peds GI Flashcards
newborn in the nursery a few hours after birth because the infant vomited and choked after feeding. Non-bilious emesis (clear not green). The nurse reports that she has to frequently suction oral secretions.
37WGA. Pregnancy complicated by polyhydramnios (too much fluid)
-normal abd, hrt, clear to auscultation, but coughing
upper gut obstruction, before ampulla of vater -
- T-E fistula (more common)
- esophageal atresia
- esophageal web, stenosis
If respiratory distress and scaphoid abdomen: consider diaphragmatic hernia (may be either non or Bilious…consider Duodenal Atresia)
Other: GE reflux (Not burped adequately), Cardiac lesions, CNS
what to do for non-bilious emesis newborn??
what can you see on XR esophageal atresia??
don’t want to do barium swallow, do NG tube (actually OG tube- go thru mouth, like thick spaghetti) have pre-known length to get to stomach, if coils before, know there is obstruction in esophagus, can see on XR
-see no air in abdomen
DDX: non-bilious emesis in newborn: GI, metabolic, CNS, infectious causes
- GI: GERD, Overfeeding
- Neuro: Subdural hematoma, Hydrocephalus, Mass lesion
- Metabolic: Galactosemia, Hypercalcemia, Urea cycle defects, Amino academies
- Infectious: Sepsis, Meningitis, UTI, Gastroenteritis
DDX: non-bilious emesis in newborn: Anatomic causes
Cleft Palate Laryngopharyngeal Cleft Esophageal atresia Tracheoesophageal (TE) fistula Vascular ring Achalasia Antral web Duodenal atresia/stenosis Pyloric stenosis
esophageal atresia most commonly occurs with ??
coexisting tracheoesophageal fistula (92%). (This case is the rare, esophageal atresia without TEF.) air in stomach
-tracheoesophageal fold
-pure esophageal atresia will not have air in stomach
Children with Esophageal atresia usually present within ??
Treatment: ??
24-48 hours after birth with copious oral secretions and drooling. Choking, vomiting (non-bilious).
Aspiration pneumonia
-surgical
Mackyo’s case:
-make fistula in neck that drains, so no buildup
-fed by NG tube
At day ?? of gestation, a ventral diverticulum is formed from the caudal end of the primitive pharyngeal foregut. This laryngotracheal diverticulum undergoes elongation and differentiation to eventually form the larynx, trachea, bronchi, and lungs. In order to separate the dorsal foregut (future esophagus) from the ventral laryngotracheal diverticulum, ?? fuse to form a septum that completely separates these structures (eFig. 392.1). It is believed that ?? leads to the anomalies of esophageal atresia and tracheoesophageal fistula (TEF).
day 26 or 27
longitudinal tracheoesophageal folds
failure of these folds to completely form, or improper timing of their formation
Esophagus and trachea develop during ?? of life. Defects in the ?? can result in TEF and esophageal atresia.
4-6wks
mesenchyme separating the two
use gastrographing (not barium, would damage lungs)
TEF and VACTERL (if have one congenital problem, need to look for others)
V: Vertebral Hemivertebrae (etiology: sacral element agenesis, caudal regression, Dx: Plain radiography, spine US, MRI (if U/S +)
A: Anorectum Imperforate anus: Dx: Exam
C: Cardiac Structural congenital heart dz: Dx: Echo
T: TE fistula: Suspect with esophageal atresia
E: Esophageal atresia: Dx: NG tube passage with plain radiography
R: Renal Horseshoe kidney, renal collecting system anomalies: Dx: Renal ultrasound
L: Limb Radial hypoplasia, atresia: Dx: Plain radiography
DDX: What does this xray show? slide 24
Emesis may be bilious
“double-bouble” sign
duodenal atresia
-stomach is one bubble, proximal duodenum BEFORE atresia is 2nd bubble; no air below
-greenish vomiting as newborn
duodenal atresia: Due to insult during ?? week gestation:
failure of ?? of duodenum
Usually ?? part of duodenum
what is associated??
8-10th
recanalization/vacuolization
Results in occluded lumen
2nd or 3rd
Trisomy 21: Down’s syndrome
XR slide 28: scaphoid abdomen (“sucked in”), breathing difficulties, cyanotic, +/- vomiting
Diaphragmatic hernia
- intestines protrude up in utero (typ. left side)
- hear bowel sounds in thorax, push on lungs
- need to intubate, NG tube to minimize air in gut
- need surgical intervention
4wk old infant has had 6 days of projectile vomiting, Nonbilious.
- vigorously feeds but vomits forcefully afterwards.
- full term infant who had been gaining weight until the vomiting started. Today decreased wet diapers and no stools
what metabolic condition worry about??
pyloric stenosis
- dry mucous membranes
- typically lose weight, may be jaundice (reabsorb indirect)
- palpable epigastric (RU abdomen) olive mass (5–15 mm), only in 13.6%
- look hungry, drink/eat vigorously and comes right back up, peristaltic wave (can see, very dehydrated)
- hyperchloremic metabolic alkalosis (vomiting up acid)*
pyloric stenosis: Projectile postprandial vomiting usually begins ??.
Vomiting starts at birth in about 10% of cases and onset of symptoms may be delayed in ??.
Vomitus is ??
between 2 and 4 weeks (3-6 wks??) of age but may start as late as 12 weeks (pyloric muscle takes time to hypertrophy) in ddx 0-3 mos
preterm infants
rarely bilious (proximal) but may be blood-streaked
pyloric stenosis ddx
Pylorospasm (non-bilious)
GE reflux (non-bilious)
Malrotation with midgut volvulus (bilious)
Gastric bezoar (non-bilious) (obstruction in stomach)
(CNS tumor)
(poison)
what studies to do with pyloric stenosis??
U/S: width and length of pyloric muscle; will do sx based on US
upper GI with barium: try to avoid to minimize radiation (adults: apple-core lesion) see think white line getting thru, like “string-sign”
lab studies with pyloric stenosis
Hypochloremic metabolic alkalosis (correct before sx!)
This patient:
Sodium: 135 Chloride: 90 Potassium: 3
CO2: 35 (typ: 22, here too high, think metabolic acidosis)
-May have indirect hyperbilirubinemia
pyloric stenosis epidemiology/associations
6-8 per 1000 births, 5:1 male Non bilious emesis Acquired condition: Thickening of pyloric muscle, Most typically 2-12 weeks of age Peristaltic waves “caterpillar stomach” May be associated with erythromycin
pyloric stenosis imaging
XR: large stomach decreased bowel gas
US: elongation (> 15mm) and thickening of pylorus (4mm)
Barium Upper GI: “String sign”, or “beak of barium”
pyloric stenosis tx
IV fluids and electrolyte replacement When stable (after correcting Hypochloremic metabolic alkalosis!)-->Surgical intervention: pyloromyotomy
3wk old infant w/ bilious emesis 1day, irritable and not consolable.
Prior hx: NSVD, no pregnancy complications, Poor weight gain.
On exam: T: 98.6F, P:180 (high), BP 70/40 (minimal)
Abdomen: distended
-continues to have green emesis (BILIOUS)
ddx? infection and anatomical
think congenital (probably not atresia?, would have presented earlier)
Infectious: Peritonitis, Viscous perforation, Necrotizing enterocolitis, Neonatal sepsis
Anatomic: Intestinal atresia (usually duodenal atresia, also jejunal or ileal), Duodenal stenosis, Intussusception, Intestinal malrotation w/ midgut volvulus, Annular pancreas, Duodenal web, Organomegaly → obstruction
malrotation/volvulus
can present few wks after birth or could happen right after
-bilious vomit, abd. distension
