PEDS GI Flashcards
If you suspected inflammation or infection, what tests would you order?
CRP, CBC, ESR
If you felt there was a biliary or liver problem, what tests would you order?
AST, ALT, GGT, bilirubin
What will ordering amylase and lipase tell you?
possibly of pancreatitis
If you suspected Intussusception/malrotation, what diagnostic imaging would be ordered?
barium enema
an abdominal flat plate can be useful for:
Bowel obstruction, appendiceal fecalith, free air, kidney stones
What is a useful way to examine the upper GI tract?
endoscopy
What are the warning signs associated with a serious abdominal problem?
Vomiting for longer than a few days Abnormal screening lab Fever Bilious emesis Growth Failure Pain awakening child from sleep Weight loss Location away from the periumbilical area Blood in stools or emesis Delayed puberty
What is infant GERD
Frequent regurgitation without evidence of pathologic consequences
Very common : most babies have it but only some are symptomatic
When does infant GERD normally resolve?
Usually resolves by 1 year of age, no later than 18 months
What are the symptoms of infant GERD?
Arching of the back Torsion of the neck Lifting of the chin Irritability Refusal to eat/ “snacking” every 20 minutes Irritabilty and refusal to sleep
When do you treat infant GERD? How do you treat infant GERD?
Intervention is needed when symptoms become obvious
- lifestyle modifications
- lay supine to sleep
- medications
What are lifestyle modifications for infant GERD?
Avoid overfeeding Avoid tobacco smoke Try milk free diet Thicken feedings Keep upright for 20 minutes after eating
What is the medical treatment for GERD?
2 week trial:
Proton Pump Inhibitors are preferred first line
Zantac (Ranitidine) is often used first line
PPIs have risk of gastric cancer and osteoporosis with long term use
Should be used judiciously
How do you treat GERD in children?
PPI for 2-6 weeks
Not a chronic condition, but may reoccur
No indication if the child will have GERD as an adult
What is Peptic Disease?
Acid related injury to the esophagus, stomach, or duodenum.
What are risks factors for Peptic disease?
Risk Factors: Helicobacter pylori infection Drugs – NSAIDs, Aspirin, tobacco, alcohol, potassium, bisphosphonates Family history Sepsis Head trauma Burn injury Hypotension
How is peptic ulcer disease diagnosed?
by endoscopy!
do a biopsy for h. pylori !!
what is the drug treatment for h. pylori?
Multi drug regimen – BID for 1-2 weeks
Omeprazole – amoxicillin – clarithromycin
Omeprazole – clarithromycin – metronidazole
Omeprazole – amoxicillin – metronidazole
What is the treatment if there is no h. pylori infection?
Without H. Pylori present:
PPI
4 to 8 weeks for gastric ulcer
4 to 5 months for esophagitis
What is Colic/How is it defined?
Rules of threes
Crying for more than 3 hours/day, 3 days/week, for longer than 3 weeks
Limited by the definition of “crying”
Often see…
Crying with grimacing, drawing up of legs, passing flatus.
What should always be done when you suspect colic?
UA–rule out infection
what is the treatment for colic?
- Singing, Swaddling, Shooshing, Swinging, Sucking
- TAKE A BREAK
- Give parent’s permission to walk away
- Shaken baby prevention
- Car rides – gentle vibration
What is pyloric stenosis?
Pyloric stenosis is a narrowing of the pylorus, the opening from the stomach into the small intestine
What are the symptoms of pyloric stenosis?
- Infants begin vomiting feedings around 3 – 6 weeks of life
- Emesis becomes increasingly frequent and forceful
(“Projectile” – you need to have parent’s describe) - Infants ravenously hungry even right after vomiting
- Weight loss
- Malnutrition and dehydration occur with delayed diagnosis
- Hypertrophied pylorus may be palpable
“olive”. Most palpable right after emesis
What can you sometimes feel on PE for pyloric stenosis?
a bump in the upper right quadrant…feels like olive
How do we diagnose pyloric stenosis? What is the treatment?
Ultrasound is test of choice for diagnosing
Treatment:
Fluids
Surgical correction
What is functional constipation?
Two or fewer stools per week
Voluntary withholding of stool
Infrequent passage and large diameter stool
Often painful stools (which leads to more withholding)
What is encoporesis?
tChildren with functional constipation that have fecal incontinence.
