Peds GI Flashcards
pyloric stenosis more common in what gender and what child?
males and first born child
at what age is pyloric stenosis typically seen and at what age is it rare? kids born with it?
seen 3-5 weeks of life
rare after 12 weeks
KIDS ARE BORN WITH THIS AND IT WORSENS VERY QUICKLY
causes of pyloric stenosis?
don’t know
- multifactorial
- genetic predisposition
- environmental (mom doing something that causes thickening of the pyloric musculature)
Erythromycin in first 2 weeks of life or late pregnancy
symptoms of pyloric stenosis?
PROJECTILE VOMITING AFTER EATING (Hallmark)
-nonbilious
Weight loss (b/c vomiting up food)
HUNGRY AFTER VOMITING
what is found on PE for pyloric stenosis?
Palpable OLIVE at the lateral edge of the rectus abdomens muscle RUQ (where pyloric is) - felt best after vomitting
peristaltic waves may be visualized pre-emesis
child is thin or emaciated
may have jaundice from starvation
what is the GOLD STANDARD for dx of Pyloric Stenosis?
U/S
when do you do endoscopy for Pyloric Stenosis?
if U/S or UGI is inconclusive
lab studies for Pyloric Stenosis
Check electrolytes to measure dehydration status
CBC (anemia)
CMP (LFTs, electrolytes)
what is seen on U/S of pyloric stenosis?
thickening and elongation of the pyloric
what’s the first treatment for pyloric stenosis
First - correct hydration status (Fluids)
what is the surgical treatment of pyloric stenosis?
Pyloromyotomy
-relieves the constriction
what is intussusception?
invagination of the colon into itself
at what age is intussusception most commonly seen?
3 months - 5 y/o
site of intussusception is typically near what junction in the colon?
ileocecal junction
how does intussusception occur?
(1) Have surgery and then have adhesions, which cause catch point
(2) Proximal bowel segment telescopes into distal segment
(3) Associated mesentery dragged along
(4) Venous and lymphatic congestion
(5) Intestinal edema -> POSSIBLE ischemia and perforation peritonitis
what causes intussusception?
75% of cases of intussusception are ideopathic
Pain in intussusception is…
sudden, severe, crampy, progressive
kids looks sick and in pain
Child in intussusception is…
inconsolable, LEGS DRAWN UP, episodes last 15-20min
non-bilious vomiting post pain but may worsen to bilious
what’s the HALLMARK of intussusception?
Child has legs drawn up b/c having cramps and trying to relieve it
b/w episodes of intussusception, what are the s/s?
- normal and pain free
- stool may contain gross or occult blood
- CURRENT JELLY STOOL (mucous)
- may feel sausage shaped abd mass in R side of abd
what is the TRIAD of intussusception?
pain, palpable mass, current jelly stool (only 15% present with this triad)
when is x-ray done for dx of intussusception? what is seen on x-ray?
to r/o obstruction or other dx
see lack of colonic gas with massively distended loops of bowel (air levels under the diaphragm)
what signs on x-ray on seen for intussusception?
Target sign
Crescent sign
what is the Target sign for intussusception?
over right kidney (peritoneal fat surrounding intuss)
what is the Crescent sign for intussusception?
soft tissue density protruding into gas of large bowel
how is dx of intussusception usually made?
Clinically
-kids go from looking fine to looking they like they are in extreme pain
what is the GOLD STANDARD for dx of intussusception? what’s seen on it?
U/S
-classic appearance is “bull’s eye” or “coiled spring”
-Doppler may show poor/absent perfusion
what is the non-operative treatment for intussusception?
Give barium enema or pneumatic air pressure to release the intussusception
done under fluoroscopic or U/S guidance
SURGEON MUST BE PRESENT FOR YOU TO DO IT IN CASE OF PERFORATION
what is the treatment of choice in intussusception stable pt w/out signs of perforation?
Non-operative tx
-barium enema
when is the surgical tx for intussusception indicated?
if failed non-operative approach
suspected or proven perforation or bowel necrosis
whether acute or intermittent and presently asymptomatic intussusception, who MUST you consult?
