Peds GI Flashcards
What are the concerns if there are high pitched bowel sounds?
early peritonoits
gastroenteritis
intestinal obstruction
What are the concerns if there are absence of bowel sounds?
peritonitis
intestinal obstruction
Which areas should be dull to percussion vs tympany?
dull along right costal margin 1-3 cm below margin of liver
What are the 4 peritoneal signs?
rebound tenderness
obturator sign - flex hip w/ knee bent, internal hip rotation
psoas- lying on left side flex and extend right leg
Rovsing’s sign- palpation of LLQ causes RLQ pain
What is Dunphy’s sign?
Increased abd pain with cough, appendicitis
Markle sign?
stand on tip toes and fall onto heels
Murphy’s sign?
Have p breathe in and out to check for hepatomegaly, then have them breathe deeply in again, if gallbladder is inflamed they will c/o pain or stop inhaling due to pain of inflamed capsule
What are the pediatric risk factors for dehydration?
- increased extracellular fluid % and increase in body water compared to adults
- increased basal metabolic rate
- increased body surface area
- immature renal function
- increased insensible fluid loss through temp elevation
Cause of isotonic/isonatremic dehydration?
simple diarrhea
fluid loss not balanced by intake, sodium and water loss equal
Cause of hypotonic/hyponatremic diarrhea?
massive loss of water nad salt in stool, oral replacement with water only
-sodium loss greater than water
Cause of hypertonic/hypernatremic diarrhea?
vomiting and diarhea with decreased water intake
-greater water loss than salt loss
What are the steps to calculate daily maintenance fluid requirements?
- weight in kg
- allow 100ml/kg for 1st 10kg
- allow 50ml/kg for second 10kg
- allow 20ml/kg for remaining body weight
- total daily maintenance
What are the rates of rehydration for mild, moderate, and severe?
Mild 40-50 ml/kg over 4 hours
Moderate 60-100 ml/kg over 4-6 hours
Severe NS or LR, 20ml/kg bolus
How should you hydrate as out patient for each episode of stool or vomiting?
Slowly for vomiting
10ml/kg for each episode
What should you rehydrate with?
Breast feed more often and shorter periods
Avoid: plain water, apple juice, soda, milk sports drinks
Give: pedialyte, or recipe for water sugar and salt
-Reintroduce bland solids after 4-6 hours
What is the age of onset for pyloric stenosis? Who is most likely to have?
1-18 weeks (average 3 weeks)
-most common in white, first born males
What is the most common cause of intestinal obstruction in infancy?
pyloric stenosis
What is the clinical presentation of pyloric stenosis?
Non-bilious emesis, 70% becomes projectile
- still hungry after emesis
- occurs post feed
- dehydration, malnutrition, jaundice
What may you be able to palpate in a baby with pyloric stenosis?
1-2 cm olive shaped mass along lateral edge of rectus abdominus in RUQ
- best palpated after baby has vomited and is calm
- gastric peristaltic waves may be visible prior to vomiting
How do you diagnose pyloric stenosis?
U/s (gold standard)
-EGD if diagnosis is unclear
How do you treat pyloric stenosis?
electrolyte and fluid replacement
Surgery- pyloromyotomy
What is primary vs secondary peptic ulcer disease?
Primary- duodenal
Secondary- gastric
Who is more likely to have PUD?
Boys 12-18 yo familial predisposition critical illness some medications stress
How is PUD treated?
- Antacids
- GER meds
- H. Pylori treatment
What is GER?
reflux of gastric content through lower espohageal sphincter WITHOUT irritation or injury to the esophagus
What is Sandifer syndrome?
abnormal posturing of head and trunk after feeds. May be caused bu GER, head positioning relieves discomfort
What prokinetic (motility) agents can be used in GER?
- metoclopramide
- bethanechol
- erythromycin
- baclofen
What is the average age of appendicitis?
10 years
Clinical presentation of appendicitis?
periumbilical pain
- peaks, subsidel, migrates to RLQ
- vomiting AFTER pain
- anorexia (50%)
- low volume mucousy stools
- low grade fever
- After perf: symptoms lessen, fever
How do you diagnose appendicitis?
A/S (gold standard), thickened noncompressable mass
-CT has highest accuracy
What is the leading cause of abd pain in children?
constipation
At what year does constipation peak in children?
2-4
At what age is the anal sphincter mature?
18 mo
How should you manage constipation in toilet training?
Nighttime medication and morning “toilet time”
What is intussusception?
