Pediatric GU/Gi Disorders Flashcards

1
Q

differentiate
pyleonephritis
cystitis
urethritis

three time periods when UTIs are common in children

A

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

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2
Q

Risk Factors for UTIs in Children

A

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

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3
Q

Pyelonephritis
symptoms

A

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

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4
Q

Cystitis
Symptoms

A

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

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5
Q

How can a UTI be diagnosed in children
- ways to collect specimen

A

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

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6
Q

UTI in kids
- urinalysis results
- urine culutre
- pathogens

A

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

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7
Q

Treating Pyleonephritis
- infants under 2 months
- kids 2-24 moths + fever

A

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)

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8
Q

what do you do for an infant/young kid with febrile UTI based on positive culture

A

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)
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9
Q

Imaging Studies for pediatric UTIs

A

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

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10
Q

what is VUR
primary due to what
dx how
treament options

A

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

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11
Q

what is PUV
how is it diagnosed
symptoms (if found later)
results: what can happens

A

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

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12
Q

what is a DMSA Renal Scan

A

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

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13
Q

non-congential anatomical reasons for UTIs in children

A

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

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14
Q

Nocturnal Enuresis
what is it: defined
frequency for dx.
primary v non-primary

A

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

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15
Q

Nocturnal Enuresis
- why is it occuring: pathological/physiologically

A

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

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16
Q

Nocturnal Enuresis
PE to do
Workup
Possible treatments

A

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)

17
Q

Noctural Enuresis
medication optiosn (if not wanting to do the alarm)

A

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

18
Q

Chronic Abd Pain in Peds
FAPD

A

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

19
Q

Functional Abd. Pain in Kids
- how to work it up
- labs

A

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)

20
Q

FABP
red flag symptoms of the abd. pain which may clue you into something else going on

A

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

21
Q

FADP
Treatment

A

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

22
Q

Acute Diarrhea
- what is it + length of tim e
- causes by what

A

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

23
Q

Acute Diarrhea: Rotavirus

A

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

24
Q

Acute Diarrhea: Norovirus & Adenovirus

A

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

25
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
26
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
27
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)
28
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.
29
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
30
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
31
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 -
32
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.
33
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
34
GERD and GER (Reflux) in peds
GER: reflux - occurs and resolves spontaneously - no underlying complications GERD: reflux disease - causes secondary conditions/complications
35
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
36
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
37
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 ## Footnote complicatiosn = esophagitis, esophageal structire, barretts and feeding issues