaging
Renal Bladder US
- least invasive test: visualize kidneys and bladder to r/o major anatomical abd.
- however, not sensitive enough to find VUR or renal scarring
VCUG: voiding cystourethrogram
- with a febrile UTI looking for evidence of reflux to the kidneys (since fever = pyleo. more than jusy cystiti)
- VCUG: can rule out a VUR
- VUR: retrograde flow from the bladder up to the kidneys because ureter doesnt tunnel into the bladder properly
-VCUG: done via catheter in the bladder; contrast and watch when they pee what happens
what is VUR
primary due to what
dx how
treament options
vesiculourter reflex disease
dx. via VCUG
- a retrograde flow of urine back from the bladder into the kidneys (1 or both)
- graded from 1-5 ( 5= blunted calyces)
Primary Reflux = rerograde flow of urine up the urteters to kidney : due to congenital defect at utertovesical junction
VUR = increse pyleno. risk
assocaited with renal dysplasia (insufficiency leading to dyplasia)
Treatment
- prophlactic antibiotics: low dose prevention to decrease lieklihood of infection
- restaging reflux with growth
- preserve renal function and prevent UTIs and scarring
- surgical correction: ureteral reimplantation if recurrent UTIs
what is PUV
how is it diagnosed
symptoms (if found later)
results: what can happens
PUV = posterior urethral valves
can only occur in men
what is it
- an obsturction of the lower urinary tract via a valve leaflets in the posterior urethra
- “peeing aginist resistance”
- results in : significant bilateral hydrourteronephritis
- classic keyhole sign
Symptoms (if not in utero dx.)
- weak stream
- enuresis
- UTIs
Diagnosis
- can be made prerenally (due to evidence on US of dilated bladder)
- renal US
- VCUG to see full voiding phases
Results: if not managed
- obstructive uropathy
- renal dysfunction: obstruction, renal dysplasia
- bladder dysfunction
- associated VUR possible
Treament
- Surgical: valave ablation
- long term monitoring of the renal function
- usually, the damange is already done to the kidneys, need to monitor
what is a DMSA Renal Scan
a scan which shows the kidenys: detects renal scarring
happy kidneys: take up the dye and contrast easily
sacrred kidneys: dont take up the dye well
non-congential anatomical reasons for UTIs in children
UTIs in kids: non anatomical
Poor Voiding!
- constipation!
- infrequent emptying or incomplete emptying
Goals of UTI care overall
- prompt identification of the infection from symptoms/sins
- accurate dx. : culutres
- prevent renal damange and hyptensions
- avoid overuse of abx. and uncessary testing
Nocturnal Enuresis
what is it: defined
frequency for dx.
primary v non-primary
Noctural Enuresis: bed wetting
Definition
- repeated urination into clothing into the bed at night by a child who is chronolgoically and developmentally older than 5
Timeline
- must be occuring 2+ times a week for at least 3 months
Monosymptomatic : primary
- never dry at night for more thant 6 months, with no daytime accidents
- maturational disorder, no underlying organic problem
non-monosymptomatic: non-primary
- there is nighttime and daytime wetting
high % of wetters: those age 5-6 years old (15-20%) thne drops ovver
Nocturnal Enuresis
- why is it occuring: pathological/physiologically
Whats Happening
- there is an increased level of urine production; to teh point where the bladder cannot hold it all
- this occurs during sleep when the brain cannot respond
History Components
- family history: possibel genetic
- voiding history: # of times, timing and amount
- bowel patterns: constipation?
- sleep patterns: snoring, apnea
- those holding urine at daytime = increased risk
Possible Treatments
- decreasing fluids; esp. at night
- taking child to bathroom at night
- medication
- bed wetting alarm
Nocturnal Enuresis
PE to do
Workup
Possible treatments
PE and Workup
- phsycial exam: abd. , GU for abnormalities, lower spine (cord issues)
- UA and UCx. can be done (looking for DI or UTI)
Treament - first ty…
- void every 2-3 hours during the day
- shilf fluids to earlier in day (80% before 5pm)
- limit fluids 2 hours before bed
- monitor bowel movements
- double void before bed
Then… Bed Wetting Alarm
- best treatment: best cure rate
- moisture sensitive alarm: goes off when sense, to waken pt.
