Wk 6 GI Diseases Flashcards
1
Q
What is gastroesophageal reflux?
A
Intrusion of acids into the dilated esophagus resulting into the deterioration of the esophagus’ epithileum & stimulation of the vomiting reflex.
2
Q
What is the etiology of gastroesophageal reflux?
A
Low cardiac sphincter pressure
Short cardiac sphincter
Transient/prolonged relaxation of LES
Poor coordination of esophageal motility
3
Q
What are signs & symptoms of GERD?
A
Vomiting
Persistent cough
Crying w/ feeding
Choking/gagging with feeding
4
Q
What medical problems can GERD lead to?
A
Poor weight gain
Aspiration
Pneumonia
5
Q
How do you diagnose GERD?
A
Clinical s/s often adequate to diagnose
Esophageal pH monitoring w/ a probe for 24 hrs
Endoscopy
6
Q
What is the treatment for GERD?
A
Usually resolves w/ age
Mild GERD = no treatment.
Upright positioning
Thickened feeds OR small frequent feeds w/ freq. burping
Gastric acid blockers, metoclopramide (reglan), & antacids
Surgery (gastropexy or fundoplication - recreates a valve by wrapping fundus of stomach around the esophagus)
7
Q
What is esophageal atresia (EA)?
A
When the esophagus ends in a blind pouch & does not connect to the stomach
Can happen in conjunction w/ tracheoesophageal fistula
8
Q
What is a tracheoesophageal fistula (TEF)?
A
An abnormal connection btwn the esohagus & the trachea
Can happen in conjunction with esophageal atresia
9
Q
What is the etiology of esophageal atresia & tracheosophageal fistula?
A
An incomplete division of the oforegut into the respiratory & digestive portions at wk 4 of gestation.
10
Q
Esophageal atresia & tracheoesophageal fistula can be an isolated defect or appear as part of what syndrome(s)?
A
VATER, VACTERL, & CHARGE
11
Q
What does VATER syndrome/ VATERL syndrome stand for?
A
Anomalies of the following:
Vertebrae
Anus
Trachea
Esophagus
Renal
Limb
12
Q
What does CHARGE syndrome stand for?
A
CNS anomalies
Heart defects
Atresia of nasal passage/choana
Retardation of growth/dvlpment
Genital/urinary defects
Ear anomalies/deafness
13
Q
What are prenatal s/s of esophageal atresia & tracheosophageal fistula?
A
polyhydramnios
no stomach bubble in US
14
Q
What are postnatal s/s of esopheal atresia & tracheoesophageal fistula?
A
OG/NG tube does not pass
Excess salivation
Nonbilious vomiting
Feeding intolerance
Respiratory distress w/ feeds
Abdominal distention (TEF when abdomen fills w/ air)
Intermittent cyanosis
15
Q
What is the treatment for esophageal atresia & tracheosophageal fistula?
A
Usu. diagnosed @ birth
Inability to pass NG/OG tube
prenatal US
16
Q
What medical problems can esophageal atresia & tracheoesophageal fistula lead to?
A
recurrent aspiration
pneumonia
atelectasis
17
Q
What is the treatment for esophageal atresia & tracheoesophageal fistula?
A
Surgery to restore esophageal continuity & eliminate fistula.
18
Q
What is duodenal atresia?
A
The complete closure of the duodenum - causes an intrinsic obstruction
19
Q
What is the etiology of duodenal atresia?
A
Failure of bow to recannulize in 2nd month of gestation.
20
Q
What are prenatal s/s of duodenal atresia?
A
Polyhydramnios
Distended duodenum
21
Q
What symptom is a medical emergency until proven otherwise?
A
Bilious emesis
22
Q
What are postnatal s/s of duodenal atresia?
A
Bilious emesis - 1st 24 hrs of life
Abdominal distention of upper quadrants
KUB = double bubble (see pic showing air trapped in stomach & air trapped in proximal duodenum; separated by the pyloric sphincter - why looks like double bubble)
23
Q
What is the treatment for duodenal atresia?