Caused by leakage around retained stool
Often perceived by parents as diarrhea
How do you treat functional constipation and encoporesis?
they are treated the same
you need to do lifestyle modifications first!!!
change diet, do disimpaction, stool softeners…must do with NO ACCIDENTS for a minimum of 6 months.
what medicine is used to treat FC and enco?
- A Prolonged course of stool softener therapy is needed (usually several months)
- —>Polyethylene glycol – preferred
- —->Milk of Magnesia – also used
- Needed to alleviate fear of defecation
-Other Treatments:
Sitting on the toilet first thing in the am and after meals
Positive Reinforcement
NO negative reinforcement
Constipation in newborns is what until proven otherwise?
Hirschsprungs
What is Hirschprungs?
- Caused by a failure of ganglion cells to migrate into the distal bowel.
- Results in spasm and functional obstruction of the aganglionic segment
- Most affected babies rapidly become ill with symptoms of enterocolitis or obstruction (TOXIC MEGACOLON)
What are symptoms of Hirschsprungs?
Characterized by: Delayed meconium passage Abdominal distension Vomiting Occasional Fever Foul smelling stools
What is Gastroschisis?
Gastroschisis – abdominal wall defect of which intestinal contents herniate out
What is Omphalocele ?
Omphalocele – abdominal wall defect at the umbilicus – bowel herniates into the umbilical cord.
What is midgut malrotation?
Occurs with the gut does not completely rotate during fetal life. Makes child susceptible to Volvulus. Volvulus is an obstruction caused by the abnormal twisting of the stomach or intestine.
What are signs of midgut rotation?
Bilious vomiting --->1st month of life (60%) --->Later in infancy and childhood (40%) Pain and Tenderness over ischemic area Bloody emesis and stools Eventually as necrosis sets in, peritonitis and sepsis
What diagnostics should be ordered for midgut rotation? what can we expect to see?
CBC, BMP -->Decreasing platelets = bowel ischemia -->High white count = sepsis --->Electrolytes and bicarb abnormalities = dehydration Imaging Studies: 1. Abdominal X-rays 2. Ultrasound 3. Upper GI Series – A MUST for Diagnosis
What is a MUST for diagnosis of midgut rotation?
upper GI series
What is the treatment for midgut rotation?
you must get SURGERY!!!!
if not surgery, could lead to necrosis and thats even bigger problem.
complication could be short gut syndrome.
Children can sometimes just develop a colitis, especially after an infection…what are the signs and symptoms of this?
Diarrhea, blood and mucus in stool
Urgency and tenemus
Often wakes child from sleep to pass stool
What are the signs and symptoms of toxic megacolon?
Life-threatening
Fever, abdominal distention, pain, massively dilated colon, anemia, low serum albumin
what are the Extraintestinal manifestations associated with IBD?
Primary sclerosing cholangitis (inflammation of the bile ducts), arthritis, uveitis, pyoderma gangrenosum
What are the main features of crohns? what are the main features of UC?
Crohns:
- can occur anywhere along tract
- occurs in patches
- pain usually located in RLQ
- transmural
- bleeding not common
UC:
- usually large colon
- usually continuous
- pain common in lower left abdomen
- bleeding common
What is the treatment for UC?
5-aminosalicylic acid
Sulfasalazine, olsalazine, balsalazide
Steroids are NOT to be used long term
6 mercaptopurine or azathioprine (immunosuppressive drugs) limit need for long term steroids
Surgical colectomy with ileoanal anastomosis is curative.
What is the treatment for crohns?
Azathioprine or 6-mercaptopurine (immunosuppressive agents)
Methotrexate (difficult to control patients)
Infliximab (difficult to control patients)
Surgery – only when necessary. NOT curative
What is milk and soy protein intolerance and what are the symptoms?
Intestinal inflammation with rectal bleeding that occurs from intolerance to dietary proteins.
Intolerance ≠ allergy
Symptoms appear between 1 week and 1 year of age
Healthy appearing infant
Streaks of bloody mucus in their stools
Occasionally occult blood
No abdominal tenderness or vomiting
Occ. Iron Def. Anemia
Edema if a protein losing enteropathy is present
How is MSPI diagnosed?
usually by symptoms alone Lab – none in most cases Occ. Occult Stool testing CBC if anemia is suspected If child has persistent symptoms, diagnosis can be made with rectal mucosal biopsy Shows eosinophilic inflammation Unlikely to be done
How do you treat MSPI?