- eventaully the brain and baldder become conditions
- need higly motivated kid and parents (lack of sleep as a reuslt)
Noctural Enuresis
medication optiosn (if not wanting to do the alarm)
Medications
DDAVP: desmopression : synthetic vasopressin
- increasedwater reuptake in the body: decreased urine production
- not curative: just for symptoms: stopping med, can return
Ditropan (oxybutynin)
-for those with: overactive bladder (day or night)
- for those with: reduced bladder capactiy
- helps to inhibit the parasympatic effect of muslce relaxant on the detrusor muslce when relaxing
combo treatment possible: ditropan and ddavp
Chronic Abd Pain in Peds
FAPD
MC cause of abd pains is functional GI disorders
FAPD: function abdominal pain disorder
- recurrent abd. pain for at least 1 week for at least 2 months
- no organic cause
- periumbilical pain usually
- during the day, not waking them at night
- pallor, N/V, crying
- a real disorder of hypersensitivity incuding the following types
functional dyspepsia : epigastric distress and nausea/early satiety
IBS : realted to defications (worse or better), cahnge in frequency, chhnge in form, 4+ days a month
abd. migraines: periumbilical pain with episodes of N/V, sever in nature, +/- HA, photophobia, etc. ; episodes are 1hor + and come and go
functional abd pain NOS
other Abd pain can be typical GI disorders in kids: these are ones which dont have an organic cause
Functional Abd. Pain in Kids
- how to work it up
- labs
Work Up for FABP
- rule out red flag symptoms/signs
- ask fam hx. celiac and IBD
- dscuss aneity and fears about school, life stressors etc.
- may have IBS symptoms : ask about form/frequency
- abd. and rectal exams: will be normal
Labs
- CBC
- ESR
- FOBT
- can consider fecal inflamm., RBUS, pelvic US, CT or endoscopy if needed
- always rule out IBD
Dx. = clincical, once other GI causes have been ruled out
(lactose intoler, IBD, PUD, EE, cyclical vomiting)
FABP
red flag symptoms of the abd. pain which may clue you into something else going on
RED FLAG: symptoms
- waking them up at night
- right upper or right lower quadrant pain
- significant vomiting (bilious, clycical, etc.)
- unexplained fever
- GU tract issues
- dysphagia, odynophagia
- severe diarrhea or nocturnal diarrhea
- GI blood losses
- weight loss, height decreased, delayed puberty
- fam hx. of celical, IBD, PUD
RED FLAG: signs
- local tender to upper or lower righ
- localized tenderness or mass
- splenomegaly
- jaundice
- arthritis
- spinal tenderness
- perianal disase
- hematochezia
- anemia
FADP
Treatment
rule out others always
Treatment
- reassurance and education to pt and fami
- acknolege the pain they feel is real
- discuss how to tolerate pain
- discuss visceral hyerpalgeis
- psycholog, biofedback adn CBT
- pepermin oil prebiotics, deit changes = may help
Acute Diarrhea
- what is it + length of tim e
- causes by what
Acute Diarrhea
- mostly short bouts of diarrhea
- most common: a viral infection : Viral gastroenteritis
ROTAVIRUS: most common (vaccine can be given!!!!)
Norovirus
Adenovirus
bacterial and parasitic less common
Acute Diarrhea: Rotavirus
Rotavirus
- fecal-oral transmission: common cause of inpt. treatment priot to vaccine
- affects 3-15 months
Symptoms
- vomiting
- watery diarrhea 4-8 days worth
- fever
complications:dehydarrtion, metabolic acidosis
Treatment
- supprtoive: fluids, electrolyte replacements
- vaccine! to prevent
Acute Diarrhea: Norovirus & Adenovirus
Norovirus
- highly contagious
- mainly results in vomiting
- older kids = diarrhea as well
- supportive: usually only 24-48 hours
Adenovirus
- similar to rotavirus: diarrhea, vomitng fever
- lasts 8-10 days
Chronic Diarrhea
causes
definition
Causes
- infection (post-infectious) very common in kids
- celiac disease
- food allergy
- inflammatory bowel disease
- lactose intolerance
Definition
- stool > 10g/kg/day in toddelrs/infants
- stool > 200g/day
- lasting 4+ weeks
or
- lose watery stools > 3/daily
or
- persistant diarrhea: lasting > 14 days after an acute onset
Chronic Diarrhea due to..
- antibiotic use
- extraintestinal
- malnutrtion
- diet related
- others (listed)
Antibiotic use
- destroys normal gut flora
- overgorwth of others
- watery
- no other symptoms
- tends to go away on its own
Extraintestinal
- UTI, URI
Malnutrtion
- decreased ability to absorb, increaed risk of infections
Diet Related
- starches: fruit juices and carbs: creat osmotic diarrhea
- intestinal irritantas: spices, high fiber, etc.