A
Decompression
Surgery
24
Q
What disorders have a high rate of association w/ duodenal atresia?
A
Trisomy 21
CHD
Malrotation
Annular pancreas
EA
Genitourinary anomalies
25
What extrinsic causes could result in duodenal obstruction?
Malrotation/volvulus
Annular pancreas
Bowel duplications
Retroperitoneal tumors
26
What is an annular pancreas?
when the pancreas surrounds the second part of the duodenum causing constriction or blockage of the intestines.
27
What is the etiology of the annular pancreas?
when the ventral bud rotates counter-clockwise
28
What are the s/s of annular pancreas?
Polyhdramnios
Feeding intolerance
Low birth weight
29
What is the treatment for annular pancreas?
Surgical bypass of the blocked part of the duodenum
30
What is a malrotation?
When the intestines fail to rotate properly and affix improperly (the cecum ends up in the RUQ instead RLQ) & an abnormal membrane called the Ladd's band may obstruct the duodenum (see pic)
Leads to an increase likelihood of volvulus.
31
What is volvulus?
When the loops of the intestine twist on themselves causing obstruction due to malrotation
Can cause an infarct or necrosis of the entire mid-gut.
32
What is the etiology of malrotation?
Arrest of intestinal -270 degree rotation of the bowel in the 2nd month of gestation
33
What percentage of children pressent w/ s/s of malrotation/volvulus by their 1st week, 1st month, & 1st year?
1st week - 50%
1st month - 80%
1st year - 90%
34
What are the s/s of malrotation/volvulus?
Bilious emesis
Volvulus - acute episode of rectal bleeding & shock
35
How do you diagnose malrotation?
Clinical s/s
X ray shows gas bubbles & distention proximal to the site of obstruction.
36
What is the treatment of malrotation/volvulus?
Malrotation = Ladd's procedure - surgical division of Ladd's bands, widening of small intestine's mesentary, appendectomy, & correctional placement of colon & cecum
Volvulus = opening abdomen & reducing volvulus manually & performing Ladd's procedure; necrotic bowel can be resected & good bowel anastomosed.
37
What is the most common cause of exocrine pancreatic insufficiency?
Cystic fibrosis
38
What is the most common cause of endocrine pancreatic insufficiency?
39
What is pancreatic insufficiency? Treatment.
The deficient production of prancreatic enzymes required to digest proteins, carbohydrates, & fats. The main problem is maldigestion of fats --\> results in malnutrition, weight loss, & steatorrhea (large amt of fat in stool)
Treatment = lipase supplementation
40
Within what timeframe should a newborn pass stool?
Within 48 hrs
41
What is jejunal-ileal atresia?
When the intestine ends blindly w/ or w/o a gap in the mesentary.
42
Jejunal-ileal atresia is more common than duodenal or colonic atresia. True or false.
True
43
What is the etiology of jejunal-ileal atresia?
Mesenteric vascular occlusion in utero
44
What are the s/s of jejunal-ileal atresia?
SGA
1/3 polyhydramnios (rare in ileal atresia)
1/3 jaundice
Bilious emesis
Abd. distention - the more distention, the lower the lesion
May or may not pass meconium
45
How do you diagnose jejunal-ileal atresia?
KUB = dilated loops w/ air-fluid levels, the more air, the lower the obstruction
Calcifications
46
What is the treatment for jejunal-ileal atresia?
Surgery - take out the necrosed bowel & re-anastomose the rest.
47
Which disease is known as the disease of 2s?
Meckel diverticulum
48
What is Meckel diverticulum?
Outpouching from the small intestine involving all 3 intestinal layers
Can end in a blind pouch, a blind ending passage frm the umbilicus, a cyst, or cord-like attachment frm the umbilicus to the intestine (can cause obstruction if intestine twists around the band)
49
Why is Meckel diverticulum known as the disease of 2s?
