Case 15: 4yo, 8wo - Gastroenteritis, Pyloric stenosis

Question 1

ddx of vomiting: newborn

Answer 1

• duodenal atresia (VACTERL)
• malrotation –> volvulus
• congenital obstructive malformations = atresia, webs, esophagus, intestine
• Meconium ileus / plus (CF)
• Hirschprung’s dz
• inborn errors of metabolism
• food allergy
• “normal” spitting up

THINGS THAT TAKE LONGER

• pyloric stenosis = >2wo
• gastroenteritis = >3wo
• intussusceptions (VIRAL) = 2mo
• Meckel’s diverticulum

Question 2

things to consider with vomiting?

Answer 2

• age (by weeks, years)
• timing = when the vomiting occurs
• duration = how long
• appearance - billious, bloody, feculent, formula
• amount of emesis
• associated sxs = fever, diarrhea, abd pain, dysuria, flank pain, weight loss, HA
• severity / worsening

Question 3

ddx of vomiting: infant

Answer 3

• Acquired obstructive lesions: pyloric stenosis, malrotation with volvulus, intussusception, incarceratedinguinal hernia
• Metabolic disease: milder forms of inborn errors of metabolism
• variable presentation of metabolic dz (neurologic sign), allergy (blood in vomit, diarrhea / poor growth / rashes)
• Nutritional issues/intolerance to food
• Food allergy
• Ingestion, abuse, neglect
• GERD
• overfeeding
• viral / bacterial gastroenteritis
• other infections(UTI/pyelo, pneumonia, otitis media)

Question 4

ddx of vomiting: child

Answer 4

• GI infection: Viral gastroenteritis, bacterial, parasitic
• GI obstruction: volvulus, intussusception, adhesions
• peptic ulcer (uncommon), celiac disease (usually more chronic), pancreatitis
  -Neurologic: increased ICP, tumor, mass, bleed, migraine [whereas prior, they could have bulging fontanelles, Larger head circumference to compensate]
  -Respiratory: pneumonia, post-tussive
  -Endocrine: Diabetes, adrenal insufficiency
  Infectious: pyelonephritis (vomiting, fever), meningitis, encephalitis, acute otitis media
  -Other: behavioral, cyclic vomiting (migraines)

Question 5

DDX of Vomiting: Adolescent

Answer 5

Most childhood causes +

• Pregnancy, hyperemesis gravidum (improves in the shower)
• Ovarian or testicular torsion (any age)
• STD’s, PID
• Drugs of abuse, alcohol; opiate withdrawalk,
• Eating disorders

Question 6

You are called to the ER to see a one month old child who is vomiting.

What do you want to know about the history?
What do you want to look for on physical exam?

Answer 6

Hx = when start, did it worsen, what type of food does he eat, describe the emesis, what happened before, timing with food, how much are they spitting up, poops, sick contacts

Exam = vitals, hydration status, abdominal masses, distension, +/- tears. Weight growth curves.

Neuro / General

Question 7

1w old baby comes in because parents are concerned about dehydation. They say “he’s not making tears”.

what should you ask/assess?

Answer 7

1) was he making tears before

2) anterior and posterior fontanelles

Question 8

signs of dehydration

Answer 8

• decrease in tears (when they had been making tears before)
• sunken fontanelles
• prolonged capillary refill
• weight loss
• dry mucous membranes, cracked lips
• capillary refill > 2sec; cool hands and feet; dusky nailbeds
• pale and mottled skin; clammy
• listless, quickly falls asleep

vitals –> tachycardia

Question 9

pyloric stenosis: complications

Answer 9

Risk for: hypochloremic, hypokalemic, metabolic alkalosis.

Question 10

US pyloric stenosis

Answer 10

The measurements most commonly used are pyloric muscle thickness (PMT), pyloric muscle length (PML), and pyloric diameter (PD). Published criteria have ranged from 3 to 4 mm for PMT, 15 to 19 mm for PML, and 10 to 14 mm for PD.

