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Peds II Unit I > Peds GI > Flashcards

Peds GI Flashcards

1
Q

Bloody vomitus is suggestive of…

A

Maternal ingestion, esophageal varicose, foreign body

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2
Q

Bilious vomitus is suggestive of…

A

Obstruction - Urgent Eval!

Meal rotation w or w/o volvulus

Congenital intestinal atresia

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3
Q

Patients with GER can be considered to be …

A

“Happy spitters”

No complications/consequences

Normal physiologic process

Declines with age (common in infants < 6 months)

Growing well, comfortable, healthy clinically

Requires no treatment other than pt ed and reassurance

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4
Q

Patients with GERD can be considered to be …

A

“Unhappy spitters”

Complications arise
• FTT, esophagitis, respiratory complications

Fussy or irritable, dystonic neck posturing, feeding refusal

Occult blood in stool - consider food intolerance

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5
Q

Diagnosis of GERD is usually…

A

Clinical

Hemoocult (checking for hidden blood in stool)

Endoscopy, upper GI if severe Sx

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6
Q

GERD symptoms usually resolve by…

A

9-12 months (mostly because patient is now sitting up to eat)

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7
Q

First line treatment for GERD

A 
Lifestyle modification
• Upright positioning 30 min after feeds (not semi-supine)
• Trial of hypoallergenic diet
• Do not overfeed
• Avoid tobacco smoke exposure
• Thickened feeds (1-2 tsp cereal/oz)

Medications hold a limited role due to risk vs benefit
• Consider in patient with refractory Sx
• Complicated disease (underlying condition)
• Short term PPI (omeprazole) vs H2 blocker (ranitidine)

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8
Q

Hypertrophy of the pylorus, which can progress to near-complete obstruction of gastric outlet

A

Infantile hypertrophic pyloric stenosis

Genetic predisposition and environmental factors (ie maternal smoking)

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9
Q

Predisposing factors for pyloric stenosis

A

Environmental factors (maternal smoking)

Associated with use of macrolide abx during first few weeks of life

M>F (4:1), classic first born male, family history (genetic factors)

2-4/1,000

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10
Q

Classic presentation of pyloric stenosis

A

3-6 week old infant with forceful vomiting

Nonbilious “projectile” emesis (b/c obstruction is before the biliary tree)
• Immediately after feeding (postprandial)
• “Hungry vomited” (vs. GER - “Happy vomiter”)
• FTT and dehydration may occur as the disease progresses

Phys exam: “Olive-like” mass in RUQ (indicates hypertrophy)

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11
Q

Test of choice for diagnosing pyloric stenosis

A

Ultrasound —> elongation and thickening of the pylorus

If ultrasound is non-diagnostic, do an Upper GI Barium contrast study —> string sign (narrowed lumen)

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12
Q

Definitive management of pyloric stenosis is via…

A

Surgery (pyloromyotomy)

IV fluid and electrolyte resuscitation important too

Prognosis is excellent

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13
Q

Absence or obstruction of one or more segments of bowel at birth

A

Congenital intestinal atresia

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14
Q

Congenital intestinal atresia can occur at any point in the GI tract but ________ is the most commonly affected site

A

Duodenum

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15
Q

Intestinal atresia is more common in patients with …

A

Cystic Fibrosis and Down Syndrome

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16
Q

When is congenital intestinal atresia usually diagnosed?

A

At birth at Sx onset

May also be Dx via prenatal U/S

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17
Q

Clinical presentation of congenital intestinal atresia depends upon…

A

Degree of obstruction (partial vs complete)

Vomiting (may be bile-stained) within first 48 hours of life

Abdominal distinction

Failure to pass meconium (+/-)

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18
Q

Double bubble sign on plain film xray is indicative of …

A

Congenital intestinal atresia

Due to gas and dilation in both stomach and duodenum

If jejunoileal/colonic atresia —> dilated loops of bowel with air fluid levels

Upper GI and contrast enema may be used for confirmation or to further identify obstruction

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19
Q

Management of congenital intestinal atresia consists of …

A

Feedings withheld (IV fluids, correct electrolytes)

Broad spectrum abx to prevent post op infection

Surgical intervention - approach depends on site

Prognosis very good

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20
Q

Abnormal positioning of the intestines is referred to as

A

Midgut malformation

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21
Q

Midgut malrotation increases the risk of …

A

Volvulus - small bowel twisting around SMA —> risk of small bowel ischemia

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22
Q

Classic clinical presentation of midgut malrotation

A

VOMITING - typically bilious (green or fluorescent yellow)

