Peds GI Flashcards
causes of projectile vomit
obstruction, pyloric stenosis, GERD
bilious vomit
green is pathologic!
Obstruction beyond the duodenal ampulla of Vater
Treatment of GER
Reassurance and education Positional changes (sit up after feeds) Appropriate amount of food (Smaller feeds, more freq) Formula change Formula-thickened (Rice cereal) Medications: Empirical (H1-block, PPI)
Most common cause of non-bilious vomiting in infants
overfeeding
typical infant needs 100-120 kcal/kg/day
Pathophysiology of GER
immature LES muscle, so passive vomiting after feeds
How is GERD different than GER?
projectile vomiting
weight loss
abd distention
DDX of GERD in infants
milk protein allergy
anatomical problem
eosinophilic esophagitis
How to dx GERD?
primarily clinical
upper GI pH probe
Pathophysiology of pyloric stenosis
hypertrophy of pylorus muscle (elongated and thickened) eventually it can obstruct gastric outlet to duodenum
What age does pyloric stenosis usually occur?
4-6 weeks old; rarely after 12 weeks
palpable “olive-shaped” mass in RUQ
pyloric stenosis
Vomit of pyloric stenosis patient?
non-bilious
projectile
coffee ground appearance
Classic lab findings of pyloric stenosis
Hypochloremic, hypokalemic metabolic alkalosis
How is pyloric stenosis dx’d?
Abdominal U/S: Hypertrophic Pylorus
Upper GI: string sign
Tx of pyloric stenosis
surgical - pyloromyotomy
What is necrotizing enterocolitis (NEC) and who gets it?
inflamm of intestinal wall in premature and SGA infants
signs/sx’s of necrotizing enterocolitis (NEC)
Bilious vomiting, poor feeding, abdominal distention in premature neonate
NEC diagnosis
KUB XR: Dilated bowel, pneumatosis of the intestines (air within bowel wall)
NEC treatment
Bowel rest
Restore Fluid and electrolyte status
Often need surgical resection
Pathophysiology of midgut volvulus
abnormal rotation of small bowel, causing cecum to rest in RUQ and mesentery to twist (Ladd’s bands)
constriction of superior mesenteric artery and small bowel ischemia
signs/sxs of midgut volvulus and malrotation
Sudden onset severe abdominal pain, distension, and bilious vomiting
Can present as cyclic vomiting in an older child
dx of midgut volvulus
Corkscrew appearance of duodenum/jejunum
Small bowel completely on right
currant jelly stools =
intussusception
How is midgut volvulus different than NEC
occurs at any age (NEC only premies)
Tx of midgut volvulus
Surgery
Pathophysiology of intussusception
Telescoping of a proximal segment of bowel into a distal segment
most commonly ileocolic (small intestine into colon)
Anatomical lead points that cause intussusception
viral infection, Meckel’s diverticulum (most common), intestinal polyp, intestinal lymphoma (think older kids)
Classic triad of intussusception
Triad: sudden intermittent abd pain, vomiting, sausage mass in RUQ
- if blood in rectum found then definitive
Intussusception imaging
- U/S diagnostic “target sign”
- Water soluble contrast or air reduction enema both tx and dx
intussusception treatment
Stabilize patient IV fluids / IV antibiotics Water / air reduction enema ~10 % recurrence after radiologic reduction Surgical de-telescoping
Meckel’s Diverticulum Rule of 2’s
2% of the population
2 feet from the ileocecal valve (located in the distal ileum)
2 inches in length
2% are symptomatic
2 years is the most common age at clinical presentation
Boys > girls, 2:1 ratio
Define Meckel’s Diverticulum
A congenital vascular out-pouching in the small intestine. Most commonly presents as painless rectal bleeding.
Bilious vomiting is ________ until proven otherwise.
small bowel obstruction
Acute abdominal pain in neonate DDX
colic
life-threatening: volvulus, NEC, adhesions
Acute abd pain in 2-5 yo DDX
acute gastroenteritis, pharyngitis, constipation
Life-threatening: trauma, adhesions, appendicitis, HUS intussusception, foreign body
How do infants manifest abd pain?
crying episodically and drawing up legs
jaundice + abd pain =
infectious hepatitis
PE tests for appendicitis
McBurney Point tenderness
Involuntary guarding
Rovsing sign (palp of LLQ produces pain in RLQ)
Psoas Sign (with patient L. side down, extension of hip produces increased pain)
Obturator sign (increased pain with passive flexion and internal rotation of hip)
Rebound Tenderness
The “Appy Waddle” (Child does NOT want to aggravate pain and reluctant to movement)
Define diarrhea
3 or more loose or watery voluminous stools per day
acute vs chronic diarrhea
acute < 2 weeks
chronic > weeks
osmotic diarrhea
Due to presence of unabsorbed or under-absorbed solute in the intestinal lumen pulling fluid out of the interstitium into the lumen.