Question 11

pyloric stenosis tx

Answer 11

• pyloromyotomy

- nasoduodenal feedings

Question 12

important red flags of vomiting

Answer 12

• Blood or bile in vomit
• Recurrent, persistent nature
• Neonatal vomiting (not spitting)
• Association with abdominal distension
• Projectile vomiting
• Signs of systemic illness or neuro compromise

Question 13

Modes of transmission of viral gastroenteritis

Answer 13

==> usually fecal-oral

• HOME – when there is already a family member with gastroenteritis
• DAYCARE

Question 14

How to prevent transmission of viral gastroenteritis

Answer 14

• good handwashing (esp. after helping child in bathroom / changing a diaper)

NOT meds

Question 15

Complications of gastroenteritis

Answer 15

Esp. in young infants

• ## dehydration (esp. with vomiting and diarrhea)

Question 16

Treatment of gastroenteritis

Answer 16

1) fluid IV bolus with isotonic NS (10-20ml/kg); repeated as needed until reach mild dehydration / normal fluid status
2) rehydration orally / MIVF

Question 17

Electrolyte abnormalities in pyloric stenosis

Answer 17

Hypochloremic, hypokalemic metabolic alkalosis

Question 18

How to assess for severity gastroenteritis by phone

Answer 18

• “has he been around anyone else who has been ill” == sick contacts
• “has he had significant abd pain” == assess for more serious condition v. viral gastroenteritis
• “what is the character of the emesis (stomach contents/bilious/bloody)” == if bloody / bilious – more serious condition v. viral gastroenteritis
• “what is the character of the stool (bloody/watery/mucousy)” == if bloody – more serious condition v. viral gastroenteritis
• “has he had a fever” == consistent with infectious cause
• “is he eating and drinking? how much” == assessment of hydration status

Question 19

How to assess child for poor hydration status by phone

Answer 19

• decreased level of activity

- decreased ability and/or desire to take fluids by mouth

Question 20

How to determine degree of dehydration

Answer 20

Acute weight loss in setting of GI bug == assumed to be water weight loss

Weight loss (g) == water loss (mL)
Weight loss (kg) == water loss (L)

Percent weight loss == percent water dehydration
-

Question 21

Diffdx for recurrent emesis in an infant

- sxs:

Answer 21

GERD = regurgitation/spit up; reflux with overfeeding == vomiting
- sxs: blood-streaked emesis (severe esophagitis); feeding aversion (pain from reflux / esophagitis); failure to thrive (dehydration)

VIRAL GASTRO”ENTERITIS”
- sxs: large watery stools (+/- initial vomiting; bilious if repeated); dehydration

MALROTATION +/- VOLVULUS (twisting of intestine on itself== obstruction)
-sxs: signs of obstruction == vomiting (esp. bilious); bloody stool
+/- bowel ischemia
+/- shock (often confused with severe dehydration)

INBORN ERROR OF METABOLISM
- sxs: recurrent emesis, triggered by intercurrent illness (gastroenteritis, infections); diminished oral intake (d/t lethargy, irritability);
+/- shock (often confused with severe dehydration)

PYLORIC STENOSIS (obstruction above ligament of Treitz)
- sxs: escalating pattern of forceful/projectile NON-BILIOUS vomiting; rapid mild-mod dehydration; EAGER TO FEED (esp. early on); visible peristaltic wave (esp. after eating)
+ hypochloremic, hypokalemic metabolic alkalosis (contraction alkalosis)
+/- palpable “olive” (hypertrophic pyloric muscle) in epigastric region

INTUSSUSCEPTION
- sxs : bilious emesis, crampy/severe abd pain
+/- “sausage-like” mass d/t telescoped bowel
+/- “currant jelly” stool (late)

CNS DISEASE = hydrocephalus, intracranial neoplasm, trauma
NO fever, diarrhea

MILK ALLERGY
- sxs: vomiting immediately after eating; rash, loose stools
NO dehydration

UTI = non-GI vomiting (likely d/t pain, discomfort)
- sxs: fever, poor feeding and vomiting
+/- dehydration
+/- loose stool (in setting of significant infection)

Question 22

Diffdx frankly bloody emesis

Answer 22

==> forceful emesis –> Mallory Weiss tear in esophagus

• pyloric stenosis

Question 23

Workup of probable pyloric stenosis

Answer 23

1) pyloric US ==> pyloric hypertrophy

2) upper GI contrast ==>very narrow pyloric channel (“string sign”); indentation of hypertrophied pylorus on antrum, and delayed gastric emptying
+/- small bowel follow-through ==>for concerns of malrotation and/or volvulus, or bilious emesis (suggestive of obstruction beyond pylorus)

3) BMP ==>low Cl, low K, low H, high HCO3, high BUN
4) UA, urine culture – since UTi in infant can present with vomiting alone.

