Peds GI Flashcards
1
Q
What is esophageal atresia
A
An esophageal pouch that doesn’t actually lead to the stomach; may or may not have a fistula connection to the trachea
MC fistula is between distal esophagus and trachea
M>F
2
Q
How does congenital esophageal atresia present
A
Polyhydramnios (in utero) Copious secretions, choking, cyanosis, and respiratory distress within hours of birth (slower presentation with fistula) Excess saliva Choke and cough with oral feeding Can't pass orogastric tube to stomach Cyanosis or PNA form GI secretions
3
Q
How do you diagnose EA
A
Prenatal US, then MRI
Postnatal CXR after NG placement (tip in blind pouch)
If fistula is distal to esophagus, XR will show gas in bowel (no fistula= no gas)
4
Q
How do you treat EA
A
NG tube in proximal pouch on low intermittent suction
Elevate head of bed to prevent reflux
IV glucose, fluids, O2
Surgery
5
Q
When is mortality with EA the highest
A
When infant <2000g or with serious heart defects
6
Q
How do most esophageal FB resolve
A
Spontaneously pass- most are ASx
MC 6mo-3 y/o
7
Q
Most common FB Sx are
A
Dysphagia Odynophagia Drooling Regurgitation CP Abd pain (other: cyanosis, drooling, wheezing, stridor, choking)
8
Q
What is the MC FB ingested
A
coin!
Visible on neck, chest, or abd XR
Protect the airway and give continuous suction
9
Q
When would you retrieve a FB
A
If it is a button battery (emergency!! 2 hrs to perforation)
If it has not passed into stomach
If they are multiple magnets
10
Q
How do you remove a FB
A
Endoscopic retrieval if in esophagus
if in stomach, watch for 24-48 hours if it passes. If not, endoscopic removal
11
Q
Why are multiple magnets dangerous
A
Can lead to fistula formation in bowel wall
Surgical intervention
12
Q
What is the difference between GER and GERD
A
GER is uncomplicated recurrent spitting and vomiting that resolves spontaneously
GERD is when reflux causes secondary Sx or complications (FTT, food refusal, GI bleeding, U/L airway Sx)
13
Q
When does reflux occur
A
During LE sphincter relaxation if:
Small stomach capacity, large volume feedings, short esophageal length, supine positioning
14
Q
Sx of reflux are
A
postprandial regurg (effortless or forceful)- MC infant Sx
15
Q
How do you Tx reflux
A
should resolve spontaneously in by 12-18 mo.
16
Q
High risk individuals for GERD are
A
Asthmatics CF Developmental handicaps hiatal hernia repaired TE fistula
17
Q
Complications of GERD are
A
esophagitis
recurrent PNA/cough
dental erosions
18
Q
Sx of GERD in older kids are
A
Dysphagia, heart burn
19
Q
Warning signs for GERD that warrant further workup are
A
bile stained emesis (obstruction) GI bleeding Onset vomiting after 6 months FTT diarrhea, fever, hepatosplenomegaly Abd ttp/distention Neuro changes
20
Q
How do you diagnose GERD
A
Clinically!
Upper GI series is not a test for GERD
21
Q
How do you treat GERD
A
Spontaneous resolution by 12 mo. old in 85%
Thicken feeds w/ oatmeal (1tbsp/2oz formula)
Milk/Sy free diet for 2 weeks
H2 blocker/PPI
Surgery: Nissen fundoplication
22
Q
Pros and Cons to PPI
A
Pro: significantly heal and improve GERD Sx w/in 8-12 weeks
Con: high risk infection w/ long term use
23
Q
Two MC complications of Eosinophilic Esophagitis are
A
Esophageal food impaction
Esophageal stricture
24
Q
Sx of Eosinophilic Esophagitis are
A
Feeding dysfunction
Non-specific GERD Sx
Long meal times (have to wash food down w/ liquids)
Avoid highly textured foods
No response to GERD Tx
FHx of atopy, asthma, dysphagia, or food impaction
25
How do you diagnose Eosinophilic Esophagitis
Endoscopy!
