You can do this! Flashcards
Most common organisms associated with viral gastroenteritis
Rotavirus Adenovirus Astrovirus Calicivirus Coronavirus Sapovirus Parvovirus
Top 3-4 are going to be Rotavirus Adenovirus Noravirus Coronavirus
Organisms associated with bacterial gastroenteritis
Staphylococcus E.Coli Campyobacter Salmonella Shigella Yersinia Vibrio Parahaemolyticus Aeromonas Bacillus Cereus Clostridium Perfringens C.Difficile
Protozoa and parasites associated with gastroenteritis that cause infection resulting in fluid loss and malabsorption
Cryptosporidium
Isospora
Cyclospora
Protozoa and parasites associated with gastroenteritis that directly infect the small bowel leading to malabsorption
Giardia
Enteromonas hominis
most common 3 symptoms for gastroenteritis
fever
vomiting
diarrhea
not all 3 are required to be present
diarrhea definitions
1) a normal BM that has increased in frequency and large water content
2) Stool output greater than 3 times per day (24 hours)
days to be acute diarrhea
<= 14 days
days to be persistent diarrhea
15-29 days
days to be chronic diarrhea
> =30 days
bloody diarrhea, vomiting, and periorbital edema or edema of extremities
should make you think about
HUS (Hemolytic Uremic syndrome)
Can ear infections be a reason for vomiting and/or diarrhea
yes
diarrhea, vomiting and oral lesions may be a sign of
IBD
certain viral illnesses
diarrhea, vomiting, fever, and erythema in the oropharynx or malodorous breath may be evidence of
sinusitis or pharyngitis
Pain in the RLQ should make you think
appendicitis
Pain in the LUQ may be associated with what organs
pancreas
Spleen
Pain at the costovertebral angle may indicate
kidney infection
Pain at the flank may be related to
pylonephritis
localized pain is a red flag that says what about gastroenteritis
that there is another cause for the pain other than gastroenteritis
maintenance ORS guidelines
Use for maintenance fluids
<10kg- 60mL-120mL for each episode of vomiting or diarrhea
>10kg - 120-240mL for each episode of vomiting or diarrhea
plus regular diet
ORS for mild to moderate dehydration
severe requires IV fluid
first replace fluid deficits then maintain
50-100mL/kg over 2-4 hours
An additional
<10kg- 60mL-120mL for each episode of vomiting or diarrhea
>10kg - 120-240mL for each episode of vomiting or diarrhea
start small (5-10 mL) every 5-10 min and increase as tolerated
after replace losses and vomiting stops, resume diet and continue maintenance ORS
Probiotic use in gastroentritis
may shorten by 1 day
Lactobacillus rhamnosus GG (LGG) was most effective
Zinc in gastroenteritis
Not formally recommended by CDC but research shows potential reduction in diarrhea with improved outcomes
which organisms cultured from stool would a pt need to demonstrate several negative stool cultures before returning to school or daycare
Salmonella serotype Typhi
Shiga toxin-producing E.Coli (STEC)
E.Coli 0157:H7
Shigella
In general, other than Salmonella serotype Typhi Shiga toxin-producing E.Coli (STEC) E.Coli 0157:H7 Shigella
afebrile pts with gastroenteritis may return to school when?
when they have less than 3 episodes of loose stool a day
Which organism does the book point out as the cause for nearly 600,000 visits to HCPs , upwards of 70,000 hospitalizations and 20-70 deaths exceeding 1 billion in care costs
Rotavirus
Type of transmission for Gastroenteritis
Fecal-oral transmission
person to person…direct…fomites, ect
a right lower quadrant pain elicited by pressure applied on the left lower quadrant
Rovsing’s sign
appendicitis
Rovsing’s sign
a right lower quadrant pain elicited by pressure applied on the left lower quadrant
appendicitis
the point on the lower right quadrant of the abdomen at which tenderness is maximal
McBurney’s point
appendicitis
McBurney’s point
the point on the lower right quadrant of the abdomen at which tenderness is maximal
appendicitis
Pain is elicited by having the patient lie on his or her left side while the right thigh is flexed backward
Psoas sign
appendicitis
Psoas sign
Pain is elicited by having the patient lie on his or her left side while the right thigh is flexed backward
appendicitis
discomfort felt by the subject/patient on the slow internal movement of the hip joint, while the right knee is flexed with lateral movement of flexed knee outward
Obturator sign
appendicitis
Obturator sign
discomfort felt by the subject/patient on the slow internal movement of the hip joint, while the right knee is flexed with lateral movement of flexed knee outward
appendicitis
What sign?