- cows milk protein allergy
- IgE mediated disease
others
- chronic constipation
- post infectious
- IBD
- celiac
What is Toddler’s Diarrhea
Toddler’s Diarrhea
- healthy kid: typically 6-20 months olde; gaining weight normally
- having 3-6 loose stools a day; during nighttime
- no organic causes
- symptoms worsenw ith low-fat high carb diets
- resolves by age 3-4
- treament = alter diet, loperamide (in severe cases)
Constipation
- definition
Functional Constipation = 2+ of the following
- < 3 BM’s weekly
- 1+ episode of encorpresis/week (liquid stool squeezing past the constipated)
- stool clogging toilet
- retentive posuring and stoll holding
- pain with BMs
ROME IV Criteria
- 1 month of 2+ sx. in infants up to 4 months
- 2+ sx. for 1+ weeks a month without IBS sx.
Hirschsprungs Disease (congenital aganglionic megacolon)
Hirschprungs Disease
Patho
- absent ganglion cells in the mucosal and muscular lining of the colon; so the colon never relaxes; then gets restricted to the rectosigmoid colon
- without ganglion cells: no nerve signla to pass stoo
- commonly seen with trisomy 21
Manifestations
- delayed stooling at birth > 24 hours key
- mvomiting
- abd. distention
- reluctance to feed
- can develop enterocolitis , fever, dehydartion
- older kids: can see alternating constipation diarrhea
Diagnosis and Treatment
- DX: contrasnt enema to see transition zone
- dx. via rectal biopsy via sunction: lack the ganglion cells
Treament = surgical: colostomy, illeostomy, and primary repair
Majority of Constipation in kids is what
Constimpation in kids
- most often is just retnetion:: voluntary or involunatry retentive behvaiors
- ignroe teh stretch receptos in the rectum
- pain, fever of going, etc.
- “chronic rentitive constipation”
- still should rule out hisrprunsg via symptoms
Constipation in kids: treatment
constipation treatment: once you identify no underlying causes
for those older than 12 months
- disimpaction (enemas, saline or other)
- then miralax “cleanout”
then maitnence dose with miralax
- can add senna if need the stimulation
for those under 12 months
- lactulose and a suppository
other thigns
- increase fiber and hydration
-
Encorporesis
what is it and why does it occur
causes
work up
What is it
- the repeated pasage of stool in inapproprite places (underpants) in those chronilogically and developmentally older than 4 (should be potty trained)
- occuring each month for 4 months
- not due to any other reason
highest prevelence in 5-6 year olds: constipation: so the wet stool leaks
Causes
- 90% due to underlying constipation
- fear ot toilets
- stress
Work up
- abd exam: palpate
- anal exam; for fecal impaction
- lower spine: for tethered cords
- rarelt: KUB can be done
- history: frequency, volume, fears, life stresosrs, other meds/dx.
ruel out: hypothyroiid, CP, tethered cord, hisrsprungs, anal/anatomical ab.
Treatment of Encorpresis
Treatent
- bowel regimen + treat underlying constipation
- bowel cleanout with maintene bowel regimen
- MRI of spine if warrenteed
- timed toileted: after meals with teh gastrocolic reflex
- psych if needed or GI referral
GERD and GER (Reflux) in peds
GER: reflux
- occurs and resolves spontaneously
- no underlying complications
GERD: reflux disease
- causes secondary conditions/complications
GER
what is it
GER
physiologically:
- LES is immature : less tone
- smaller stomahc
- shorter esophagus length
- laying supine
will be happy spitters: not irritable, colickly or weight loss
peaks 4-5 months: resolves 12-18 months
improves with solids and sitting upright when they get to that age
GERD
infants
older kids
Infant GERD
symptoms
- feed aversion
- pain behaiors (Criying)
- gagging
- arching
- failure to thrive
- hiccups
- GI bleed
- respiratory issues
- abnormal posturing: Sandifer syndrome
Older childern GERD symptoms
- regurgitation
- heartburn
- dysphagia
Extraesophageal manifestations
- Upper Airways: hoarseness, sinusitis, laryngeal erythema
- apnea or ATLE(bruits)
- lower airway: asthma, recurrent PNA, recurrent cough
- dental erosins
- sandifer syndrome
GERD workup in kids
treatment
Workup
rule out other causes of recurrent vomiting
- alarm sx. = bilious emisis, projectile, GI bleed, diarrhea
- milk allergy, EE, pylortic stenosis, obstruction
- upper GI
_____________________
- trial of hypoallergeic formula for 2 weeks
- trial of acid suppressants
- upper GI endoscopy can be warrented
- pH probe if warrented
Treament
- more frequent smaller feeds
- thickened feeds
- H2 blockers
- PPIs
- nissen funoplications
infants
- small feeds, uprightholding, thicken, trial of non milk protein
- if that doesnt work - PPI and send to GI
Older kids
- alter lifestyle: weight loss, diet cahnges, no smoking
- PPI or H2
- severe disease: nissen funpod. procedure with stomach wrapped
complicatiosn = esophagitis, esophageal structire, barretts and feeding issues