Surgery
what is Phenylketonuria (PKU)?
a d/o that affects the amino acid Phenylalanine
deficiency of Phenylalanine Hydroxylase (PAH) - can’t break down phenylalanine to tyrosine -> INCREASE PHENYLALANINE -> INTELLECTUAL DISABILITY
what does an increased phenylalanine lead to and interfere with?
leads to intellectual disability
interferes with brain growth, myelination, and neurotransmitter synthesis
HAVE NEUROLOGIC COMPLICATIONS
etiology of PKU?
autosomal recessive genetic mutation
what are the clinical findings in PKU in patients that are untreated?
- mental disability and impaired IQ
- epilepsy
- abnormal gait
- pigmentation issues (decreased pigment - hair, eyes, skin)
- eczema
- blood and urine may smell “mousy”
what do the blood and urine smell like in PKU?
“mousy”
how do you dx PKU?
newborn screening at birth
done on dried blood sample obtained from heel (like in CF)
when should tx for PKU be initiated?
by 1 week of life (ASAP)
what’s the tx for PKU?
eliminate phenylalanine from your life completely
how long is the tx for PKU?
throughout life
what needs to be monitored in PKU?
levels of phenylalanine
when is the monitoring for phenylalanine levels in PKU?
- weekly first year of life
- twice a month years 1-12
- monthly after age 12 for life
how <5 y/o kids present with appendicitis?
fever, diffuse pain, anorexia, vomiting, rebound guarding
HAVE PERFORATED APPENDIX
how do kids 5-12 y/o present with appendicitis?
- abd pain, anorexia and vomitting
- maybe migratory paining RLQ
- KEEP high level of suspicion
temperature of kids with appendicitis?
low grade 100.2-101 F
how may kids with appendicitis appear?
limping or bending over
tired or irritable
wha are the appendicitis diagnostics in kids?
- CBC/diff (elevated WBCs and polys - left shift)
- UA (r/o UTI, see sterile pyuria)
- UHCG (r/o pregnancy in child bearing girls)
if moderate risk of appendicitis, do you go further with workup?
NO
when do you consider U/S for appendicitis? also consult who?
if young, thin, female or male that are at less than or equal to moderate risk after exam and labs
consult pedi surgeon
when consider CT w/out rectal contrast for appendicitis?
- U/S inconclusive
- not a good U/S candidate
- the surgeon requests the CT
what is high risk appendicitis? what to do if high risk?
classic exam, classic hx, classic labs
- surgeon may take to OR immediately
- consult surgeon
what’s the tx for NON-PERFORATED appendicitis before the OR?
- Fluids
- Pain control (anti-pyretics, anti-emetics)
- NPO (4-6 hrs before surgery)
- Pre-op abx (cefoxitin, but ask surgeon)
what’s the tx for PERFORATED appendicitis?
May get admitted for a couple of days before surgery
- fluids, pain control, NPO
- Abx Triples (amp/gent/flagyl)
what abx used for perforated appendicitis?
amp/gent/flagyl
when is surgery for appendicitis?
6-8 hrs of dx if non-perforated
24-48 hrs of IV abx first if perforated
post-op appendicitis tx
- Pain control
- PO when pt awake
- d/c post-op day 1 if not ruptured
- 3-5 days IV abx if perforated
never ask a kid you think is constipated what?
are you constipated?
what should you ask the kid that you think is constiapted?
what are the stools like? (give choices)
what’s the normal stooling pattern of newborn?
normal stool w/in 36 hours
what’s the normal stooling pattern of 0-3 months?
3-4 stools/day
what’s the normal stooling pattern < 2 y/o?
1-2 per day
what’s the normal stooling pattern by 4 y/o?
1 per day
what are organic causes of constipation in kids?
Anatomic, metabolic, Neuropathic, Intestinal nerve, Abd musculature d/o, Food intolerance
what are functional causes of constipation in kids?
Painful defecation (so don’t poop and get constipated)
Toilet training issues (fighting toilet training)
Dietary issues (cheese, milk, etc.)
what’s the tx of constipation in kids?
treat the cause
ensure enough fluids, dietary fiber
NO COW’S MILK UNTIL 1 Y/O
Don’t force toilet training
what are kids NOT ALLOWED to have before 1 y/o? why?