Abdominal pain

Hemodynamic instability

+/- hematochezia (sign of bowel ischemia)

PE: abdominal distention and tenderness

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23
Q

How do you work up a suspected midgut malrotation

A

1st do abdominal xray to r/o bowel perforation

Gold standard: Upper GI
• Displacement of the duodenum
• Duodenal obstruction
• “Corkscrew appearance” of the duodenum

Ultrasound with barium enema = useful adjunct to UGI but not best for confirming malrotation

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24
Q

What is the Ladd procedure?

A

Main purpose: to prevent ischemia and recurrent Sx in patients with midgut malrotation

Bowel is untwisted and repositioned in abdomen which creates adhesions to “hold” bowel in place

Prognosis: Resolution of Sx in approx. 90% post op with <1% recurrence

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25
Q

Most common cause of abdominal emergency in kids <2 years

A

Intussusception (telescoping of the intestine)

Typically in kids aged 6 months to 36 months, and it is the most common cause of obstruction in this age group

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26
Q

Clinical presentation of intussusception

A

Sudden, intermittent, severe, cramps abdominal pain
Inconsolable crying, draws legs to chest
Vomiting common

Classic triad (only 15% will have ALL three)
• Abdominal pain, abdominal mass, and “Currant jelly” stools
• Current jelly: combo of blood and mucous
• Palpable sausage-shaped mass (swollen bowel)

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27
Q

75% of cases of intussusception are…

A

Idiopathic

Remaining cases may be caused by “lead point” - a lesion/variation in the intestine dragged by peristalsis into a distal segment

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28
Q

Conditions that increase risk of intussusception

A

Meckel’s diverticula (most common cause)
Polyp
Tumor
Cyst
Underlying conditions: Crohns, Celiac, CF, viral infections (ie Gastroenteritis)
Rotashield vaccine (22x increased risk of intussusception)

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29
Q

Initial test of choice for the diagnosis of intussusception

A

Abdominal ultrasound —> “target sign” or “coiled spring”

Hydrostatic/pneumatic enema is both diagnostic and therapeutic
• Treatment of choice if no perforation, ~90% success rate
• U/S or fluoroscopic guided

If reduction unsuccessful, must intervene surgically

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30
Q

The most common pediatric surgical emergency

A

Appendicitis - obstruction of the appendices lumen leading to inflammation

Peaks in the 2nd decade of life, rare before 5 years

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31
Q

Clinical presentation of appendicitis

A

Anorexia

Migrating abdominal pain (periumbilical —> RLQ, with increasing pain with movement)

Vomiting after onset of pain

Fever

Signs of peritoneal irritation (guarding, rebound tenderness, positive rousing, obturator, or ileopsoas signs)

32
Q

Do we do imaging on patients with suspected appendicitis?

A

If classic presentation, may proceed with surgical consult prior to imaging

If you DO proceed with imaging:
• Ultrasound (no radiation)
• CT scan (low dose CT if available)

33
Q

Treatment of appendicitis

A

Surgical consult —> appendectomy is treatment of choice

Pre-op management should include fluids, electrolytes, abx

Some indication for Nonoperative Treatment (Abx) for early appendicitis

Prognosis is excellent, especially if detected and treated early

34
Q

What is the actual definition of diarrhea?

A

> 3 loose watery stools/day (WHO)

35
Q

What questions are important to include in the history when dealing with diarrhea?

A 
Acute vs chronic
Stool characteristics and frequency
Associated SSx (nausea, vomiting)
Dehydration
Sick contacts/exposures (daycare)
Pets/animals
Med history
Travel
Diet
36
Q

DDx for acute diarrhea (>3 loose, watery stools/day x 5 days or less)

A

Abx associated: Clostridium difficile

Bacterial: Salmonella, Shigella, E.coli, campylobacter, yersinia

Viral: ROTAVIRUS, Adenovirus, Calicivirus (Norovirus)

Parasitic: Giardiasis lamblia, Entamoeba histolytica, cryptosporidium

37
Q

Most common cause of gastroenteritis

A

VIRAL!!!!