Occurs in 2% of all infants at 2 yrs of age with boys 2x more affected
2 inch outpouching of ileum, 2 feet frm the ileocecal valve
50
What are the s/s of Meckel diverticulum?
Painless rectal bleeding
Bowel obstruction
Diverticulitis
51
How do you diagnose Meckel diverticulum?
radionuclide scan Tc-99m - detects gastric mucosa
52
What is the treatment for Meckel diverticulum?
Surgical resection
53
What is the etiology of Meckel diverticulum?
Remannt of the vitelline duct that involutes in 5-7wks during gestation
54
What is Hirschsprung disease?
Absence of gangion cells in the bowel wall causing an obstruction
55
Hirschsprung dx is also known as...
Congenital aganglionic megacolon
56
What is the etiology of Hirschsprung disease?
Failure of the neural crest cells to migrate frm the proximal to distal bowel at 8-10 wks gestation
57
What is the most frequent GI anomaly?
Meckel diverticulum
58
Is Hirschsprung disease more common in males or females?
Males 4:1
59
What is the most common cause of lower intestinal obstruction in neonates?
Hirschsprung disease
60
What are the s/s of Hirschsprung disease?
No meconium in 1st 24-48 hrs
Abd. distention
Constipation / foul smelling diarrhea
Bloody diarrhea
FTT
urinary obstruction
Acute bacterial enterocolitis (25-30% mortality)
61
What would increase your risk for Hirschsprung dx?
Positive family hx (incr. w/ length of affected bowel)
Siblings w/ Hirschsprung
Trisomy 21
62
What is meconium plug syndrome?
Transient obstruction of the colon caused by functional immaturity of the colon characterized by a delayed passage of meconium & intestinal dilation
Presents clinically the same as meconium ileus
63
Meconium plug syndrome is also known as...
Small left colon syndrome
64
What are the s/s of meconium plug?
no stool w/in 48 hrs
abdominal distention
emesis
65
When does meconium plug syndrome occur?
1st 3 days of life
66
What is the etiology of meconium plug syndrome?
IDM (50%) due to hypoglycemia
Hypermagnesia - causes reduced acetylcholine release & myoneural depression --\> neonate can be this is mom has received Mag sulfate as treatment
Systemic sepsis (hypoglycemia)
Functional immaturity of myenteric plexus
67
What is the treatment for meconium plug?
Rectal exam
Contrast enema
Surgery (in rare cases)
Rectal biopsy for Hirschsprung's dx & testing for CF
68
What is meconium ileus?
Obstruction of the ileus caused by hyperviscous secretions frm the mucous glands of the small intestine.
Meconium has decr. H20 content & adheres to intestinal lining & has elevated concentrations of albumin
69
What medical condition is a concern & should be tested for if a neonate is found to have meconium ileus?
Cystic fibrosis - 90% have meconium ileus
70
What are the s/s of meconium ileus?
no stool w/in 48 hrs
abdominal distention
palpable bowel loops
bilious emesis
71
What is the treatment for meconium ileus?
Hypertonic enemas - Mucomyst enemas (60% success rate)
Surgery
72
What other conditions can complicate meconium ileus?
Volvulus
Intestininal necrosis
Perforation
Meconium peritonitis - rupture of bowel prenatally leading to inflammation of the peritoneum due to fetal stool in the space.
Meconium pseudocyst - when the meconium is walled off in the peritoneal space.
73
What is gastrochisis?
When abdominal contents protrude b/c of an abdominal wall defect without a sac to the right of the umbilicus.
74
What is an omphalocele?
When abdominal contents protrude out the abdominal cavity covered by a sac (unless ruptured) due to a failure of the gut to retract back to the abdominal cavity from the umbilical cord at 8-11 wks gestation.
75
What is the treatment for omphalocele?