pain with coughing
Dunphy
appendicitis
Dunphy sign
pain with coughing
appendicitis
What sign
pain with heel drop
Markle sign
appendicitis
Markle sign
pain with heel drop
appendicitis
stool that has the appearance and consistency of liquid tar, is black in color and offensive in odor
Melena
The vast majority of patients with UGI bleeding have ________ or _____ secondary to _____
lesions of the GI mucosa
esophageal varices
liver disease
The vast majority of patients with UGI bleeding have lesions of the GI mucosa or esophageal varices secondary to liver disease
most common cause of colonic bleeding worldwide
Infectious colitis
an infant with GI bleeding who is fed cows milk or soy based formula may have
allergic collitis
A history of dry heaves followed by hematemesis or melena may suggest
Mallory Weiss tear
Recent illness with GI bleeding may lead you to what
HUS
Ingestion of ______ can lead to gastritis, duodenitis, or ileal and right colonic lesions
NSAIDS
Liver disease may be related to what inherited deficiency
Alpha 1 antitrypsin
what disease can be transmitted at birth and affect the liver
Hepatitis B
BRUE symptom with GI bleed…think…
UGI bleed such as esophagitis, gastritis or ulcer
Urgency to defecate or Tenesmus ( the feeling that you need to pass stools, even though your bowels are already empty) suggests
colitis
Delayed passage of meconium or constipation in infancy can be a sign of
Hirschsprung disease
Cystic Fibrosis
The presence of spider angiomata, palmar erythema, fetor hepaticus or splenomegaly suggests chronic ______ disease and _____ _____
Chronic liver disease
Portal Hypertension
If a pt is on antibiotics and getting no enteral nutrition, what should you be concerned with?
Killing the intestinal track’s vitamin K producing bacteria which will cause the patient’s prothrombin time (PT) to rise, resulting in a coagulopathy. Add NG suction to this perfect storm and you have an UGI bleed from the NG tube suction induced mucosal injury
GI bleed patient that you find a palpable moveable rectal mass on might identify _____ as a possible etiology
Polyps
what are some things that patients may ingest that can give the appearance of blood in stool
commercial dyes (#2 and #3)
Blueberries
Beets
Bismuth
what diagnostic exam is used if you suspect upper GI bleeding
upper endoscopy
what diagnostic exam is used if you suspect bright red lower GI bleeding
Colonoscopy
what organism is associated with bleeding duodenal or gastric ulcer
Helicobacter Pylori
What should occur with bleeding esophageal varices or varices that have recently bled
Should be sclerosed or banded to decrease risk of re-bleeding
what medication is used to decrease central venous pressure for management of bleeding esophageal varices before endoscopic intervention
Octreotide
In the case of variceal bleeding that is not controlled by endoscopic and/or tamponade intervention, what procedure is warranted
emergency transjugular intrahepatic portosystemic shunting (TIPS) or surgical shunting to decrease portal hypertension may be warranted
In patients with significant GI bleeding who the source was not detected by upper endoscopy and colonoscopy, what is next step
a nuclear medicine tagged RBC bleeding study to help find source of blood loss
(bleeding will have to be brisk enough to detect with this scan)
If actively bleeding, an angiogram with selective vessel embolization may be required
A single or double balloon enteroscopy may help identify a radiographically silent lesion or one beyond the reach of the conventional upper or lower endoscope
does a negative gastric lavage test with NGT rule out UGI bleed
No, bleeding may have stopped or pylorospasm could be preventing blood from a duodenal source from entering the stomach
Not routinely performed for a stable patient with formed brown guiac positive stools
why is continuous suction via NGT controversial in GI bleeds
can exacerbate bleeding
Polyps are removed with what during a colonoscopy
Electrocautery
When does GI bleeding resolve in Henoch-Schonlein Purpura (HSP) and HUS
