are below their expected weight for day of life can-

165. Peds GI Flashcards by Tegan Turner

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DDX unconjugated/indirect hyperbili jaundice in infants? “1. Benign - physiologic 2. Hemolysis: abo incompatibility

cephalohematoma

IC bleed

spheroytosis

sickle cell

thal

G6PD

Pyr kynase defic 3. Infxn - torchs

UTI

sepsis 4. Obstr: mec ileus

hirchsprung

duod atresia

pyl stenosis 5. metab/genetic: galactosemia

crig-najar

gilbert <table><tbody>

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DDX conjugated/direct hyperbili jaundice in infants? 1. Infxn - torsh

sepsis ## Footnote listeria tb hep b varcicella cocksackie hiv UTI
2. Obstr - biliary atresia cyst bile duct stricture neon hepatitis
3. metab/genetics: galactosemia tyrosinemia glc storage dis IV alpha 1 antrityp
4 misce - drugs and toxins parenteral nutrition

How is bilirubin formed? breakdown of heme containing products

primarily hbg

bilirubin physiologic removal? 1. unconjug binds to albumin
2. carried to liver
3. conjug by glycuronyl transferse
4. excreted to bile

Unconjug vs conjug hyperbili - jaundice cause where vs where? outside liver

at liver

3 factors contributing to neonatal jaundice: 1. incr bili production
2. decr clearance and excr
3. incr enterohepatic reabsorption

Why do we worry so much about a high unconjug hyperbili? crosses BBB

causing cell death: BIND - bili induced neuro dysfunction --> chr irrev sequelae is kernicterus

What is the cause of physiologic jaundice in a newborn? immature metabolism
peak d2-5 of life

resolves first 2 weeks of life

When does jaundice need to be evaluated? 1. first 24h of life
2. elevated direct
3. rapidly rising by hx/pe
4. total bili approaching exchange level or not tx by phototherapy
5. jaundice beyond 3 weeks of age
6. sick infant

What is breast milk jaundice? not exact clear on pathophys
but likely hormone mediated or related to incr enterohep reabs of milirubin

Breast milk jaundice timeline? unconjug hyper bili peaks a bit later than physiologic (this was 2-5d

breast milk peaks 10-21d of life) and may persist sev weeks (3-10) to mo

When do normally newborn levels of bilirubin peak? 6mg/dl at 3d of life then decline to N within 2 weeks

Symptoms of BIND poor feed and lethargy
m rigid

opisthotonis ## Footnote seizz death
gaze abn (upward limit) SNRL Cerebral palsy

Acute bilirubin encephalopathy - defn early and potentially rev signs and sx of hyperbili

Acute bilirubin encephalopathy sx somnolence
poor feed
incr or decr in tone
high pitched cry

RF for neonatal jaundice male
prior hx phototherapy
asian heritage
premature
blood/hematology fam hx

Minimum labs for neonatal jaundice cbc with peripheral smear
coombs test

Sick looking infant - labs for neonatal jaundice unconjug cbc with peripheral blood smear
bili direct and indir
coombs
glucose
electrolyte
urine assay for reducing substances

serum ammonia ## Footnote ketones lactate
eval for infection

Tx unconjug hyperbili causing neonatal jaundice 1. encourage oral intake
2. phototherapy if too high

Indications for exchange transfusion in unconjug hyperbili infants? 1. bilirubin above sp per age
2. fail phototherapy
3. jaundiced infants with signs and sx of BIND

How exchange therapy works for unconjug bili in neonatal jaundice? "

A double-volume transfusion (180 to

190 mL/kg packed red blood cells) replaces approximately 85% of an

infant’s blood volume and reduces the total bilirubin level by at least

50%. It is performed by serially removing small aliquots of the infant’s

blood

typically no more than 5 to 10 mL/kg and replacing it with a

similar volume of packed red blood cells until the total transfusion vol-

ume is achieved.