38
Q

Clinical manifestations of gastroenteritis

A 
Diarrhea
Vomiting
Fever
Anorexia
Headache
Abdominal cramps
39
Q

What are the red flags when it comes to diarrhea?

A 
Fever
Severe abdominal pain
Blood in stool
Recent abx
Persistent Sx
Dehydration
Leukocytosis
Growth/development affected
40
Q

Main causes of chronic diarrhea (>1 month)

A

Celiac Disease
Allergy (ie milk, soy)
Malabsorption (ie CF)
Toddler’s diarrhea

41
Q

Immune mediated inflammatory disease of the small intestine caused by gluten sensitivity

A

Celiac disease

Dx: IgA antibodies to tissue trans glutamine seems (TTG), small bowel bx

SSx: FTT, anemia, possible foul smelling stools

Tx: gluten free diet

42
Q

Most common food allergies in children

A

Milk and soy

Microscopic blood and mucous in stools, gassy, fussy

Tx: dietary elimination - hydrolyzed or free amino acid based formula (ie Nutramigen)

43
Q

Are stool cultures recommended for most cases of diarrhea?

A

No

Pursue further w/u if red flags —> CBC, CMP, celiac testing, urine Cx, stool testing, imaging

44
Q

Treatment for acute diarrhea

A

HYDRATION always, abx sometimes, anti-motility agents rarely

Keep an eye for signs of dehydration (consider PO vs IV hydration)

45
Q

Should antibiotics be used routinely for well-appearing children with acute bloody diarrhea?

A

NO

No recommended for routine use unless a specific pathogen has been isolated (Risk of HUS)

46
Q

Peak incidence for IBD

A

15-30 years

Increasing in kids

47
Q

Smoking is associated with a 2x increased risk for _____________ but with a 50% decreased risk for ___________

A

2x increased for Crohns Disease

50% decreased for Ulcerative Colitis

48
Q

Clinical presentation of IBD

A

Diarrhea, abdominal pain +/- hematochezia

Growth failure, delayed puberty

Nutrient deficiencies

Anemia

Can also have extraintestinal manifestations (mouth, skin, joints, liver, eye) sometimes developing before GI Sx

49
Q

Differences in the pattern of inflammation between Crohn Disease and Ulcerative Colitis

A

Crohn: “Skip lesions” - Terminal ileus, distal descending colon, and rectum

UC: Continuous colonic involvement beginning in rectum

50
Q

What is the clinical presentation of Crohn Disease?

A

Presentation variable

Transmural inflammation - mouth to anus (can involve entire GI tract)

Skip lesions

Cobblestone appearance

Perianal fissures, fistulas

Dx: colonoscopy

51
Q

What is the clinical presentation of ulcerative colitis?

A

Involvement of rectum and large colon
• Mucosal layer only
• Inflammation starts at rectum and extends proximally into colon
• Bloody diarrhea common
• Diffuse/continuous edema, erythema, friability, ulceration of colon

52
Q

Which IBD condition holds an increased risk of colon cancer?

A

Ulcerative colitis

53
Q

Crohn Disease vs Ulcerative Colitis

A

Location: Mouth to Anus for CD, Rectum and Colon for UC

Ulceration Pattern: Skip lesions/cobblestoning for CD, Continuous for UC

Depth of inflammation: Transmural inflammation for CD, mucosal layer only for UC

Etiology: Genetic, autoimmune, environmental factors for BOTH

54
Q

Goal of treatment for IBD

A

Clinical and laboratory remission with mucosal healing, not just symptomatic improvement

Accelerated “step-up” therapy for most vs “Top-down” therapy for high risk patients - choice of treatment varies based on severity of disease

55
Q

5 principle components of treating IBD

A

Medications

Surgery

Nutritional rehabilitation

Behavioral health support

Colorectal cancer screening for older patients

Treatment involves a multidisciplinary effort

56
Q

Medications for the treatment of IBD

A

Aminosalicylates: 5-ASA (Sulfasalazine, Mesalamine, etc)

Immunomodulating agents (Mercaptopurine, Azathioprine, Methotrexate) or Biologics (Infliximad, Remicade etc)

Steroids - primary therapy for acute flare but concern for bone density, growth and development

+/- antibiotics

Surgical intervention for refractory cases

Monitor growth, nutrition, infection risk, psychological issues and cancer surveillance