Ileum “telescopes” inside the ascending colon
-causes edema, strangulation, gangrene, sepsis, shock, death
How do stools appear with intussusception?
Currant jelly stools
Clinical presentation of intussusception?
paroxysmal episodic abd pain w/ vomiting Q 5-30 min
- screaming w/ drawing up of legs
- calm or sleeping in between
What is the Dance’s Sign?
palpation of “sausage-shaped” mass in RUQ with empty space in RLQ
How do you treat intussusception?
Air or barium enema
-surgical management may be needed
What is the most common malabsorption syndrome?
Lactose intolerance
Clinical findings of malabsorption?
chronic diarrhea (may not be present)
- gassy
- abd distention
- increased appetite
- growth failure
- pallor
- cheilosis
- glossitis
- peripheral neuropathy
- food aversions
- delayed puberty
Management for malabsorption?
assess and treat for underlying infection
- diary of symptoms and food intake
- exclusion diet- exclude food for 3 weeks at a time
What is inflammatory bowel disease (IBD)?
Inappropriate and ongoing activation of mucosal immune system driven by normal flora.
Which part of the bowel does Crohns affect?
small and lower
Is Crohns a continuous disease?
No, it is segmental
What labs are different in Crohns?
High ESR,
microcytic anemia
low albumin
What changes in the bowel are associated with Crohns?
granulomas, abscesses, diarrhea (may be bloody)
Which part of the bowel is affected by ulcerative colitis (UC)?
Total colon
Is UC a continuous disease?
Yes, it affects the whole/continupus colon
What symptoms are related to UC?
Abd pain, bloody diarrhea, urgency, tenesmus
What abx do you treat C. diff and Giardia with?
metronidazole
What abx do you treat cholera with?
tetracycline/doxy
-azithro if younger than 8
What causes osmotic diarrhea
damage to the villous brush border, causing malabsorption of intestinal contents
What causes secretory diarrhea?
release of toxins that bind to specific enterocyte receptors and cause the release of chloride ions into the intestinal lumen
Name the pathogen! A. frequent watery diarrhea B. bloody/mucous C, Rice water D. long duration >14 days
A. viral
B. bacterial
C. cholera
D. non-infectious/parasitic
What abx are most likely to trigger C. diff
PCNs, cephalosporins, and clindamycin
What are the most common parasites found?
Giardia and cryptosporidium
What percent of body weight decrease would you see in minimal, moderate, and severe dehydration?
Minimal - 3%
Moderate - 3-9%
Severe - 10%
What is Zollinger-Ellison syndrome?
A rare syndrome involving refractory severe PUD caused by gastric hypersecretion due to the autonomous secretion of gastrin by a neuroendocrine tumor
What formula can infants with cow’s-milk allergy have?
Extensively hydrolyzed
- partially hydrolyzed formula is NOT appropriate
- if SEVERE allergy use amino-acid formula
- extensively hydrolyzed soy formula if older than 6 mo (younger may cause nutritional deficit
Should mothers of infants with cow’s milk allergy and CMPI avoid milk products?
yes
What are the extraintestinal symptoms of adenomatous polyposis?
- opthalmologic (hypertrophy of retinal pigment
- dental (supernumerary or unerrupted teeth)
- osteomas of skull
- multiple lipomas
Name 5 physical findings that may be seen on a pediatric patient with Crohn’s disease?
perianal skin tags deep anal fissures perianal fistulas clubbing of digits erythema nodosum
What does fecal calprotectin measure?
The level of inflammation in intestines
-higher level = more inflammation
What medications are used for Crohn’s disease?
1st line (mild-mod)- corticosteroids (po, IV, per rectum)
Mild- 5-aminosalicylates (balsalazide, sulfasalazine, olsalazine, mesalamine)
Severe- immunomodulators (azathioprine, 6-mercaptopurine, methotrexate, cyclosporine)
Severe/remission- biologics
What is the 1st line medication for UC?
topical mesalamine
What is the steroid taper for UC?
oral prednisone 40-60 mg/day for 1-2 weeks (until response is established). Then taper by 5-10 mg/week
What diet changes are recommended in UC?
- high protein and carbs
- normal fat
- low roughage
- omega-3
- avoid lactose
What is the expected weight gain for 0-3 mo, 3-6 mo, 6-12 mo, and 12+ mo?
0-3: 25-30 g/day
3-6: 15-20 g/day
6-12: 10-15 g/day
12+: 5-10 g/day
What are the most common viral pathogens implicated in acute diarrhea?
norovirus and rotavirus