COW’S MILK
-will have micro bleeding in their intestines -> can cause significant anemia
interventional tx for constipation in infants
Glycerine suppository (only works at the rectum)
Lubricated thermometer
interventional tx for constipation in older children
- glycerine suppository
- Miralax
- enema
- laxative
what is Encopresis?
the involuntary leakage of stool into the underpants with or w/out constipation
what gender gets Encopresis?
males
what is the MOST COMMON cause of Encopresis?
Constipation
-causes leakage of watery stool from cecum and proximal colon
is Encopresis dangerous?
NO, but it is serious and is socially stigmatizing and causes a vicious cycle
when does Encopresis occur?
around times of toilet training, teasing about stooling and a school onset (pooping avoidance)
can be at times of social stress at home/school
Encopresis is a ___ dx
psychiatric dx
criteria for Encopresis dx?
(1) Voluntary/involuntary passage of stool outside of bathroom or diaper
(2) One event a month for at least 3 months
(3) >4 y/o
(4) Stooling not a result of laxative or illness involving colon such as colitis, etc.
tx of Encopresis
Clean out: LOTS OF MIRALAX (or other laxative, enema, etc.)
Stool softeners
Scheduled stooling
Parental and patient education
GET KIDS ON THE CYCLE OF REALLY POOPING
what is Hirschprung’s disease?
congenital genetic abnormality
-mutations of the RET pro-oncogene
-incomplete migration of neural cells in the myenteric and submucosal plexus
what part of the colon lack in Hirschprung’s disease? what does this result in?
Part of the colon LACKS GANGLION CELLS
Results in the affected segment constriction, thus the normal PROXIMAL segment becomes distended with feces
where in the colon does Hirschprung’s disease most commonly occur?
rectosigmoid
newborn s/s of Hirschprung’s disease
failure to complete stooling or stool
child s/s of Hirschprung’s disease
- swollen belly/distended, vomiting, constipation, diarrhea
- failure to thrive (b/c not eating well), fatigue
what’s the GOLD STANDARD dx of Hirschprung’s disease?
Bx
dx of Hirschprung’s disease
X-ray -> Barium enema (shows huge rectosgimoid colon) -> bx and looking for aganglion cells
tx of Hirschprung’s disease?
surgical excision of the affected area with anastomosis of the healthy ends
what is Meckel’s diverticulum?
congenital diverticulum of the small intestine
what’s the Rule of 2’s for Meckel’s?
2% of population 2:1 males to females 2 y/o M/C time of presentation 2 feet proximal to the ileocecal valve 2 inches in length
most common age for Meckel’s?
2 y/o
where is Meckel’s seen? what is also here?
2 feet proximal to the ileocecal valve
appendix is also here, so if 18 y/o male and pain in RLQ then probably appendicitis
how is Meckel’s typically diagnosed?
incidentally - b/c most children asymptomatic
if Meckel’s symptomatic, what may they present with?
GI bleeding, intestinal obstruction, diverticulitis, bezoar
how is Meckel’s treated?
with excision
what is Malrotation?
intestines are rotated
congenital anomaly of the mid gut that occurs embryologically
what is situs inverses
everything is inverted
where are small intestines found in malrotation?
small intestine found on right side abdomen
where is cecum found in malrotation?
cecum displaced into epigastric region
what else is displaced in malrotation besides small intestines and cecum?
ligament of treitz
what forms in malrotation?
fibrous bands leading to obstruction
narrow base of small intestine -> volvulus
what is volvulus?
twisting that can cause ischemia, perforation, death
how do infants with malrotation present?
Infants present with sx’s of volvulus or obstruction
- BILIOUS vomiting
- abd pain (fussy, crying, not eating/drinking)
- abd distention
- melena and/or mucous stool
if have clinical suspicion of malrotation, what is the dx?
surgery
may support suspicions of malrotation with what?
- abd x-ray (obstruction)
- UGI series (if not emergent) - see corkscrew appearance of the distal duodenum
- contrast enema if very doubtful