Surgery at 6-12 mos. to allow abdominal cavity to enlarge.
Gradual reduction by enlarging abdominal cavity accomodate intestinal contents. A plastic pouch is placed over the abdominal contents to contain the bowel & aid in reduction until surgical closure.
76
What is the treatment for gastroschisis?
Silicone pouch (silo) placed over the bowel & gradually pushed slowly back into the abdomen over a period of days & abdominal opening closed surgically.
77
Which has greater incidence, gastroschisis or omphalocele?
Gastroschisis
78
When comparing gastroschisis to omphalocele, is there a difference in occurence with regards to gender ?
Gastroschisis - occurs equally
Omphalocele - more males 3:1
79
Btwn gastroschises and omphalocele, omphalocele is more likely to occur in babies of young mothers. True or false.
False - gastroschisis is more likely to occur in babies of young mothers.
80
Comparing gastroschisis to omphalocele, is there a difference in the location & size of the defect?
Gastroschisis - right lateral to umbilicus & \< 4cm
Ompalocele - central (umbilical ring) & \> 4cm
81
In comparison to omphalocele, gastroschisis is more frequently associated w/ anomalies. True or false.
False. Gastroschisis infreq. associated w/ anomalies (if it is, usu. GI atresias)
Omphalocele is frequently associated with CV, GU, craniofacial, & skeletal anomalies
82
In comparison to omphalocele, gastroschisis is a better diagnosis & has a better survival rate. True or false.
True - gastroschisis = \>90% survival rate
Omphalocele = 90% survival rate w/o other anomalies, 60-70% survival rate w/ anomalies
83
What is an ileus?
Paralysis / partial paralysis of intestinal propulsion from non-mechanical reasons causing obstruction of the bowel
84
What are s/s of ileus?
abd. pain
constipation
abd. distention
N/V
lack of flatulence or BM
85
What is the etiology of ileus?
Surgery (postsurgical ileus)
Drugs
Inflammation
Electrolyte imbalance - hypermagnesia = slow bowel movement
86
Name 3 syndromes associated w/ GI malformations.
Trisomy 21 (down syndrome)
Beckwith-Wiedemann
Pentalogy of Cantrell
87
Which GI anomalies are children w/ trisomy 21 more likely to have?
TEF
Pyloric stenosis
Duodenal atresia
Hirschsprung dx
Annular pancreas
Imperforate anus
88
What percentage of Trisomy 21 children have GI anomalies?
12%
89
What is Beckwith-Wiedemann?
Chromosmal defect of chromosome 11 causing visceral marosomia (large organs) associated w/ macroglossia (enlarged tongue), diastesis recti (separation of abdominal muscles), omphalocele, ear creases/pits, cryptorchidism (undescended testes)
90
What is pentalogy of Cantrell?
Failure of growth & fusion of the lateral & cephalic folds.
5 distinct defects: 1) Cleft sternum (failed fusion of sternum)
2) Anterior midline diaphragmatic defect
3) Pericardial defect
4) CHD including ectopic cordis (when heart partially or totally outside of thorax)
5) High omphalocele
91
What is biliary atresia?
Absence or closure of ducts that drain bile from the liver causing bile to be trapped in the liver --\> can cause damage, cirrhosis, & liver failure
92
What is the etiology of biliary atresia?
Uknown
93
Biliary atresia is more common in females & Asians & African Americans. True or false.
True
94
At what age should you be suspicious of biliary atresia if the child presents w/ jaundice?
4 wks
95
What are the s/s of biliary atresia?
Jaundice
Hepatomegaly
Darker urine
Lack of color to stools
FTT
96
How would you diagnose biliary atresia?
Abdominal xray, US, HIDA scan (in 4 & 24 hrs)
Labs: liver enzymes, conjugated (direct) bilirubin - hyperbilirubinemia does not lead to kernicterus
Liver biopsy
97
Desribe the difference between intra-hepatic & extra-hepatic biliary atresia.