Question 24

Management of pyloric stenosis

Answer 24

1) REHYDRATION with repeated IV boluses NS @ 20mL/kg, electrolyte correction (D5W, NS + K)
+ NPO

2) surgery to excise / dilate hypertrophied pyloric muscle
3) advance to oral full formula feeding within 24h of surgery

Question 25

Management of dehydration

Answer 25

1) ORT = containing glucose, electrolytes (Na of 45-50mEq/L); under clinical supervision
- even when still have some vomiting
- 50-100mL/kg –> to at least total of 1000mL

2) IVF = only when UNABLE to take in PO

3) breast/formula feeding through period of rehydration == esp. for concerns of malnutrition
- can feed if not dehydrated
- can feed once rehydrated (hydrate first, then feed)

DO NOT GIVE – sports beverages, apple juice, colas, ginger ale == b/c low Na, high glucose

Question 26

Infant with forceful vomiting - what considerations / further history do you need?

Answer 26

• pregnancy history / birth history
• dietary hx
• immunizations
• medications / herbal remedies
• family history
• vitals

Question 27

signs of mild dehydration

tx

Answer 27

Mental status= well, alert
thirst = drink normally, might refuse liquids
tachycardia
fewer wet diapers

tx = ORT if able

Question 28

signs of moderate dehydration

Answer 28

Mental status= normal - listless, pale and tired
thirst = thirsty; eager to drink
tachycardia
fewer wet diapers
sunken eyes
cracked lips
cool skin, cap refill >2 sec 

tx = ORT if able; otherwise IV bolus

Question 29

signs of severe dehydration

Answer 29

Mental status= apathetic, lethargic
thirst = thirsty; eager to drink
tachycardia
few wet diapers
sunken eyes
cracked lips
cold skin, cap refill >2 sec, cyanosis
ABSENT TEARS

tx = IV bolus 50-100mL/kg

Question 30

prognosis of pyloromyotomy for pyloric stenosis

Answer 30

Oral feeding can generally be resumed within 12-24 hours after surgery.

Vomiting in the first few days after surgery is common but not severe.

Most babies can return home within just a couple of days of the surgery.

Question 31

Johnny is a 25-month-old male who presents to the ED with a 2-day history of vomiting and diarrhea. Dad relays a history of abrupt onset of vomiting that started yesterday around 1 pm. Johnny has had 6 episodes of emesis since yesterday and 3 episodes of diarrhea. The emesis is non-bilious and the diarrhea is described as watery with specks of blood throughout the diarrhea. There are no sick contacts in the home. Vital signs: T 37.1, P 102, R 20, BP 90/60. Physical examination is normal and Johnny has still been tolerating some PO feeds without instant vomiting. What is the most immediate intervention for this patient?

 Multiple Choice Answer:
A		IV bolus with D5W	
B		IV bolus with 0.9% saline	
C		CT scan and surgical consult	
D		random glucose test	
E		no immediate intervention is necessary

Answer 31

E.

nonbilious vomiting
spots of bloody diarrhea

nontachycardic -no real signs of dehydration, and still tolerating PO feeds

At this point the patient is most likely suffering from a case of viral gastroenteritis. Because he is still tolerating some PO feeds, has no obvious signs of dehydration, and has normal vital signs, there is no need for aggressive IV fluid administration or diagnostic work up. Strict return precautions should be given and it should be advised that Johnny maintains fluids as much as possible.

Question 32

Rashid is a 5-week-old baby boy who presents to clinic with 4 days of repeated, forceful, non-bilious, non-bloody vomiting without diarrhea. He has 8 to 9 episodes of vomiting per day immediately following breastfeeding. The episodes started 2 weeks after the entire family suffered from severe viral gastroenteritis. His birth history is uncomplicated (full term, NSVD, unremarkable 30-week ultrasound) and birth weight was 3.6 kg (50th percentile). On exam, his vitals are: T 36.7°C, HR 185, BP 85/45, RR 36, Wt 4.1 kg (25th percentile). On exam, his eyes are moderately sunken without production of tears, his lips are cracked, and his throat is without erythema. His capillary refill is ~3 seconds, and his pulse is thready. What is your first step in management?