with resolution of the disorders
UGI bleeds - when can the patient resume their diet
within 24 hours
Upper GI bleed discharge meds
PPI for gastritis
Beta blocker (propanolol) for esophageal varices
follow up with GI
lower GI bleeds will depend on the etiology of the bleed
upper GI bleeding differentials
infant vs young child vs older child/adolescent
Bolick chart pg 441
All ages
- Hemorrhagic gastritis/gastritis
- Stress ulcer
- Reflux esophagitis
Infant only
-Vascular malformation
Young child to adolescent
- gastric/duodenal ulcer
- Esophageal varices
- Epistaxis
- Mallory-Weiss tear
Young Child
- Foreign Body
- Toxic Ingestion
Lower GI bleeding differentials
infant vs young child vs older child/adolescent
Bolick chart pg 441
All ages
- Infectious colitis
- Anal fissures
Infant only
- Necrotizing enterocolitis
- Milk Protein Allergy
- Hirschsprung disease
- Lymphonodular hyperplasia
Infant and young child
- Midgut volvulus
- Intussusception
young child only
- Pseudomembranous colitis
- Ischemic colitis
young child through adolescence
- Hemorrhoid
- Ulcers
- Polyps
- Juvenile Polyps
- Hemolytic-uremic syndrome (HUS)
- Inflammatory bowel disease
- Henoch-Schonlein purpura (HSP)
- Meckel Diverticulum
- Angiodysplasia
- Graft-vs-host disease
older child through adolescence
-Bacterial enteritis
Pediatric end-stage liver disease scoring formula
PELD score = 1 x (0.48 x (bilirubin)) + (1.857 x (INR)) - (0.687 x (albumin)) + listing age factor + growth
Upper GI bleed vs Lower GI bleed is differentiated by the
Ligament of Treitz (located between jejunum and duodenum)
hematemesis is associated with upper or lower GI bleeding
upper
Hematochezia is associated with upper or lower GI bleeding
Lower
Most common intra- abdominal tumors in children
neuroblastoma and Wilms tumor
an ischemic and inflammatory disorder of the bowel most prominently seen in the jejunum, ileum, and colon primarily affecting premature infants after then initiation of enteral feeding.
Necrotizing enterocolitis (NEC)
What happens in NEC
intestinal injury then activates the gut’s inflammatory cascade, causing mucosal damage and allowing invasion of the bowel wall by bacteria
who is at highest risk for NEC
preterm infants in the first 6 weeks of life
more than 90% of cases occur in preterm infants born less than 32 weeks PCA and birth weights less than 1500gms
10% of NEC cases occur in term infants with underlying pre-existing illnesses such as congenital heart disease
Maternal risk factors associated with NEC
placental insufficiency
gestational hypertension with superimposed pre-eclampsia
maternal smoking
maternal infection/inflammatory conditions
shiga-toxin producing organism strain that causes gastroenteritis
E. coli O157:H7
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1222). Wolters Kluwer Health. Kindle Edition.
what organism for bacterial gastroenteritis is antibiotics contraindicated in treating
E. coli O157:H7
antidiarrheal medications for gastroenteritis for kids
Antidiarrheal medications often contain aspirin, which contributes to Reye syndrome and should be avoided.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1223). Wolters Kluwer Health. Kindle Edition.
causes of inflammatory bowel disease
Crohn disease
ulcerative colitis.
Meckel diverticulum (ectopic gastric mucosa) is most common in what age
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1224). Wolters Kluwer Health. Kindle Edition.
school aged children
coffee ground emesis….are you thinking upper or lower GI bleed
upper
Management of GI bleed, unstable
- Obtain IV access and administer fluid volume.
- Initial fluids: normal saline, lactated Ringer solution, and/or packed RBCs (PRBCs).
- NPO.
- Proton pump inhibitor; intravenously.
- Consider octreotide for bleeding esophageal varices; may also require banding via upper endoscopy.
- Consider vitamin K administration if coagulopathy noted.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (pp. 1225-1226). Wolters Kluwer Health. Kindle Edition.