Esophageal mucosa thickening, fissures, strictures, and rings
Esophagus sprinkled w/ pinpoint white exudates (looks like candida) made of eosinophils
26
How do you Tx Eosinophilic esophagitis
Eliminate food allergens
| Swallow topical steroids (2 puffs fluticasone BID) and do NOT rinse mouth. Avoid eating
27
What is Pica
Eating non-nutritive substances (animal feces, clay, dirt, hair, ice, paint, sand) for at least 1 month, inappropriately to developmental level
Associated w/ iron and zinc deficiency
Can also be a manifestation of iron deficiency anemia
28
What labs should you get for Pica
CBC
| Zinc and Lead levels
29
How do you treat Pica
Address nutrient deficiency or lead poisoning
Behavioral therapy
Family Education
30
What is rumination
repeated regurg and re-chewing of food, MC 3-12 mo. old
| In older kids, associated w/ depression and ED
31
Rumination can lead to
```
Malnutrition
FTT
Weight loss
Bad breath
Tooth caries
```
32
CHO malabsorption can be due to
```
Lactose intolerance (celiac disease, transient gastroenteritis)
Lactose deficiency (cystic fibrosis)
```
33
Fat malabsorption is associated with
Cystic fibrosis
34
Protein malabsorption is associated with
Cystic fibrosis
| Milk protein allergy (cow milk, even soy milk)
35
How does malabsorption present
```
weight loss
malnutrition
diarrhea/steatorrhea
n/v
abdominal pain
```
36
How can you assess malnutrition
stool sample, substance removal challenge, or work up celiac disease or cystic fibrosis
37
What is the MC inborn error of amino acid metabolism
Phenylketonuria;
Auto Recessive d/o where Phenylalanine hydroxylase has decreased activity, so phenylalanine does not get converted to tyrosine= build up of Phenylalanine
38
How does PKU present clinically
```
Intellectual disability (MC*)
Fair skin and hair (impaired melanin synthesis)
Atopic dermatitis
Hyperactivity
Seizures
Musty odor
Epilepsy
```
39
When is intervention preferred with PKU
as early as possible for best outcome!
| This is why PKU is part of the newborn screen
40
How can you treat PKU
*Diet restriction of phenylalanine and aspartame (<6mg/day)
Tyrosine supplementation
Eliminate high protein foods (legumes, meat, dairy, nuts)
Restrict starches
Essential AA, vitamin, and mineral supplementation
41
What are most kids allergic to
```
Cow's milk
Fruit (citrus, strawberry)
Veggies (tomato)
Egg
Fish
Nuts
Cereals
```
42
What mediated food allergies
IgE- Sx in min-hours
43
How do food allergies manifest
*Urticaria and angioedema*
Allergic rhinitis, pruritis, lip/tongue swelling, irritation
Asthma, Anaphylaxis
N/V, abdominal pain, cramping, diarrhea
44
How do you diagnose a food allergy
In vivo IgE against specific foods (skin test)
In vitro for IgE (radioallergosorbent testing-FEIA)
Remove and re-challenge
Clinical reactivity vs IgE antibodies
-BUT- food allergen testing overestimates the prevalence!
45
How do you treat food allergies
Avoid and re-introduce annually
Epinephrine
H1 blocker
46
What is celiac disease
Immune mediated enteropathy triggered by gluten (wheat, barley, rye)
Causes abd pain and bloating, diarrhea, vomiting, +/- constipation
associated oral ulcers, pruritic rash, growth/puberty delay, iron deficiency anemia, decreased BMD, and arthritis
47
RF for celiac disease are
```
T1DM
Down syndrome
Turner syndrome
AI thyroiditis
FHx of celiac disease
```
48
What are GI manifestations of celiac disease
6-24 mo old with poor weight gain, diarrhea, abd distention
| older kids w/ chronic abd pain, v/d, constipation, bloating- may be confused w/ lactose intolerance or IBS
49
Non-GI manifestations of celiac disease are
delayed puberty, short stature, delayed menarche
50
How do you diagnose celiac disease
```
serology
duodenal biopsy (villous atrophy, increased intraepithelial lymphocytes)
```
51
How do you treat celiac disease
gluten restrict for life
intestinal mucosa improves in 6-12 mo.
supplement calories, vitamins, and minerals in acute phase
52
What are some abdominal wall defects
Gastroschisis and Omphalocele
M>F
usually discovered on pre-natal US in 1st trimester; also shows high AFP!!