Intra-hepatic: failure of duct formation in fetus
Extra-hepatic: progressive inflammatory process, ducts outside liver are affected 1st --\> WBCs invade the ducts which get damaged & become withered or disappear.
98
What is the treatment for biliary atresia?
Kasai procedure by 1st 3 months of life - removal of atretic biliary ducts & attaching small intestine directly to liver at the spot where bile expected to drain.
Liver transplant - 50% of children will need by age 5
99
What congenital anomaly is associated with pyloric stenosis?
Tracheoeophageal fistula
100
What is pyloric stenosis?
Narrowing of the pylorus due to muscle hypertrophy
101
What is the etiology of pyloric stenosis?
Uknown
102
What factors may increase the occurrence of pyloric stenosis?
Male (first born) 4:1
Family hx (mother \> father)
Type B & O
103
What are s/s of pyloric stenosis?
non-bilious projectile vomiting
"olive," visible peristaltic wave
not anorexic - child still hungry
104
How do you diagnose pyloric stenosis?
Clinical s/s
US (thickness of pylorus \> or = 4mm, length \> or = 14mm)
UGI
105
What is the treatment for pyloric stenosis?
Correct fluid, acid-base, & electrolyte losses
Ramstedt pyloromyotomy - dividing the muscle of the pylorus to widen it's opening
106
What is nectrotizing enterocolitis (NEC)?
An ischemic inflammatory condition of the bowel that causes necrosis, perforation, & death if untreated.
107
What is the greatest risk factor of NEC?
prematurity
108
Cocaine is a risk factor for NEC. True or false.
True
109
When is NEC likely to occur?
3 days - 3 wks postnatally
110
What is the etiology of NEC?
Unknown
111
Describe the pathophysiology of NEC.
1) Mucosal injury & poor host protection
2) Hypoxic insult
3) Enteral feedings
4) Flora
5) Inflammatory mediators
6) Migratory motor complexes - waves of activity that sweep through the intestine during a fasting state --\> stimulate peristalsis & transports bacteria frm small intestine to large intestine
112
What are the enteric s/s of NEC?
Abd. distention & tenderness
Abd. wall mass, erythema, & induration
Ascites
Bloody stools
Emesis
Gastric aspirates (can be + / - bilious)
Ileus
113
What are the systemic s/s of NEC?
Resp: Respiratory distress, apnea
CV: Bradycardia, poor peripheral profusion, hypotension
Neuro: Lethargy, irritability, temp instability
GI/GU: Poor feeding, acidosis, oliguria
Heme: bleeding diathesis (tendency to bleed)
114
Besides clinical s/s how do you diagnose NEC?
Blood work - look for blood work triad
Stool analysis: hemoccult test, clinitest (carbohydrate malabsorption)
Cultures: (blood, urine, stool, CSF)
KUB - bowel gas, ileus, bowel wall edema, ascites, air
115
What is the blood work triad of NEC?
Acidosis
Hyponatremia
Thrombocytopenia
116
What is pneumoperitoneum?
Air trapped in the peritoneal cavity outside the lumen of the bowel --\> signals perforation
117
What is pneumatosis?
The presence of gas WITHIN the walls of the intestine, indicative of NEC
118
What are the 3 diffrent types of pneumatosis? (inner to outer)
Linear submucosal pneumatosis - btwn mucosa & submucosa
Cystic submucosal pneumatosis - bubbly air trapped w/in the submucosa
Linear subserosal pneumatosis - underneath the serosa
119
What is Bell Staging?
Criteria in stages for NEC
120
What is Bell Stage I?
Suspect NEC
Apnea, bradycardia, temp instability, positive stools/frank blood
121
What is Bell Stage II?
Definite NEC (mild-moderate)
Stage I + abd. tenderness, absent bowel sounds, abd. wall discoloration, R lower quadrant mass
Mild metabolic acidosis, mild thrombocytopenia
Intestinal dilation, pneumatosis, portal venous gas
122
What is Bell Stage III?