infant risk factors for NEC
gestational age birth weight less than 1500 gms nonhuman milk enteral feeding circulatory instability with associated GI ischemia Anemia with blood transfusion
clinical presentation of NEC
mild to gaseous abd distention feeding residuals - can be bilious or bloody vomiting bloody stools signs of shock
also can have lethargy episodes of apnea resp distress bradycardia desaturations temp instability
diagnostic for NEC
AP or Lat decub of abdomen may show ileus, dilated loops of bowel, pneumatosis intestinalis, ascites, intrahepatic portal venous air, persistent fixed loops of bowel and free air indicative of perforation
lab findings commonly found in NEC
metabolic acidosis thrombocytopenia neutropenia coagulopathies electrolyte disturbances
Management of NEC
decompression of bowel broad spectrum abx coverage for sepsis supportive care NPO collect blood cultures, urine, CSF
pneumatosis intestinalis on x ray
NEC
The infant with medical NEC will typically recover after
prolonged period of bowel rest (parenteral nutrition support)
empiric treatment for infection (7-10 days)
if they perforate they will need peritoneal drain or laparotomy of diseased segments of bowel
abd mass with weight loss, anorexia, fever, night sweats, and often easy bleeding or bruising
think neoplasm
abd mass with hx of bilious emesis or encopresis (fecal incontinence)
bowel obstruction
cola- colored urine and acholic stools
Urinary excretion of bile salts
associated with renal pathology of abd mass
RUQ masses most often involve
liver
gallbladder
biliary tree
Epigastric masses can include both
epigastric hernias
Diastasis recti
LUQ masses think
spleen
stomach
adrenal gland
kidney
R and LLQ masses may be from
ovarian and fallopian processes
or intestines in orgin
suprapubic masses are most commonly ____ in nature
genitourinary
mobility or immobility of abd mass suggest
degree of attachment or invasion of the retroperitoneum
immobile abd mass
invasive tumors or
masses that arise from the retroperitoneal organs
Tenderness to abd mass generally suggests
a recent change such as bleeding
Firmness, hardness and irregularity of an abd mass suggest either
tumor or
desmoplasia (scar)
smoothness of an abd mass suggests
encapsulated mass
Tympany indicates
gas such as in a hollow viscus
dullness indicates
fluid or solid mass
diagnostic imaging for Hepatobiliary and pancreatic masses
Neither US nor CT is effective at imagining the biliary and pancreatic ductal system HIDA scan (Hepatobiliary iminodiacetic acid)- traditionally used first now have MRCP (magnetic resonance cholangiopancreatography is now used for hepatobiliary and pancreatic disease
milk allergy typically presents how long after introduction of dairy into diet
within a week
types of benign cystic lesions (uncommon in children)- abd masses
choledochal cyst
polycystic kidney disease
duplication cyst
cystic teratoma
most common age of presentation of a neuroblastoma
18 months with the prevalence greatest in children <4 yrs
Most common renal tumor and 5th most common pediatric malignancy
Wilms tumor
Most common age of presentation of Wilms tumor
1-5 yrs
most common malignant liver tumor
Hepatoblastoma
mean age at diagnosis for hepatoblastoma
1 year old
What is hepatoblastoma associated with (increased risk factors)
extreme prematurity very low birth weight Beckwith-Wiedemann syndrome Gardner syndrome Familial Adenomatous Polyposis Disease
what is the preferred diagnostic test for neuroblastoma
CT
what race and gender is at highest risk for NEC
Black males
prevention for NEC
Breastfeeding
preliminary evidence shows probiotics
type of small bowel obstruction….
history of surgery
adhesive SBO
type of small bowel obstruction….
with bilious or feculent vomiting and no gas or stool
Complete obstruction
type of small bowel obstruction….
decreased stool and almost no gas
partial SBO
Bilious vomiting should always suspicious for
malrotation with volvulus
why? In pyloric stenosis, their vomitus never contains bile
because gastric outlet obstructed proximal to duodenum
Gastric peristaltic waves are often visible in LUQ in
pyloric stenosis
“olive” may be palpated
pyloric stenosis
Hypertrophied pylorus “olive” may be palpated
lab expectations in pyloric stenosis
Hyperchloremic, hypokalemic metabolic alkalosis, elevated BUN secondary to dehydration
xray in pyloric stenosis
xray- show huge stomach and diminished or absent gas in intestine
string sign
pyloric stenosis
treatment for pyloric stenosis
Hydration
electrolyte correction
Surgery - Pyloromyotomy (Ramstedt’s procedure)
Before surgery correct dehydration and hyperchloremic alkalosis
NS bolus followed by infusion of ½ NS containing 5% dextrose and KCl when urine output is observed
classic presentation age for pyloric stenosis
3-6 weeks old
Alvardado/MANTRELS rule
Appendicitis 1 point for each the following- -Migration of pain to RLQ -Anorexia -N/V -Rebound pain -Temp of at least 37.3 -WBC great then 75% neutrophils 2 points for each of -tenderness in RLQ and -leukocytosis greater than 10,000
Children with score of 4 or less- unlikely appy
Score of 7 or greater- increased likelihood
thick-walled appendix with surrounding fluid
Diameter over ___mm considered dx
6
most common reason for abd surgery in kids in the US
appendicitis
most common age and gender for appendicitis
Although it can occur at any age, it is most commonly diagnosed between 10 and 12 years of age and occurs more often in males than females.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1200). Wolters Kluwer Health. Kindle Edition.
a finger-like structure projecting from the cecum,
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1200). Wolters Kluwer Health. Kindle Edition.
Appendix
perforated appendicitis treatment
• Antibiotic therapy is generally prescribed for 5 to 7 days depending on patient response. Ceftriaxone and Flagyl for perforated appendix have proven to be adequate.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1204). Wolters Kluwer Health. Kindle Edition.