57
Q

Most common congenital anomaly of the GI tract

A

Meckel’s Diverticulum

Vitelli next duct (embryonic remnant) leads to formation of diverticulum (congenital outpouching of small intestine)

Pouch is usually made of intestinal and gastric epithelium - gastric acid produced and causes damage —> bleeding occurs from mucosal ulceration

58
Q

What is the “Rule of 2’s” with regards to Meckel’s Diverticulum

A

2% of the population
2:1 M:F ratio
2% develop complication (usually before age 2)
2 feet from the ileocecal valve

59
Q

Clinical presentation of Meckel’s Diverticulum

A

Painless rectal bleeding
Obstruction (volvulus or intussusception)
Diverticulitis (can mimic appendicitis)

60
Q

Dx study for Meckel’s Diverticulum

A

Technetium-99 scan (aka Meckel’s Scan) - Nuclear medicine scan identifies ectopic gastric mucosa in diverticulum

Management - surgical resection (excellent prognosis)

61
Q

________ affects 30% of children and accounts for 3-5% of all visits to the pediatrician

A

Constipation - regular passage of firm or hard stools or infrequent passage of stool

If impacted, encopresis can occur

Etiology: frequently multifactorial (r/o anatomic or biochemical cause)

62
Q

95% of cases of constipation are considered __________ while only 5% are considered ________.

A

95% Functional (Psychological or Psychosomatic, Dietary)

5% Organic - the “Do Not Miss” causes
• Anal stenosis
• Hypothyroidism
• Celiac Disease
• Hirschprungs
• Hypercalcemia
• CF
63
Q

Periods during which kids are most likely to develop constipation

A

Intro to solid foods or cow’s milk

Toilet training

Start of school (high prevalence age 5-6)

64
Q

Leakage of retained stool

A

Encopresis

65
Q

Dietary suggestions for avoiding constipation

A

Under 2 is 5g per day and if they are older than 2 it’s their age +5-10 grams so like a 4 year old would have a range of 9-14 g/day

66
Q

Findings that suggest an organic cause of constipation

A

Failure to pass meconium
FTT
Abdominal distension or obstructive symptoms
Lumbosacral problems, neurological abnormalities
Anterior placed anus/other alterations
Occult blood in stool

67
Q

Clinical presentation of constipation

A

+/- fecal leakage
Abdominal discomfort - generalized or LLQ
If impacted, bowel sounds may be hypoactive
Anal fissures

68
Q

Red flags for constipation

A

Weight loss, poor weight gain/growth
Anorexia, fever, hematochezia, vomiting
History of delayed passing of meconium (CF)
Acute onset
Failure to respond to conservative measures

69
Q

Management of constipation

A

Fluids
Gradual increase in daily fiber intake (puréed veggies, fruits)
Decrease dairy intake (cow’s milk < 16 oz/day)
Juice - apple, prune, or pear (infants)
If encopresis, relieve impact ion if present (Polyethylene glycol aka Miralax)

70
Q

First line treatment for encopresis/constipation

A

Miralax (polyethylene glycol)

71
Q

Condition characterized by absence of ganglion cells in mucosal and muscular layers of colon

A

Congenital Aganglionic Megacolon or Hirschprung Disease

Spasm and abnormal motility —> colon fails to relax and may lead to obstruction

M>F 3:1
80% present < 6 weeks of age
Patients with Down syndrome at high risk

72
Q

Classic presentation of Hirschprung Disease

A

Failure to pass meconium in first 48 hours of life
Bilious vomiting
Abdominal distention

Late presentation less common - Newborn passes meconium but develops Sx later
Older children may present with chronic constipation and FTT
Later the Dx, less severe disease (usually a small segment of the colon affected)

73
Q

Physical exam findings in Hirschprung disease

A

Abdominal distention
Tight anal sphincter —> “Squirt Sign” (explosive release of gas/stool when finger removed - relieves obstruction temporarily)

74
Q

Gold standard for diagnosis of Hirschprung disease

A

Rectal biopsy to confirm absence of ganglion cells

Other Dx studies:
• Contrast enema unprepared to localize “transition zone”
• Change from narrowed aganglionic segment to the dilated proximal colon

75
Q

Treatment for Hirschprung disease

A

Surgical resection of the aganglionic segment of the colon

Overall good prognosis

May have some abnormal bowel function (fecal incontinence, constipation) but most have excellent quality of life

Peds II Unit I (4 decks)

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