Week 5 - GI

Question 1

Dehydration

Answer 1

loss of water and extracellular fluid

Question 2

Levels of dehydration

Answer 2

‣ Mild <3% weight loss children <5% infants
‣ Moderate 6% in children, 10% in infants
‣ Severe 9%+ in children, 15%+ in infants

Question 3

Most frequent cause of dehydration

Answer 3

Viral. Often accompanied by diarrhea

Question 4

Three types of dehydration

Answer 4

‣ Isotonatremic – simple diarrhea, body able to maintain salt balance
‣ Hyponatremic – large amount of diarrhea, water and salt is lost
‣ Hypernatremic – vomiting and diarrhea results in water loss and decreased intake

Question 5

Clinical findings for dehydration

Answer 5

‣ Hypotension
‣ Nuchal rigidity
‣ Decreased level of consciousness
‣ Irritability
‣ Lethargy

‣ Tachypnic (most helpful)
‣ Skin turgor (most helpful)
‣ Increased capillary refill time (*most helpful)

Question 6

Parameters used for assessing dehydration

Answer 6

‣ general appearance
‣ eyes (sunken or not)
‣ moistness of mucous membranes
‣ presence of tears.

Question 7

Labs for dehydration

Answer 7

‣ CBC with differential
‣ Blood culture
‣ Electrolytes
‣ BUN, creatinine
‣ Glucose
‣ LFTs
‣ Sodium level
‣ CRP/ESR
‣ Lactate
‣ UA & culture
‣ Stool for culture
‣ Toxicology screen

Question 8

Imaging for dehydration

Answer 8

‣ Abdominal xray (mass or obstruction)
‣ Chest xray (pneumonia)
‣ US (abscess, mass, stenosis, cysts, pyloric stenosis)
‣ CT or MRI – masses, inflammation, herniation, perforation, obstruction

Question 9

Management of dehydration

Answer 9

‣ Determine degree of dehydration
‣ Minimal, mild, moderate
 oral rehydration soluation
‣ Severe
 immediate IV fluids
‣ Pediatric SQ rehydration with human hyaluronidase
‣ Initial rehydration, maintenance of fluids, replacement of ongoing fluid losses
‣ Frequent small fluids (less than 5ml), give larger amounts as tolerated
‣ Antiemetics
‣ Treat fever over 38.2

Question 10

Colic

Answer 10

Crying for no apparent reason that lasts for 3 hours or more per day and occurs 3 days or more per week in an otherwise healthy infant younger than 3 months of age

Question 11

S/S of Colic

Answer 11

‣ Difficult to soothe crying
‣ Frowning and grimacing.
‣ Reddening of the face.
‣ The baby may pull up its legs, suggesting stomach pains.
‣ Loud and long screaming fits.
‣ Loud tummy rumblings.
‣ The baby cannot be consoled.
‣ The crying lasts for three hours or more.

Question 12

Treatment for colic

Answer 12

‣ Reassure the parents and address how difficult colic is
‣ Use white noise to help calm infant
‣ Ceiling fan
‣ Lactobacillus probiotic

Question 13

Appendicitis

Answer 13

inflammation of the appendix that leads to distention and ischemia that can result in necrosis, perforation, and peritonitis or abscess formation

Question 14

Time management for appendicitis

Answer 14

36- to 72-hour maximum window from the onset of pain to the rupture of the gangrenous appendix.

Question 15

S/S of appendicitis

Answer 15

‣ Periumbilical pain shifting to RLQ becoming more intense and localized
‣ Anorexia
‣ Low volume stool with mucous
‣ Fever
‣ Irritability
‣ Crying from pain or silent due to pain when crying
‣ RLQ rebound tenderness
‣ Maximal pain over mcburneys point
‣ Positive psoas or obturator sign
‣ Rovsing’s sign

Question 16

Psoas sign

Answer 16

Having the patient lie supine and placing your hand just above the knee. Ask the patient to lift the straight right leg up against resistance of your hand

Question 17

Obturator sign

Answer 17

Pain on passive internal rotation of the hip when the right knee is flexed

Question 18

Rovsing’s sign

Answer 18

pain elicited in the right lower quadrant with palpation pressure in the left lower quadrant

Question 19

Scoring for appendicitis (less than 4 then less likely appendicitis)

Answer 19

‣ Nausea/emesis (1 point)
‣ Anorexia (1 point)
‣ Migration of pain to RLQ (1 point)
‣ Low-grade fever (1 point)
‣ RLQ tenderness on light palpation (2 points)
‣ Cough/percussion/heel tapping tenderness at RLQ (2 points)
‣ Leukocytosis (>10,000/mm3) (1 point)
‣ Left shift (>75% neutrophilia) (1 point)

Question 20

Diagnostics for appendicitis

Answer 20

‣ CBC with differential
‣ Amylase, lipase, LFTs
‣ UA
‣ Abdominal x-ray may show fecalith or rupture
‣ US – enlargement of the appendix wall
‣ CT with contrast

Question 21

Management for appendicitis

Answer 21

‣ Surgical consultation
‣ Narcotics for pain
‣ Lap appy with f/u in 2-4 weeks

Question 22

S/S of Abdominal Foreign Body Ingestion

Answer 22

‣ cramps
‣ abdominal pain
‣ bloating
‣ streaks of bloody sputum or in stool
‣ edema of the hypopharynx

Question 23

Treatment for abdominal foreign body

Answer 23

‣ Most ingested objects that reach the stomach pass through the remainder of the GI tract without difficulty. Items greater than 5 cm in diameter or 2 cm in thickness tend to lodge in the stomach and need to be retrieved.
‣ leave to pass through the system (button batteries included).
‣ Have parents check stool for 2-3 days, f/u if not passed during this time.

Question 24

Esophageal foreign body ingestion S/S

Answer 24

‣ initial episode of choking, gagging, and coughing
‣ Excessive salivation
‣ Dysphagia
‣ food refusal
‣ emesis/hematemesis
‣ pain in the neck, throat, or sternal notch
‣ Respiratory symptoms such as stridor, wheezing, cyanosis, or dyspnea may occur if the esophageal body impinges on the larynx or tracheal wall.
‣ Cervical swelling, erythema, or subcutaneous crepitations may indicate perforation of the oropharynx or proximal esophagus

Question 25

Diagnostics for esophageal foreign body ingestion

Answer 25

‣ xray of chest, neck, abdomen - both front and lateral views

Question 26

Management of esophageal foreign body

Answer 26

‣ If in the esophagus consider object impacted, removal through UGI or removal by experienced GI doc with xray before and after removal.

Question 27

Intussusception

Answer 27

section of intestine being pulled antegrade into adjacent intestine with the proximal bowel trapped in the distal segment

Question 28

S/S of Intussusception

Answer 28

‣ intermittent colicky (crampy) abdominal pain
‣ vomiting
‣ bloody mucous stool
‣ history of URI
‣ Lethargy
‣ Fever
‣ sausage like mass in the abdomen on palpation
‣ bloody or guiac positive stools

Question 29

Diagnostics for intussusception

Answer 29

‣ Abdominal ultrasound
‣ Abdominal xray
‣ Air contrast enema (diagnostic and treatment)

Question 30

Treatment for intussusception

Answer 30

‣ Air contrast enema under fluorosopy is gold standard
‣ IV antibiotics and surgery for perforation