Hosp adm for which infants with high unconjug hyper bili causing neonatal jaundice? "

Infants

who appear ill

are below their expected weight for day of life ## Footnote can-

not maintain oral intake

or require exchange transfusion

Home photo criteria for which infants with high unconjug hyper bili causing neonatal jaundice? well appearing otherwise
reliable caregivers iwith access to care
can receive f/u in 24 hours

Direct hyperbili cause neonatal jaundice is an automatic __ adm

Hypertrophic pyloric stenosis: RF prematurity and infant exposure to macrloide abx
boys
first born

Sx Hypertrophic pyloric stenosis: vomiting

Hypertrophic pyloric stenosis: hypochloremic hypokalemic metabolic alkalosis: how? incr size of obstr leads to emesis hcl
loss fluid and elyte derangements
kidney try to keep H in exchange for K leading to low cl and low k

Hypertrophic pyloric stenosis: clinical features? present at 2-6 weeks
progressive emesis
projectiile

nonbilious
later stages = dehydr ## Footnote poor w gain and malnu

Hypertrophic pyloric stenosis: diagnostic test palpable pyloris on exam
ultrasound
chem

confirmed via UGI

Hypertrophic pyloric stenosis: ultrasound dx measurements pyloric m thickness >4mm

pyloric diam >14mm ## Footnote elongated >19mm

Hypertrophic pyloric stenosis: ddx GER
UTI
inborn error metab
med SE
drug intox
ILL - surgical emerg - midgut volvus and malrot

dudo atresia ## Footnote nec
DKA sepsis ICP

Tx of hypertrophic pyloric stenosis 1. correct labs and fluids
2. talk to surg pyloromyotomy

Malrotation with midgut voluvlus: RF/epi 1:500 births
male
1/3s: first mo of life

at ~1y ## Footnote at ~5y (rare beyond 5)

Malrotation with midgut volvulus: Normal physiology embryo development

GI tract rotates around SMA
duodenum forms c loop ## Footnote fixed in retroperitoneum in LUQ at lig of Treitz
Cecum similar fixation RLQ
thus wide separation and fixed in position by periotneal attachments called Ladd bands

Malrotation with midgut volvulus: pathophysiology of rotation duod and cecum do not become rotated completed so lie closely and are suspended by mesenteric vascular stalk
can easily twist on itself to block distal duod and bowel ischem

necrosis secondarily ensue to compress SMA

Malrotation with midgut volvulus: sx hallmark: sudden onset bilious emesis

abdo distension in infant
++ ill ## Footnote +/- shock

Malrotation with midgut volvulus: diagnostic study of choice? limited upper GI contrast series to show failure of normal C loop to cross midline R to L --> corkscrew appearnace of more distal sm bowel

u/s: whirlpool sign +/- abn orientation SMA and vein

DDX: differentiating Malrotation with midgut volvulus from nec XR: NEC has diffuse dilated sm bowel

presence of air within bowel walls (pneumatosis intestinalis)

Malrotation with midgut volvulus: management peds surg for any infant with bilious emesis immediately
IV access
BW - CBC

BG ## Footnote chem 7 LFT
shock - 20ml/kg fluid bolus
empiric abx per age
NG or OG placed

Necrotizing enterocolitis: RF "neonates in ICU
PREMATURITY #1 RF"

Necrotizing enterocolitis: complications of surviving nec include strictures
fistulas
sh gut syndrome

Necrotizing enterocolitis: clinical sx feeding intolearnce
bilirious OR NOT emesis
ILL: hematoemesis

hematochezia ## Footnote fever shock

Necrotizing enterocolitis: ddx ger but these kiddos with nec are ++ ill
osbtructive pathology otherwise

Necrotizing enterocolitis: image of choice XR: pneumatosis intestinalis (ischemia) or pneumoperitoneum (bowel perforation)

Necrotizing enterocolitis: management CALL SURGERY
1. NPO --> NG/OG
2.+/- intubation
3. IV
4. BW - cbc

chem 7 ## Footnote LFT T+S
blood and urine cultures
5. fluid resus
6. broad spec abx
7. +/- epi/NE

Sandifer syndrome: stereotypical opisthotonic movement highly suggestive of severe GERD

chronic GERD complications cough
recurrent stridor
wheeze
BRUE ddx

GERD: management - small feeds
-freq burping
-formula thick with cereal
-semi upright post feeds

Severe GER = surgery? Nissan fundoplication

Intussusception: what is this? inagination of part intestine into itself

Intussusception: what is epidemiology of this? <2y
most freq 5-12mo of age
mc cause idiopathic