Characterized by the triad of microangiopathic hemolytic anemia, thrombocytopenia, renal injury
HUS
Most common type of HUS
prodromal diarrheal illness (D+HUS)
Contaminated meat, fruit, veggie, or water with verotoxin producing E.coli (O157:H7) or Shigella → will have hemorrhagic enterocolitis and progress to HUS
what am I? presents without prodrome of diarrhea Can occur at any age More severe Can be secondary to infection (strep pneumo, HIV), genetic, medication, malignancy, SLE, pregnancy
Atypical HUS
Entercolitis with bloody stools, followed in 7-10days by weakness, lethargy, anuria/oliguria
Irritable, pallow, petechiae
Dehydration, however some children have volume overload (hypertension may occur)
CNS seizures in 25%, pancreatitis, cardiac dysfunction, colonic perforation
D+ HUS
Lab smear: microangiopathic hemolysis
Anemia, thrombocytopenia, schistocytes/helmet/burr cells on smear, incr LDH, incr indirect bili, incr AST, incr reticulocyte
Coombs test is NEGATIVE
Renal injury: elevated Cr, hematuria, proteinuria, pyuria, casts on UA
Leukocytosis, E coli stool culture, shiga toxin, elevated amylase/lipase
HUS
Treatment of HUS
Volume repletion
Hypertension control
Managing renal insufficiency – dialysis
RBC transfusions
DO NOT GIVE PLATELETS – may add to thrombotic microangiopathy
Only give if active hemorrhage or procedural
NO ABX OR ANTIDIARRHEAL – will make HUS worse
double bubble sign on x ray
volvulus
coffee bean sign on x ray
volvulus
swirl sign on CT
volvulus - diagnostic
an infant with acidosis and abdominal distension is most suspicious for
bowel obstruction
infant with aganglionic section of bowel
Hirschsprung’s disease
absence or obstruction (due to fibrosis) of the biliary tree, (extrahepatic) leading to intrahepatic bile duct obstruction and proliferation.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1207). Wolters Kluwer Health. Kindle Edition.
Biliary atresia
types of Biliary atresia
(1) syndromic BA and associated malformations (i.e., BA splenic malformation syndrome, cat-eye) and random malformations (e.g., esophageal atresia (EA), jejunal atresia, malrotation)
(2) cystic BA—cystic change in an obliterated biliary tract
(3) cytomegalovirus-associated BA, in which the infants have positive serology
(4) isolated BA (largest group of infants).
•Proposed nongenetic etiologies: infection, intrauterine infection, toxin exposure.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1207). Wolters Kluwer Health. Kindle Edition.
physical exam findings in biliary atresia
jaundice
acholic stools
dark urine
labs
hyperbili
elevated LFT
infectious causes of biliary atresia
viral hepatitis TORCH Toxoplasmosis other agents Rubella Cytomegalovirus Herpes simplex
diagnostics for biliary atresia
• Radiologic evaluation. • Abdominal ultrasound: gallbladder noted to be absent or small. • Hepatobiliary scintigraphy, in which there is no excretion of the isotope detected in the intestine. • Confirmatory cholangiogram is done at the time of laparotomy/laparoscopy for surgical intervention.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1208). Wolters Kluwer Health. Kindle Edition.
surgical management for biliary atresia
• Kasai procedure or portoenterostomy. • Best results in children <2 months of age in experienced hands. •Excision of the extrahepatic biliary tract and anastomosis of a Roux-en-Y limb to the jejunal limb at the porta hepatis. •The goal of the procedure is to reestablish bile flow as evident by pigmented stool in the immediate postoperative period. •Deemed a successful operation if conjugated bilirubin level is <2 mg/dL at 3 months postop; long-term outcome is variable with a small percentage of children achieving lasting drainage that is effective. • Complications: bacterial cholangitis.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1208). Wolters Kluwer Health. Kindle Edition.
mutation in CFC1 gene
biliary atresia
most common indication for liver transplant
biliary atresia
biliary atresia nutritional requirements
- Nutrition. • Require 130% to 150% of the recommended daily allowance, and many require 150 kcal/kg/day to achieve appropriate growth. • May require formulas with increased medium chain triglycerides as they do not require bile acids for digestion (e.g., breastmilk, Pregestimil, or Portagen). • Supplement with fat-soluble vitamins (A, D, E, and K).
- Supplemental nocturnal feeds with a nasogastric (NG) tube may be necessary for growth failure.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (pp. 1208-1209). Wolters Kluwer Health. Kindle Edition.
