PEDS GI Flashcards
1
Q
why do infants get gastroesophagual reflux
A
- reflux of gastric contents into the stomach
- combination of lower esophageal sphincter immaturity, small stomach, and short esophagus
2
Q
gastroesophagual reflux is common in infants at what age group
A
< 6 months
3
Q
differentiate between gastroesophagual reflux (GER) and gastroesophagual reflux disease (GERD)
A
- gastroesophagual reflux (GER) = “happy spitter”
- growing well, healthy clinically
- gastroesophagual reflux disease (GERD) = “unhappy spitter”
- failure to thrive
- fussy or irritable/ dystonic neck posturing
- feeding refusal
- occult blood in stool
4
Q
what is esophageal atresia
A
- upper esophagus does not connect with lower esophagus (+/- tracheoesophageal fistula)
5
Q
treatment for infants with GERD
A
- positional therapy: upright after feeding
- elimination diet (milk) or change in formula
- thickened feeds: rice in formula
- don’t overfeed
- medications
- H2 blocker (ranitidine)
- proton pump inhibitor (iansoprazole) > 1 yo
6
Q
GERD prognosis
A
symptoms usually resolve by 9-12 months
7
Q
what is Pyloric stenosis
A
- Pylorus muscle thickening, causing stenosis of the pyloric channel and gastric outlet obstruction
- M > F (4:1)
- more common in first born children
8
Q
clinical presentation
- 3-12 week old infant with vomiting
- Projectile vomiting after eating
- non-billous vomitus
- “hungry vomiter” infant is hungry
A
Pyloric stenosis
9
Q
physical exam
- upper abdomen distended after eating
- prominent peristaltic waves moving from L to R
- “olive” sized mass in RUQ
A
pyloric stenosis
10
Q
test of choice to diagnose pyloric stenosis
A
ultrasound
11
Q
if ultrasound is nondiagnostic, what test can be done if you expect pyloric stenosis? what do you expect to see on this test?
A
- Upper GI series: The test uses barium contrast material, fluoroscopy, and X-ray.
- “string sign”
12
Q
treatment of pyloric stenosis and prognosis
A
- treatment
- IV fluids and electrolyte resuscitation
- Pyloromyotomy
- incision down to mucosa and fully across length of pylorus
- prognosis: excellent
13
Q
Define congenital atresia and name the different types
A
- one or more segments of bowel may be absent and/or obstructed at birth
- types
-
Duodenal atresia
- trisomy 21 (30%)
-
Jejunoileal atresia
- cystic fibrosis
- Colonic atresia - least common
-
Duodenal atresia
14
Q
differentiate between etiology of Duodenal atresia and jejunoileal atresia
A
- Duodenal atresia: secondary to events that occur during early development of gut (8-10 weeks of gestation)
- jejunoileal atresia: utero vascular accident occuring 11-12 weeks
15
Q
clinical presentation
-
bile stained vomiting
- within first 24-48 hours of life
- mild abdomen distension
- failure to pass meconium (+/-)
A
Congenital atresia
16
Q
“double bubble” sign is common of what condition
A
- Duodenal atresia
- due to gas and dilation in both stomach and duodenum
17
Q
what will be characteristic of jejunoileal or colonic atresia on abdominal plain film
A
- dilated loops of bowel and air fluid levels
18
Q
how is congential atresia diagnosed
A
- CMP: electrolytes, biliruben
- abd plain film
-
Upper GI series/constrast enema
- used to confirm diagnosis and identify area of obstruction
19
Q
Etiology of midgut malrotation +/- volvulus
A
- incomplete rotation of midgut during embryonic development
- malrotation can result in
- shortening of mesenteric root -> increases small bowel mobility which can lead to volvulus
- volvulus: small intestine twists around SMA causing vascular compromise
- **surgical emergency
20
Q
clinical presentation
- >50% present before 1 month of age
- bilious vomiting, abdominal pain
- +/- hematochezia
- PE
- abd distension
- tenderness
- visible peristalsis
A
midgut malrotation +/- volvulus
21
Q
how is midgut malrotation +/- volvulus diagnosed
A
- abd xray: r/o bowel obstruction
- UGI
- “Corkscrew appearance” - proximal jejunum spiraling downward in the right or mid-upper abd
- barium enema: if diagnosis is in question
- will see cecum in RUQ instead of RLQ
22
Q
What is intussusception
A
invagination of one portion of intestine into another (usually near ileocecal junction)
23
Q
What is the most frequent cause of intestinal obstruction in the first two years of life
A
intussusception
- ** rare in newborns
24
Q
What causes intussusception
A
- idiopathic (75%): no clear link
- stem from lead point
- lesion/variation in intestine is dragged by peristalsis
- Meckel’s
- tumor
- hematoma
- vascular lesion
- lesion/variation in intestine is dragged by peristalsis
25
clinical presentation
* intermittent, severe crampy abd pain
* cries and draws legs up toward chest
* vomiting
* does not feed
* **"Currant jelly" stools**
* blood and mucous
* triad (15%)
* pain
* palpable sausage shape
* currant jelly stools
Intussusception
26
how is Intussusception diagnosed
* abd ultrasound
27
managment of Intussusception
1. urgent surgical consult
2. air enema
* can reduce with 74% success rate
* US guided
* risk: perforation
3. sugical intervention
* can be fatal if reduction is not performed
28
What is Meckel's Diverticulum
* embryonic remnant of vitelline duct
* incomplete obliteration and diverticulum formed
* located **within 2 feet of Ileocecal valve**
* gastric acid produced -\> damage
* **bleeding occurs from mucosal ulceration**
29
Meckel's Diverticulum **rule of 2's**
* 2% of the population
* 2:1 M:F ratio
* 2% become symptomatic
30
clinical presentation
* **Painless rectal bleeding**
* obstruction (volvulus or intussusception)