Switch to a hydrolyzed protein formula
–>Nutramigen, Pregestamil, Alimentum $$$$
Milk/Soy Free Diet for 2 weeks before resuming breast feeding
VERY restrictive diet (mostly meat, fruit, veggies)
Self resolves by 1 year of age or sooner
What is Intussusception?
Telescoping of a segment of proximal bowel into downstream bowel Occurs in 1 to 2 year olds Under 2 years – idiopathic cause. Over 2 years – suggests pathology Usually a ileocolonic intussusception
What are the symptoms of intussusception?
Crampy abdominal pain Infants draw up knees and cries out Toddlers will squat Feedings are refused If prolonged, obstruction symptoms : -->bilious vomiting -->Currant Jelly Stool -->Sausage shaped mass may be palpable
How do you diagnose intussusception? What is the treatment for intussusception?
Diagnostics: --Abdominal ultrasound --Barium enema -------->>Shows and TREATS intussusception Treatment: -IV and NG -Fluids -Refer for surgical reduction if not treated by barium enema
What is biliary atresia?
- Bile ducts are present at birth but are destroyed by an inflammatory process
- Develops in the first 1 – 2 weeks of life.
- Jaundice is often the only symptom
What happens if livery injury progresses to cirrhosis?
Symptoms of portal hypertension, splenomegaly, ascites, muscle wasting, and poor weight gain by a few months of age
If surgical drainage is not performed by two months of age, liver failure is inevitable
If you suspect biliary atresia, what MUST you order?
MUST order and total and direct bilirubin
High direct bilirubin indicates cholestasis
How do you diagnose and treat?
Imaging studies to diagnose = US or CT
Treatment – surgical “Kasai” procedure.
Occasionally liver transplant
What is the clinical presentation of prancreatitis in children?
Clinical presentation: severe abdominal pain, vomiting
May evolve into chronic pancreatitis, pancreatic insufficiency
What are some of the causes of pancreatitis in children?
Causes: trauma, infection (viral), gall-stone related, metabolic, drug induced, idiopathic, (autoimmune)
What are the diagnostics and treatment for pancreatitis?
Dx – clinical suspicion, ↑amylase, ↑lipase,
imaging: USabdo, CTabdo, MRCP
Management; NPO, IVF/TPN, low fat diet, octreotide steroids (controversial)
Describe Functional Abdominal Pain:
Recurrent abdominal pain is common (10%)
Peak incidence is 7-12 years
Pain occurs daily, usually.
Not associated with meals or relieved by defecations
Associated with a tendency toward perfectionism and anxiety
Symptoms often stress in school or novel social situations
Symptoms often the worse in the mornings and prevents or delays school attendance
*** very similar to IBS!!! BROUGHT ON BY STRESS
What is IBS?
Subset of functional abdominal pain
Characterized by onset of pain with a change in stool frequency or consistency
Stool patterns fluctuate between diarrhea and constipation
What kind of diagnosis is FAP and IBS?
diagnosis of exclusion!!
watch out for secondary gain by kids!
What is the treatment for FAP and IBS?
Eliminate secondary gain
Return to school
Fiber supplements
In severe cases, amitriptyline or SSRI may be helpful
Referral to mental health (significant anxiety or dysfunction present)
What is the most commonly ingested FB?
coins
Most coin ingestions by children <2cms in diameter (dimes 18mm / pennies 19mm)
Esophageal coins are usually identified at the thoracic inlet or at the gastroesophageal junction
Coins are usually non-corrosive
If it FB makes it to where, then it can usually pass safely?
stomach
What are the symptoms of an esophageal FB?
Sudden onset of dysphagia, wheezing or respiratory distress
Dysphagia / drooling & hoarseness (caustic ingestion)
Chest discomfort
(long standing) neck / thoracic mass
What does the diagnosis of a FB require and how is it managed?
Diagnosis:
–>If symptomatic Chest x-ray / ? Metal detector +/- barium swallow / CT (NO MRI!!!)
Management:
Heimlich maneuver may lead to esophageal rupture
(AAP) 4 x strong back blows followed by chest trusts
Observation
Endoscopic removal / surgical referral
Caustic ingestions can lead to…
perofrations and strictures
How do you manage caustic ingestions
Early neutralization (orange juice / cola) has been shown to decrease esophageal injury
**Do not induce vomiting
**Do not pass NG tube to gastric lavage
All children with suspected caustic ingestion should be admitted for evaluation and CXR
NPO / IVF
Early endoscopy <12 – 24hrs
Broad spectrum antibiotics
i.v. steroids