Acute cholecystitis is often attributed to the presence of
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1210). Wolters Kluwer Health. Kindle Edition.
Gallstones
Hypoalbuminemia and abdominal mass may suggest
nonspecific but indicates significant illness
Uric acid and LDH plus abdominal mass may indicate
Solid tumors
Abdominal mass plus BUN and Creatinine may indicate
Renal dx
Abdominal mass plus elevated amylase and lipase levels may indicate
pancreatic dx
Abdominal mass plus elevated LFTs think
Liver dx
2 view abd x ray with abdominal mass will show things such as
Intestinal obstruction
fecal impaction
calcifications associated with tumor
US in the setting of abdominal mass may be used to
identify origin of the mass
solid vs cystic
can help further lab testing and imaging
CT scan with IV contrast in the setting of abdominal mass may be used to
- evaluate solid abd mass
- vascular abnormalities
- associated lymph nodes
- stage many types of cancers
- helps with cystic mass to see if there is continuity with bowel or bladder
- Not helpful if mass of primary bowel or bladder -> Fluoroscopic studies such as UGI series, BE and voiding cystourethrogram
- Oral contrast will cause artifact to the bowel and bladder
best diagnostic exam for abdominal mass of primary bowel or bladder
Fluoroscopic studies such as UGI series, BE and voiding
what diagnostic is used for hepatobiliary and pancreatic masses?
- Neither US nor CT is effective at imagining the biliary and pancreatic ductal system
- HIDA scan (Hepatobiliary iminodiacetic acid)- traditionally used first now have MRCP (magnetic resonance cholangiopancreatography is now used for hepatobiliary and pancreatic disease
radiograph after standing for 2 minutes has maximum sensitivity for free gas suggesting perforation. (Bowel perforation)
Abdominal X-ray- upright chest radiograph
radiograph that has better sensitivity than other radiograph views because gas collects around the liver. Looking for bowel perforation
Left lateral decubitus
Radiograph useful for proximal bowel obstruction
Upper GI contrast series
imaging Usually appropriate if the abdominal radiograph or physical examination suggests distal bowel obstruction (as might be seen in Hirschsprung disease).
contrast enema
imaging used to determine bowel obstruction site
CT with IV contrast. Do not use contrast if suspect perforation
on imaging you see numerous air fluid levels, distended bowel normally more central
what does this sound like
small bowel obstruction
on imaging you see few to no air fluid levels. Distended bowel normally more peripheral
Large bowel obstruction
what type of obstruction?
a small bowel obstruction in a patient who has had surgery or a severe infection of the abdominal cavity
Adhesive bowel obstruction
what type of bowel obstruction?
there will be bilious and feculent vomiting with no gas or stool passage per anus
Complete bowel obstruction
what type of bowel obstruction??
decreased stool passage and almost no gas passage
Partial bowel obstruction
causes of functional bowel obstruction
Abd surgery Peritonitis Sepsis Trauma Medications (opioids, anxiolytics) Metabolic imbalances (hypokalemia, hyponatremia, hypomagnesemia, acidosis)
causes of mechanical bowel obstruction
Postoperative adhesions Hematoma Intussusception Distal intestinal obstruction syndrome Malrotation with volvulus Tumors Bezoar Congenital abnormalities: -Duodenal atresia -Duodenal web -Annular pancreas -Jejunoileal atresia
an obstruction caused by a loop in the intestines that twists around itself and surrounding mesentery
Volvulus
volvulus that happens in the last part of the large intestines leading to the rectum
Sigmoid volvulus
volvulus that happens in the beginning part of the large intestines
cecal volvulus
volvulus that happens in the small intestines
midgut volvulus
which type of volvulus is the most common type?
sigmoid volvulus
occurs when small bowel twists around the superior mesenteric artery, resulting in vascular compromise to large portions of the midgut.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1242). Wolters Kluwer Health. Kindle Edition.
Volvulus
______volvulus may lead to widespread intestinal ischemia and progress rapidly to necrosis of the bowel, perforation, shock respiratory failure, and death.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1242). Wolters Kluwer Health. Kindle Edition.
Midgut
At approximately the _____week of embryonic life, the gut begins to change from a straight-line structure to an elongated tube herniating into the umbilical cord.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1242). Wolters Kluwer Health. Kindle Edition.
4th
Abdominal rotation and attachments are complete by __ months’ gestation.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1243). Wolters Kluwer Health. Kindle Edition.
3
______ occurs when the bowel fails to rotate after it returns to the abdominal cavity.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1243). Wolters Kluwer Health. Kindle Edition.