53
Complications of gastroschisis and omphalocele are
GERD
Volvulus
Malabsorption
-Must deliver via c-section for surgical correction after birth
54
What is an Omphalocele
Hernia of abdominal contents into base of umbilical cord, covered by a membrane (can also contain liver and spleen)
MC with extreme gestation ages (<20 or >40)
55
What is Gastroschisis
Herniation of intestines through abdominal wall to RIGHT of umbilical cord, w/o a sac covering them
56
What factors are increasing the prevalence of Gastroschisis
illicit drug use (meth, cocaine)
ASA/Ibuprofen use during pregnancy
Young maternal age
57
What are the types of congenital hernias
```
Inguinal hernias (direct or indirect)
Umbilical hernia
Femoral hernia
Diaphragmatic hernia
-Can be reducible, Incarcerated (bad), or Strangulated (worse bc of vascular compromise)
```
58
Info about diaphragmatic hernias
usually LEFT sided 2/2 posterolateral diaphragm defect
8-10 weeks gestation
Diagnosed on prenatal US
May be associated with polyhydramnios
59
How do diaphragmatic hernias present
Respiratory distress (retractions, cyanosis, grunting) in first min-hours of life
+/- aggressive resuscitation
Scaphoid abdomen (caves in) and Barrel chest
Decreased BS on ipsilateral side (PTX!)
Dysmorphisms
Chromosomal abnormalities
60
What CXR findings are associated with diaphragmatic hernia
bowel loops seen in chest w/ mediastinal shift to opposite side on CXR
61
How do you treat a diaphragmatic hernia
Intubation
Mechanical vent
Decompress GI tract with OG tube
Surgery to reduce abd contents and close diaphragm once infant is stable and pulm HTN/compliance improve (24-48 hours after birth)
62
Long term complications of diaphragmatic hernia are
```
Pulmonary HTN
Severe GER/GERD
behavior problems
hearing loss
poor growth
```
63
What is an indirect inguinal hernia
passes lateral to deep epigastric vessels but IN the inguinal canal
MC than direct! also MC in children (M>F)
Usually on RIGHT side
64
What is a direct hernia
Passes medial and inferior to deep epigastric vessels and does NOT go through inguinal canal
2/2 to weakness in Hasselbach triangle or s/p indirect hernia repair later in life
NOT common in kids!
65
What are the borders of Hasselbach's triangle**
Lateral: inferior epigastric artery
Medial: lateral border of rectus abdominis
Inferior: inguinal ligament
66
What is a femoral hernia
Follows tract below inguinal ligament, through femoral canal
Medial to femoral vein, Lateral to lacunar ligament
Frequently become *incarcerated or strangulated*
MC in women!!
67
What is an umbilical hernia
MC in full term, african american babies
Contents go through umbilical fibromuscular ring
Most regress spontaneously, esp. if fascial defect is <1cm
If they last past 4 y/o, repair surgically
68
What is pyloric stenosis
post-natal muscular hypertrophy of pylorus leading to gastric outlet obstruction
MC in first born kids, and caucasians
M>F
Low mortality rate!