Intussusception: pathophys lead point causing telescoping of 1 segment of intestine into anther
bowel wall edema
mechanical obstruction

vascular compromise and ultimately bowel wall ischemia and necrosis

Intussusception: MC site? ileocecal

Intussusception: in yo children what are lead points normally from? enlarged peyers patches secondary to recent viral infection

Intussusception: children >5 lead point causes: HSP vasculitis
Meckel's
lymphoma
polyps
post surgical scar
celiac disease
CF

Intussusception: triad of sx abdo pain
palpable sausage shaped abdo mass
bloody stools

Intussusception: what are the episodes of abdo pain like? last 10-15 minutes

occurring in intervals of 15-30 mins
usually draw legs up and screaming in pain
vomiting present

Intussusception: two less common symptoms? lethargy
ALOC

DDX of acute onset severe pain kids abdo pain "

acute bowel obstruction

such as intussusception or volvulus

or acute vascular compromise ## Footnote as

seen with torsion of a testicle or ovary.

"**nfants and children with intus- susception classically have severe intermittent colicky pain."

Intussusception XR findings

" -dilated loops of small bowel followed by paucity of gas in decompressed colon
-+/= perforation showing pneumoperitoneum
- soft tissue mass/mass effect in R abdomen
- target sign: air in intuss as telescopes into adj bowel
-meniscus sign: air compressed from invaginating bowel
ULTIMATELY DOES NOT EXCLUDE DX

Intussusception: preferred imaging? us

Intussusception ultrasound findings highly sn and sp
taget sign/bullseye: telescoping intesrtinal wall into transverse or cross sectional view
vs longitudinal view: pseudo kidney sign

Intussusception occassional first line tx air contrast enema

Intussusception: management IVF
NPO
success rate of air contrast/barium enema = 90%
talk to surgery asap

Intussusception: concern for recurrence over what period of time? 48 hours

Hirschsprung: epidemiology early infancy obstruction cause
boys
DS

congenital abnormality higher risk

Hirschsprung: what is this? aganglionosis of the colon
cannot relax - functional obstr

Hirschsprung: classic sx in neonates? fail to pass mec fist 24hrs

Hirschsprung: hx of chronic ___ constipation

Hirschsprung: diagnostic studies barium enema with narrowed aganlionic segment of distal colon

proximal dilation

confirmed - manometry/bx

Hirschsprung: management fluid and lyte statys
compression of rectum if acute sx obstruction
surgery ultimately

Meckel's Diverticulum: what is this? remnant of omphalomesenteric duct

has bowel wall in it which is typically gastrtic mucosa
get bleeding when acid secretes onto this and ulcerates/erodes it

Meckel's Diverticulum: rule of 2s diverticulum is 2cm wide
2cm long
located within 2ft of ileocecal vvalve
2% pop and only 2% effected
50% by age of 2

Meckel's Diverticulum: classic presentation? PAINLESS rectal bleed
+/- abdo cramping

Meckel's Diverticulum: complications intusss
obs
perforation
peritonitis

Meckel's Diverticulum: ddx eat something red
melena vs hematemesis ddx
milk pro allergy

Meckel's Diverticulum: diagnostic test Technetium 99/meckel scan
definitive dx is surgery

Meckel's Diverticulum: management 1. resus from bleed as needed
2. bw - cbc

coag studies ## Footnote type and screen
3. surgery chat

Henoch Schonlein Purpura: what is this? hypersens vasculitis with immune complex deposition of IgA

Henoch Schonlein Purpura: 4 key sx abdo pain
palpable purpuric rash
arthralgias
renal disease

Henoch Schonlein Purpura: what age? 4-11y

Henoch Schonlein Purpura: after what kind of illness? viral URTI

Henoch Schonlein Purpura: where is palpable purpuric rash? buttocks '
LE

Henoch Schonlein Purpura: other sx classic rash
nausea/emesis
diarrhea
intestinal bleed
ileoileal intuss

Henoch Schonlein Purpura: lab finding? NORMAL platelets

Triad of abdo pain

palpable purpura ## Footnote hematuria in otherwise well appearing child think ? HSP

Henoch Schonlein Purpura: diagnostic testing cbc
urinalysis
cr

Henoch Schonlein Purpura: management 1. mild-mod pain: NSAID/tyl
2. sev: predn 1mg/kg/day ie abdo pai sev

bleeding GI ## Footnote hematuria sev arthralgias

Henoch Schonlein Purpura: indications for hosp adm? possible meningococcemia as ddx
sev abdo pain
intractable emesis
renal issues --> nephro