* Diverticulitis (can mimic appendicitis)
Meckel's Diverticulum
31
how is Meckel's Diverticulum diagnosed
* Technetium-99 scan (Meckel's scan)
32
what is the most common pediatric surgical emergency
**appendicitis**
33
appendicitis is most often caused by
obstruction of the appendiceal lumen leading to inflammation
34
when does appendicitis become most prevelant
* peaks 2nd decade of life
* rare before 5 yo
35
clinical presentation
* anorexia
* migrating abd pain (periumbilical to RLQ)
* vomiting (after onset of pain)
* fever
* guarding
* rebound tenderness
* + Rovsing sign
* Obturator or ileopsoas sign
appendicitis
36
how is appendicitis diagnosed
1. US
2. CT scan
37
What is Hirschsprung's disease
* aka: congenital aganglionic megacolon
* occurs secondary to **absense of ganglion cells** in mucosal and muscular layers of **colon**
* begins in distal bowel (usually rectosigmoid)
* peristaltic waves cannot extend beyond this zone of de-nervation and bowel may become obstructed
38
what is the most common cause of lower bowel obstruction in neonates? is it more prevalent in males or females
* Hirschsprung's disease
* M\>F 3:1
39
clinical presentation
* 80% present within first 6 weeks of life
* 20% develop _enterocolitis_
* fever, vomiting, explosive diarrhea
* newborns **fail to pass meconium within 48-72 hr**
* **bilious vomiting**, abd distension
Hirschsprung's disease
40
older children with Hirschsprung's disease may present with
* chronic constipation
* failure to thrive
* \*later diagnosis -\> less severe disease : smaller segment of colon affected
41
physical exam
* abd distension
* anal canal may feel **narrow on rectal exam**
* anal canal and rectum **devoid of fecal material******
* explosive release of gas/stool when finger removed = "**squirt" or "blast" sign**
Hirschsprung's disease
42
how is Hirschsprung's disease diagnosed
* rectal biopsy is gold standard
43
managment of Hirschsprung's disease
1. resection of aganglionic segment
2. colostomy
3. colorectal anastomosis performed later
* over prognosis is good
44
inflammatory bowel disease consists of what two conditions
* Crohn's disease
* ulcerative colitis
45
inflammatory bowel disease is most prevalent in what patient population and age group
* peak incidence: 10-25 yo
* 20-30% present before age 20
* whites \> african americans \> hispanics
46
smoking has what effect on risk for inflammatory bowel disease
* doubles risk of crohn's disease
* halves risk for ulcerative colitis
47
clinical presentation
* diarrhea, abd pain, +/- hematochezia
* weight loss
* growth failure
* arthritis, sacroileitis, uveitis, anemia
inflammatory bowel disease
48
Crohn's disease affects what part of intenstine
* transmural inflammation
* can occur from mouth to anus
* ileum most commonly affects
49
colonoscopy that reveals skip lesions and cobblestone appearance is indicative of
Crohn's disease
50
ulcerative colitis affects what part of intestine
* involvement of **rectum and large colon**
* **mucosal layer only**
* starts from rectum and extends proximally
51
colonoscopy that reveals erythematous and friable mucosa with small erosions is consistent with
ulcerative colitis
52
ulcerative colitis greater than 10 years puts a person at a high risk for
colon CA
53
treatment of inflammatory bowel disease
* 5-ASA (sulfasalazine)
* immunomodulating agents (6-MP)
* biologics (remicade)
* steroids
* used during flares
54
what is the definition of diarrhea
\> 3 loose watery stools/day
55
diarrhea that is diet related can be due to what
* toddler's diarrhea: fruit juice
* cow's mil/soy protein enteropathy
56
what are the red flags to look for when a patient complains of diarrhea
* fever
* severe abd pain
* blood in stool
* vomiting
* dehydration
* leukocytosis
* persistent symptoms
* growth and development affected
57
evaluation and management of diarrhea
1. focus on **hydration**
2. pursue further if red flags
* labs
* stool cx
58
functional diarrhea has a high prevelance at what age
* 5-6 yo
* functional: no anatomical biochemical abnormality
* voluntary withholding of stool
* often at times of change
* intro to solid foods
* toilet training
* start of school
59
encopresis
stool incontinence
60
differential diagnosis for constipation
* Hirschsprung
* neuropathic disorders (spina bifida)
* hypothyroidism
* cystic fibrosis
* medications
* psychological
61
managment for constipation
* decrease cow milk intake
* if encopresis -\> releive impaction (polyethylene glycol)
* laxative therapy
62
clinical jaudice is defined at what level
biliruben greater than 3 mg/dl
63
neonatal jaundice
* elevation of indirect biliruben
64
breast milk jaundice
* benign
* appears in breast fed infants - _1st week of life_
* inhibition of conjugation of biliruben -\> increase in **indirect biliruben**
* resolves spontaneously
* may be contributed to Gilbert's syndrome
65
what is pathological jaundice defined as
* hyperbilirubinemia that requires intervention
1. clinical jaundice appearing in first 24 hours
2. clinical greater than 14 days of life (in term infant)
3. total bili higher than 95% on nomogram
66
what are the causes of \< 24 hours pathological jaundice
1. severe hemolysis
* ABO incompability
* Rh iso-immunisation
* sepsis
67
coombs test
detect antibodies on the baby's red cells
68
biliary atresia
* rare disease that destroys bile ducts, resulting in obstruction to bile flow which damages liver
69
clinical presentation
* jaundice
* dark urine
* light stools
post hepatic jaundice- biliary atresia