Malrotation
Presentation of malrotation is usually when and how does it appear?
Presentation of infants older infants children adolescents
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1243). Wolters Kluwer Health. Kindle Edition.
in the first year of life with symptoms of acute or chronic bowel obstruction.
Infants present within the first week of life with bilious emesis and acute bowel obstruction.
Older infants present with episodes of recurrent colicky abdominal pain.
Children may present with recurrent episodes of vomiting, abdominal pain, or both.
•Occasionally, patients may present with malabsorption or protein-losing enteropathy associated with bacterial overgrowth. Symptoms are caused by intermittent volvulus or duodenal compression by Ladd bands or other adhesive bands affecting the small and large bowel.
25-50% of adolescents with malrotation are asymptomatic
Symptomatic adolescents present with acute intestinal obstruction of history of recurrent episodes of abdominal pain with less frequent vomiting and diarrhea.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1243). Wolters Kluwer Health. Kindle Edition.
If you suspect malrotation what labs are you ordering?
what is diagnostic?
CBC
type and screen
electrolytes (imbalances secondary to vomiting and 3rd spacing fluid into the bowel and abd cavity)
anemia can be caused by pooling of blood intestines
-Flat and upright or lat decub abd x rays - evaluates for intestinal obstruction but cannot diagnose malrotation
Upper GI Series is the preferred study to evaluate the position of the ligament of Trietz
•If malrotation exists, UGI will show abnormal position of the ligament of Trietz, partial obstruction of the duodenum, with a spiral or corkscrew appearance, and proximal jejunum in the right abdomen.
•When volvulus is present, the barium column is noted to end in a peculiar beaking effect and pathognomonic for a volvulus.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1244). Wolters Kluwer Health. Kindle Edition.
management of Malrotation with volvulus
emergent LADD procedure
Preop management for Malrotation with volvulus
cardiopulmonary and circulatory resuscitation. A gastric decompression tube should be placed, along with the administration of broad-spectrum antibiotics, to cover gut flora.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (pp. 1244-1245). Wolters Kluwer Health. Kindle Edition.
bilious vomiting in a neonate is highly suspicious for
malrotation with volvulus until proven otherwise
cecal volvulus usually occurs in what age group
young adults
______ volvulus is most commonly seen in babies and small children
midgut volvulus
coffee bean sign on x ray
volvulus
birds beak shape on barium enema
volvulus
sigmoid volvulus is usually treated with
sigmoidoscopy
A _______ may be used to resolve a cecal volvulus
Colonoscopy
A colonoscopy cannot be used to treat a _____ volvulus
midgut
The most common presenting symptom in Chrohn’s disease
is abdominal pain. Pain is commonly crampy, epigastric or periumbilical, and intermittent
increases the risk of IBD
smoking
oral contraception
infectious colitis
infectious agents
treatment of Chrohn’s disease
Aminosalicylates; oral or IV steroids are more important in reducing remission.
is an umbrella term for Crohn disease and ulcerative colitis, which are inflammatory processes of the GI tract with very similar presentations.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1235). Wolters Kluwer Health. Kindle Edition.
Inflammatory Bowel Disease
•The difference between Crohn disease and Ulcerative Colitis is
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1235). Wolters Kluwer Health. Kindle Edition.
based on the location and characteristics of the inflammation.
inflammatory process that can affect any portion of the GI tract. Most commonly affects the terminal ileum. The inflammation is in the entire lumen of the intestines.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1235). Wolters Kluwer Health. Kindle Edition.
•Crohn Disease:
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1235). Wolters Kluwer Health. Kindle Edition.
inflammatory process that affects the colon and rectum. The inflammation is in the mucosal layer of the intestinal wall.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1235). Wolters Kluwer Health. Kindle Edition.
Ulcerative colitis:
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1235). Wolters Kluwer Health. Kindle Edition.
Inflammatory bowel disease is most commonly diagnosed between ____ and ____ age with a second peak between 50-80 yrs of age
15 and 30
genetic predisposition that is turned on by environmental factors that causes an excessive immune response that results in chronic intestinal inflammation.
pain, diarrhea, weight loss, perirectal inflammation with fistula.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1236). Wolters Kluwer Health. Kindle Edition.
Crohn disease
bloody, watery diarrhea, weight loss, tenesmus, and urgency.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1236). Wolters Kluwer Health. Kindle Edition.