Lactose Intolerance, excess mannitol, or sugar substitutes
Elevated Stool Ion gap > 100 mOsm/kg
secretory diarrhea
Occurs when there is active secretion of water/electrolytes into the lumen
inflammatory diarrhea
Intestinal Inflammation resulting in exudation of mucus, protein, and blood into the lumen which leads to water and electrolyte loss
EHEC, EPEC, Salmonella
motility diarrhea
Rapid transit through intestines leading to inadequate absorption
Metoclopramide, hyperthyroid, some laxatives
Appearance of acute diarrhea and associated symptoms
bloody, greasy, watery
sweats, palpitations
Acute diarrhea management
Remove the underlying cause Treat dehydration Oral rehydration therapy preferred Occasionally IV fluids Do not use antibiotics unless a treatable specific pathogen has been isolated (stool culture) Advance diet as soon as tolerated Probiotics proven to be beneficial
Causes of infectious chronic diarrhea
Post infectious: Occurs after acute infection damages mucosa; recommend probiotics to facilitate recovery
Bacterial: Children treated with antibiotics
Parasites / protozoal infections
Immune mediated cause of chronic diarrhea
Celiac disease
Inflammatory bowel disease
Allergic enteropathy
Malabsorption syndromes of chronic diarrhea
Cystic fibrosis
Pancreatic Insufficiency
“Short gut” syndromes
Toddler’s Diarrhea signs/symptoms
Chronic, painless passage of 3 or more large or unformed stools during waking hours x 4+ weeks
Normal weight gain and growth
Excessive high fructose juices intake
Toddler’s diarrhea management
Stop the juices
Provide other rehydration solutions including milk and water
Increase solid foods
Post-infectious diarrhea symptoms and management
Acute infection damages intestinal mucosa, causing chronic diarrhea
Still well hydrated, improves with fasting
Management
- Hold the dairy and high fructose juices
- Rehydration solution
- Probiotics
- Gradual advancement of foods
Define constipation
Having a bowel movement fewer than three times per week with stools which are usually hard, dry, small in size, and difficult to eliminate
DDX of constipation
- Functional constipation (most common)
- Hirschsprung Disease
- Small Left Colon Disease
- Celiac Disease
Vicious cycle of functional constipation in children
Most commonly caused by painful bowel movements with resultant voluntary withholding of feces by child who wants to avoid unpleasant defecation; this causes more pain as colon dilates
encopresis
leakage of stool around hard ball of stool
Etiology of functional constipation
Poor diet high in fats and low in fiber Withholding Pain Embarrassment and social stress School “Dirty Toilets” Improper toilet training Developmental delays / cerebral palsy
Location of pain in functional constipation
periumbilical or LUQ/LLQ
functional constipation treatment
Mild: Increase fluids, fiber; increase activity; may add juice; bowel training (am and post-meals)
Severe: Meds - Fleets Enemas, Miralax. Milk of Magnesia, Mineral Oil; at worst admit for Go-lytely (polyethylene glycol)
TREAT FOR 3 MONTHS!
Etiology and pathophysiology of Hirschsprung Disease
Congenital aganglionic megacolon
Failure of colonic nerve cells to migrate to rectum and anus during development
Lack of neuroganglia causes the involved segment of bowel to constrict and be unable to relax
Leads to severe dilatation proximal to the affected bowel
signs of Hirschsprung Disease
Sx: Failure to pass meconium during 1st 24 hours of life, consistent ribbon-like stools, +/- bilious vomiting
PE: And distension, rectal exam is “empty”
Dx of Hirschsprung Disease
ano-rectal biopsy showing absence of nerve ganglion
Treatment of Hirschsprung Disease and small left colon syndrome
surgical resection
“bird’s beak” appearance of colon
Hirschsprung Disease
How to differentiate between Hirschsprung Disease and Small left colon syndrome?
Biopsy
Increased risk of Small Left Colon Syndrome
poorly controlled maternal diabetes
Signs of incomplete development of colon
chronic constipation in infancy, pencil-like stools, distended abdomen, empty rectal vault
How is small left colon syndrome dx’d?
Barium enema
+/- biopsy
Differences btw functional constipation and Hirschsprung Disease?
Hirschsprung Disease: meconium passes > 24 hrs, vomiting, begins after birth, toxic megacolon, no stool in rectal vault, no soiling, FTT
Functional constipation: meconium passes < 24 hrs, vomit unlikely, begins with toilet training, fecal soiling, no enterocolitis, stool in rectal vault, dilated anal canal, no FTT
How can fluids be lost in the body?
vomiting, diarrhea, sweating, fever, burns, polyuria
low eating/drinking
What indicates that dehydration is compensated in infant?
good urination/wet diapers
Normal vitals
Labs to eval hydration status
bicarb
Na, K
Urine: color, specific gravity, ketones
Low bicarb indicates what acid/base state and GI symptom?
metabolic acidosis
diarrhea
High bicarb indicates what acid/base state and GI symptom?