IBD: typically present ED in flare - sx? incr diarrhea
bloody
abdo pain
fever
+/- toxic megacolon or perf

IBD flare dx is __ clinical

IBD: labs to order for flare? cbc
lyte
esr or crp

IBD: flare tx 1.fluid resus
2. cs pred 1mg/kg/d
3.+/- immunosup by GI

What are 3 areas where FB get lodged? 1. Upper eso sphincter c6-t1
2. aortic arch/tracheal birfuc at t4-6
3. lower eso sphincter/diaphr haitus at t10-11

Why do we care so much about lithium button batteries? - sev mucosa erosion

burns and mediastinitis in <2hrs due to charge between batteries or from them

Li button batteries - who to call? gen surg/ GI

Button batteries in the stomach - what to do about them? no removal unless fail pass pylorus within 48 hours

If objects are longer than _ cm and wider than -_ cm unlikely to pass pyrlorus on own 5
2

FB GI: dx with first test? xray

Multiple magnets or magnet and metal thingy need removal by __ endoscopy

When to consult surgery for removal of GI FB? bowel necrosis
obs
perf
peritonitis

Except button batteries

time frame to remove esophageal FB? within 24 hours

Appendicitis mc age to develop? 9-12y

Appendicitis: peforation highest in which age group? <5y

Appendicitis sx: nausea
abdo pain - crampy

vague ## Footnote periumbilical to RLQ sev
anorexia

progressive over 24h

Appendicitis screening labs cbc
crp
urine
electrolyte
renal
liver

Lab findings consistent with appy but not dx? wbc >10
ANC elevated
CRP elevated

Appendicitis dx testing recommended first test u/s

+ u/s for appendicitis: 1. noncompressive: wall thick >2mm

total diameter >6mm painful during exam

if u/s does not visualize appendix

consider __ CT

DDX appendicitis - MC? mesenteric adenitis: sign diffuse tender RLQ with lack of true peritoneal signs

what is mesenteric adenitis? post viral illness

from nonsp inflamm mes LN

ddx appendicits mes adenitis
ectopic pregn.ov torsion/cyst/PID _/- TOA
testicular torsion
GAS pharyngitis

Appendicitis management 1. surgery within 12-24 hrs dx
2. Iv pain meds and anti nausea

Pancreatitis causes in kids trauma
infection
struct abnormalities
syst disease
drugs/toxins
idiopathic

Pancreatitis children sx sev epigastric pain worsens adn radiates to back

ddx pancreatitis in kids appy
constipation
sev - surgical r/o

Pancreatitis management in kids NPO
correct fluids and lytes
pain and antiemetics

Biliary tract disease: ac acaculous chole diseases assoc with which diseases? rocky mountain
shig and salmonella

Biliary tract disease: gallstones from which diseases? hemolytic dis like sickle cell
cf
tpn
sepsis
dehydr

1. What is the most common cause of jaundice in the newborn? a. Breast milk jaundice
b. Crigler-Najjar syndrome
c. Gilbertsyndrome

d. Physiologic jaundice of the newborn

" d

2. A 4-week-old white infant presents with projectile vomiting. The

mother denies that the patient has a history of fevers, irritability, or signs suggestive of abdominal pain. On physical examination, you palpate an olive in the patient’s right epigastrium. Which of the following laboratory abnormalities would you expect to find?

a. Hyperchloremia and hypokalemia b. Hyperglycemia and hypokalemia c. Hypernatremia and hyperkalemia d. Hypochloremia and hypokalemia

" d

. An 11-month-old infant presents with vomiting. The patient’s mother reports that he has been crying out in pain intermittently throughout the day, at which times he brings his knees to his abdo- men. In between these episodes, the patient acts normally and plays. He has not had a fever, but the mother complains that his stool earlier looked like currant jelly. On examination, you find a playful afebrile patient, with a soft nontender abdomen. Which of the following may be used as an initial screening examination?

a. Air-contrastenema
b. Barium enema
c. Computed tomography scan of the abdomen-pelvis d. Ultrasound

" d

165. Peds GI Flashcards

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