69
What are Sx of pyloric stenosis
**Projectile vomiting** but hungry vomiters- they want to eat but can't keep it down
Start around 3-6 weeks old
Upper abd distention after feeding
prominent peristaltic waves
**Olive mass: 5-15mm mass in RUQ, more prominent after vomiting. This is the stricture!**
70
How do you diagnose pyloric stenosis
```
Pyloric US (hypOechoic muscle ring >4mm w/ hyperdense center and channel length >15mm)
Barium upper GI (string sign**, contrast retained in tummy)
```
71
What is String sign
long, narrow pyloric channel w/ double track of barium
| pyloric stenosis
72
How do you treat pyloric stenosis
Surgical repair: Pyloromyotomy
| Good outcome, but higher risk for chronic abd pain in adulthood
73
What is duodenal atresia
blind pouch or stenosis of the duodenum
associated w/ trisomy 21
Causes *bilious vomiting hours after birth, dehydration, weight loss, electrolyte abnormalities
74
How do yuo diagnose and treat duodenal atresia
Abd XR: *double bubble sign* dilated stomach and proximal duodenum
Surgical correction
75
What is short bowel syndrome
condition resulting from reduced intestinal absorptive surface
Causes alteration in intestinal function= compromised growth, fluid/electrolyte balance, or hydration status
76
When does short bowel syndrome usually occur
S/p surgical resection of intestines (necrotizing enterocolitis, intestinal atresia, gastroschisis, volvulus, intussusception)
77
Sx of short bowel syndrome are
diarrhea
dehydration
electrolyte or micronutrient deficiency
excess gas, foul smelling stool
78
How do you Tx short bowel syndrome
```
we want to promote growth so:
diet, TPN, G tube, meds to slow motility, antacids/H2 blocker/PPI
Abx to prevent or Tx bacterial growth
Surgery
last resort: intestine transplant
```
79
What is intussusception
telescoping of one segment of intestine into another segment MCC of bowel obstruction <2 y/o
Starts at ileocecal valve usually
M>F
80
What causes intussusception
```
**Idiopathic!!** 85%
Viral (rotavirus)
Meckel diverticulum
Small bowel polyp
carcinoma
celiac disease
crohn's
henoch-schonlein purpura
```
81
Is there a rota virus vaccine
yes but they should only be given to infants w/ pre-existing GI conditions not on immunosuppressives
82
What are Sx of Intussusception
Recurrent paroxysms of abdominal pain (screaming, drawing up knees) in previously healthy infants
intermittent, severe cramping abdominal pain followed by vomiting/diarrhea
*Red current jelly poop*
palpable right sided sausage shaped mass
NO right sided and cecal gas shadow on abd XR
83
How do you diagnose intussusception
Abd XR: target sign (2 concentric radiolucent circles superimposed)
Barium and air enema (diagnostic AND therapeutic!)
**US
84
When should you NOT reduce intussusception by enema
if there are signs of strangulated bowel, perforation, or toxicity
85
How do you treat intussusception
Non-operative reduction (contrast enema, hydrostatic pressure, pneumatic pressure)
*Air enema best in stable pt (best if w/in 24 hrs)
-low risk of bowel perforation and recurrence
Surgery if non-op reduction unsuccessful, or if there is a mass present
86
What is Hirschsprung disease
When an area of the colon does not have ganglionic cells
Causes a functional obstruction=massive dilation and accumulation of gas and feces
Associated with trisomy 21
87
How does Hirschsprung disease present
Newborn does not pass meconium, then has vomiting, abdominal distention, and reluctance to feed
Constipation
Empty, contracted distal rectum
Bilious emesis
DRE causes explosive expulsion of gas and stool
Older kids: constipation, foul smelling gas, ribbon stools, no visible stool on anal and rectal exam
88
How do you diagnose Hirschsprung disease
- Rectal Bx: lack of neurons, absent ganglion cells in submucosal and muscular layers of bowel
- Plain XR: dilated proximal colon, no gas in pelvic colon
- Barium enema: Dilated colon, narrow distal segment w/ sharp transition to proximal dilated but normal colon
- Anorectal manometry
89
How do you treat Hirschsprung disease
Surgically remove anganglionic bowel w/ temp colostomy
| Surgical reconstruction
90
MC long term complications of Hirschsprung disease are
*Fecal incontinence
| Fecal retention, constipation, enterocolitis
91
What is Meckel's diverticulum
out-pouching or bulge lower part of small intestine- Leftover internal umbilical cord
Contains cells from stomach and pancreas= secretes acid= causes ulcers and bleeding
92
What is the rule of 2's (Meckel's)
```
2% of population
M:F is 2:1
50% of complications in first 2 years of life
within 2 feet from ileocecal valve
2 inches in length
```
93
How does Meckel's present
```
ASx
PainLESS lower GI bleeding
Can look like appendicitis!!
Recurrent atypical intussusception
obstruction
```
94
How do you diagnose and treat Meckel's
Arteriography or CTA, Meckel's scan (radionuclide scan)
| Surgical resection if symptomatic