Severe NEC
Stage II + peritonitis, hypotension, shock
Severe metabolic acidosis, DIC, neutropenia, hyponatremia
Ascites, pneumoperitoneum
123
What is treatment for NEC?
NPO, parenteral nutrition support
Bowel decompression
Broad spectrum abx
Respiratory support
Correct acidosis, hypotension, thrombocytopenia, anemia, & DIC
Monitor renal function
Serial labs & radiographs
Surgery: perforation, necrosis, portal venous air
124
What are medical sequelae to NEC?
Strictures, enteric fistulas, short bowel syndrome, malabsorption, chronic diarrhea, dumping syndromes, FTT
Hepatitis & cholestasis (frm longterm TPN)
Infection (frm longterm central line)
Prolonged need for respiratory support
Dev delay, metabolic bone dx
125
What can we do to prevent NEC?
Prevent prematurity
Antenatal steroids
Conservative feeding approach
Oral immunoglobulins
Arginine supplementation
Oral probiotics
126
What is intussusception?
When a segment of the bowel into a segment distal to it; gets caught in downstream peristalsis & is pulled into the distal bowel --\> can cause necrosis & perforation
Can occur anywhere in the small bowel & colon
127
What are the s/s of intussusception?
Classic triad - intermittent colicky pain, vomiting, bloody stool
Dance sign
Tender & distended abdomen = signs of peritoneal irritation/necrosis or perforation
128
What is the classic triad s/s of intussusception?
Classic triad: intermittent / colicky abdominal pain, non-bilious vomiting, bloody currant jelly stools
129
What is the Dance sign of intussusception?
Pathognomic sign
Palpation of the abdomen may reveal a sausage-like mass in the right upper quadrant representing the actual intussusception, and an empty space in the right lower quadrant representing the movement of the cecum out of its normal position.
130
When is the most likely age for intussusception?
3 mos - 6 y/o
131
What is the most common type of intussusception?
Ileocolic intussusception
132
Distinguish btwn intussusceptum and intussuscipiens.
Intussusceptum - proximal intestine that prolapses
Intussuscipiens - distal intestine into which the proximal intestine prolapses
So in ileocolic intussusception, the intussusceptum is the ileus & the intussuscipiens is the colon.
133
How would you diagnose intussusception?
Clinical s/s
CBC / manual diff, electrolytes, glucose
KUB: look for normal vs obstructive, free air
Contrast air enema
US
134
In intussusception, what is the gold standard for diagnosis & therapy? Describe what intussusception looks like on film.
Contrast air enema
Coiled spring appearance on the film, "cervix-like" mass as contrast reaches intussusception
135
Can intussusception reoccur?
Yes
136
What is toxic megacolon?
An acute form of colonic distention - a complication of inflammatory bowel disease (IBS)
137
What is appendicitis?
Obstruction of the appendix with bacterial overgrowth, inflammation, ischemia & perforation
138
Which gender & at what age is appendicitis more likely?
Males
Peaks in late teens - early 20s
139
What is diverticulitis?
herniations or saclike outpouchings of mucosa through muscle layers of colon wall
140
What is the etiology of diverticulitis?
Unknown, but associated with decreased dietary fiber and intracolonic pressure
141
What is the pathogenesis of diverticulitis?
Habitual consumption of low residue diet decreases fecal bulk and decreases diameter of colon
Hypertrophy and contraction of muscle layers increase intraluminal pressure and degree of herniation
Can cause abscess formation, fistula, peritonitis or obstruction
142
What are s/s of diverticulitis?
Carmping pain
Diarrhea / constipation
Diverticula w/ obstructed opening b/comes inflamed or forms an abscess = fever, leukocytosis, tenderness in LLQ
Rare: hemorrhage, perforation with peritonitis, bowel obstruction, and fistula