metabolic alkalosis
vomiting
Acute volume resuscitation
Mild: home management, electrolyte solution (Pedialyte, Rehydralyte, Oral Rehydration Salts), fluid challenge
* No free water, apple juice, soda, +/- gatorade
Mod: IV fluid bolus, NS bolus; if good response and no vomiting send home
Severe: IV fluids, transport to ER
Mild, moderate, severe dehydration %
mild: 5% (fairly asx)
moderate: 10%
severe: 15%
Signs of severe dehydration in infant (15%)
increased, thready pulse tenting skin No tears Cracked oral mucosa Sunken anterior fontanelle Sunken eyes Clammy skin >3 sec cap refill Anuria Lethargy
Maramus nutritional deficit and symptoms
Severe caloric, protein, vitamin, and mineral deprivation
Marked emaciation: loss of cutaneous fat, brittle/sparse hair, poor nail growth, diarrhea, hypothermia
Kwashiorkor nutritional deficit and symptoms
Diet deficit in protein but adequate caloric intake
signs: edematous child, hepatomegaly, poor wound healing
Effects of Vit A deficiency
Lack of carotenoids Blindness (Starts as night blindness) Brittle hair and nails Dry skin Chronic diarrhea
Effects of Vit D deficiency
fragile bones - Rickets
Effects of Vit E deficiency
Hyporeflexia, loss of peripheral vision, peripheral neuropathy, hemolytic anemia
Effects of Vit K deficiency
bleeding disorders
All breast fed infants need Vitamin __ supplementation shortly after birth.
D
Thiamine deficiency causes and effects? common in what patients?
“Beriberi”
Lack of whole grains, legumes, dairy
Neuro symptoms: arrhythmias, neuropathies, muscle weakness
Alcoholics / Jejunal resection
Effects of folate deficiency
Macrocytic Anemia
Effects of Cobalamin (B12) deficiency
Pernicious Anemia
Macrocytic anemia
Neuropathies
How to calculate total fluid deficit?
10 kg patient who is 5% dehydrated
- 5 kg = (10 kg x .05%)
1 kg of water = 1000 mL
Thus the patient has lost 500 mL of water weight
0.5 kg x (1000 mL/kg)
Patient has total fluid deficit of 500mL
Holliday-Segar Rule to calculate maintenance fluids
0 – 10 kg: 100 mL/kg per day
> 10 – 20 kg: 1000 mL + [(50 mL/kg/day) x (#kg over 10)]
> 20 kg, 1500 mL + [(20 mg/kg/day) x (#kg over 20)
How do you know how much fluids child needs? How fast is this corrected?
maintenance fluids + total fluid deficit
1st half over 8 hours, then 2nd half over remaining 24 hrs (16 hrs)
ex: if 1500 mL deficit, then 90 mL/hr x 8 hrs (750 mL) and 45 mL/hr x 16 hrs (750 mL)
How many mLs in an ounce?
30 mL
Vitamin C (ascorbic acid) deficiency
“Scurvy”
Lack of Citrus Fruits and veggies
Small intestinal disease
Sx: Irritability, bleeding problems, bony abnormalities
Zinc deficiency effects
Mutation in zinc transport protein
Incidence 1 in 500,000
Glossitis, photophobia, nail dystrophy
Acrodermatitis enteropathica
4 yo boy with fever, cramp abdominal pain, and loose, guiac positive stool. Parents just bought him a pet turtle. dx and tx?
Salmonella (reptiles, exotic pets)
No abx given
16 yo healthy adolescent boy eats left out rice. Then gets nausea, non-bilious vomiting, abd cramps and loose stool shortly after. No fever. What is dx?
“food poisoning” (Enterotoxin from Staph aureus or Bacillus)
ABRUBT and short-lived
3 yo girl with apparent febrile seizure. Went on camping trip with no running water. mucoid appearing stool. Temp 101F, bicarb 20, glucose 110, white count elevated at 15,000, Guiac+ stool. Dx?
seizures + bloody diarrhea = Shigella
contaminated water, tenemus, painful rectal exam
5 yo girl with 1 day of stomach ache and loose diarrhea. 4 days ago at petting zoo. Give Bactrim and sent home. 2 days later HA and nausea. Decreased urine output. BP 124/86. Likely dx?
HUS
due to abx treatment of E. coli 0157:H7
DDx: MAHA, thrombocytopenia, acute renal failure
clear watery diarrhea, undercooked seafood, rapid and severe dehydration, coastal waters. what organism?
Vibrio cholerae
campers, infected water source, lakes
chronic diarrhea, bloating, flatulence. what organism?
Giardia
Tx for Giardia and entamoeba Histolytica
Flagyl (metronidazole)
Diarrhea with recent abx use
C. diff
C. diff treatment
stop antibiotic use, Flagyl
Diarrhea with pork
Yersinia
Charcot’s triad for ascending cholangitis
fever, RUQ pain, jaundice
How is pancreatitis diagnosed?
upper abdominal pain that radiates to back
vomiting
elevated lipase
TG > 1000
Loose bloody stool after eating uncooked poultry or unpasteurized milk. Dx and Tx?
Campylobacter
Tx: macrolides or quinolones
Most common viral diarrhea in infants and young children
Rotavirus
Giardia
campers, beaver dams, lakes
cysts/trophozoites in stool
Inflammatory colitis that is continuous only from rectum to colon is _______ and colitis with “skipped” lesions that can affect any part of GI tract is _________.
Ulcerative colitis
Crohn’s
Inflamm bowel disease that causes severe weight loss and growth failure.
Crohn Disease