Ulcerative colitis
gold standard diagnosis of IBD
Endoscopy of the intestinal tract with biopsy and histology
Labs in IBD workup
CBC ESR CRP LFT GGT IBD serology Stool studies looking for infectious etiology of diarrhea
induction of remission in IBD
- Corticosteroids are used as first-line therapy for induction and remission after an IBD flare-up. During induction of remission, all maintenance medications are continued because they have the ability to induce remission or help the action of the corticosteroids.
- Exclusive PN for 8 weeks with bowel rest. This therapy has a similar remission rate as corticosteroids with less side effects.
- Biologic agents (e.g., Infliximab) are used for severe inflammation or refractory to other treatments to help induce remission.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (pp. 1236-1237). Wolters Kluwer Health. Kindle Edition.
Maintenance of remission in IBD
• Immunosuppressive medications are used to maintain remission because of slow onset of action. • Aminosalicylates (5-ASA) reduce inflammation to maintain remission in mild UC and Crohn disease. • Immunosuppressive therapy should be started while still on steroid treatments; steroids are then tapered. • Supplementary nutrition with any treatment. Probiotics are useful as adjunct therapy. • Antibiotics have a role in treating perirectal fistula or abscess in Crohn disease. •Surgical intervention is appropriate for patients with refractory disease, uncontrolled GI bleeding, bowel perforation, or stricture causing an obstruction, with bowel resection being the last option. •Total colectomy in UC with J-pouch is the surgical treatment of refractory disease, toxic megacolon, perforation, or severe colitis. In UC, a total colectomy can be curative. •Resection of a stricture or area of colitis in Crohn disease is the surgical treatment. In severe cases when the intestines become perforated, an ostomy is required.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1237). Wolters Kluwer Health. Kindle Edition.
Ulcerative colitis is most commonly seen in what age group
20-30 yrs old
Ulcerative colitis symptoms
Systemic:
- Fatigue
- Fever
- Weight Loss
- Dyspnea
- Palpitations (iron def anemia secondary to blood loss)
GI
- Bloody Diarrhea
- Colicky Abd pain
- Tenesmus
Extraintestinal
- Arthritis
- Uveitis
- Episcleritis
- Skin Lesions (pyoderma gangrenosum & erythema nodosum)
- Primary sclerosing cholangitis
- Venous/Arterial Thromboemboli
Acute complications of UC
Severe GI bleeding Fulminant colitis (bleeding with more than 10 stools per day) Toxic megacolon (nerves and muscles damaged with the colon atonic and dilated) -> can lead to perforation with peritonitis (fevers and severe abd pain)
Long term complications of UC
- increased risk for colorectal cancer
- strictures ->rectosigmoid colon which can lead to bowel obstruction
Chrohns disease symptoms
Systemic
- Fatigue
- Fever
- Weight loss
Gastrointestinal
- Crampy abd pain
- Watery diarrhea
- Malabsorption symptoms (Steatorrhea)
- Fistulas (Communication between 2 epithelial organs)
- Phlegmon -> abscess
- oral (ulcers, gingivitis)
- Gallstones (biliary colic
Extraintestinal
- Arthritis
- Uveitis
- Episcleritis
- Skin Lesions (pyoderma gangrenosum & erythema nodosum)
- Primary sclerosing cholangitis
- Venous/Arterial Thromboemboli
- Kidney stones
string sign
strictures
can be seen in Crohns disease
skip lesions
Chrohns disease
not seen in UC
IBD with ileal involvement
common in Crohns disease
not seen in UC
IBD with fistulas
Common in Chrohns disease
very rare in UC
smoking decreases risk of
UC
increases risk of CD
an ilieus is a
non-mechanical obstruction of the intestines (caused by a disruption of peristalsis that can be partial or complete resulting in dilation of proximal intestines
Most common cause of an ileus is form
manipulation of intestines during surgery
clinical presentation of ilieus
Abd distention
absent/hypoactive bowel sounds
pain
vomiting
diagnostic for ileus
abd x ray
management of ileus
Bowel rest
decompression with NG
Adequate postop pain management w/non-narcotic meds
Routine postop care to include ambulation and time
if an infant doesnt pass meconium within first 48 hrs abd distension refuses to feed bilious vomiting what should be on your differential
Imperforate anus
Meconium ileus
Hirschsprung’s disease
VACTERL Syndrome
Vertebral defects Anal atresia Cardiac anomalies Tracheoesophageal fistula Esophageal atresia renal anomalies limb anomalies
meconium ileus is seen with what disease process
Cystic fibrosis
what test is for cystic fibrosis if newborn screening test isnt back yet
Abnormal sweat chloride test
>60mmol/L
on exam the newborn has a empty rectum with no meconium and with normal sphincter tone
Meconium ileus which is a surgical emergency