Multiple Choice Answer:
A Close observation in the office for 6 hours and encourage PO intake until vitals normalize.
B Intravenous lactated Ringer’s solution of 20mL/kg boluses until baseline clinical status is achieved, then 100 mL/kg oral rehydration solutions over next 4 hours.
C Intravenous 20 mL/kg boluses of ¼ normal saline solution until baseline clinical status is achieved, then closely monitor vitals for 6 hours while encouraging PO formula intake.
D Observe for 6 hours with normal PO intake and administer 60-120 mL of oral rehydration solution for every episode of vomiting.
E Administer 75 mL/kg of oral rehydration solution over 3-4 hours and 60-120 mL of oral rehydration solution for every episode of vomiting.

Answer 32

B

nonbilious,, nonbloody
5weeks
after feeding
started after viral gastroenteritis
tachycardic (max HR 140s)
weight loss
sunken eyes, no tears, cracked lips, cap refill 3 sec

severe - NO TEARS

maintained BP

Lactated Ringer’s solution or normal saline in 20 mL/kg boluses until urine output is established and mental status improves, then 100 mL/kg oral rehydration solutions over next 4 hours. This follows current CDC guidelines for treating a severely dehydrated child. Intravenous hydration with 5% dextrose ½ normal saline at twice maintenance fluid rates may be substituted for the oral rehydration solution if the child is not tolerating PO intake. To replace ongoing losses, the CDC recommends 60–120mL of oral rehydration solution per diarrheal/emetic episode (through a nasogastric tube, if necessary).

Question 33

A 6-month-old male comes to clinic with a chief complaint of several weeks of vomiting after large feedings. The vomiting has become blood-streaked, which is when the mom became concerned and brought him in. The baby’s PO intake has been down and he has been losing weight. Abdominal exam is normal, with no masses palpated. What is the most likely diagnosis?

 Multiple Choice Answer:
A		Pyloric stenosis	
B		Gastroenteritis	
C		GERD	
D		Volvulus	
E		Intussusception

Answer 33

C.

blood-streaked in 6mo
too old for pyloric stenosis
gastroenteritis usually vomiting and diarrhea
volvulus = blood in stool (not vomitus)
intussusception = abdominal pain; draw in legs

regurgitation/spitting up may be difficult to distinguish from true vomiting. Infants who reflux with overfeeding may sometimes have forceful vomiting. Severe esophagitis may result in blood-streaked emesis. Pain from reflux or esophagitis may lead to feeding aversion when gastroesophageal reflux is severe.

Question 34

You are seeing a 1-month-old male who is < 3rd percentile for weight. He is breastfed every 2 hours and latches on well. However, he has frequent non-bilious episodes of vomiting that have been increasing over the past week despite his mother taking “reflux precautions.” He does not have mucus or blood in his stool. Physical exam reveals a small, olive-sized mass in his abdomen. What is the most likely diagnosis?

 Multiple Choice Answer:
A		Cleft palate	
B		Pyloric stenosis	
C		Cystic fibrosis	
D		Non-organic failure to thrive	
E		Munchausen syndrome by proxy

Answer 34

B. history of frequent vomiting, poor weight gain, and the finding of an abdominal mass are consistent with pyloric stenosis. Children with pyloric stenosis often present at 3 weeks of age

Question 35

A 15-month-old boy presents to the ED in January with a 3-day history of diarrhea. His current weight is 11 kg. He was born at 39 weeks, without any perinatal complications. There is no significant history of travel, sick contacts, or recent changes in diet. The mother notes that he has had only 2 diaper changes over the last day. Physical exam is remarkable for an irritable but consolable infant with tachycardia and normal blood pressure. He is crying without tears and his mucous membranes are dry. His abdominal exam is benign. There is no tenting, and capillary refill is 2 seconds. He is diagnosed with gastroenteritis and started on rehydration therapy. Which of the following statements is true?

Multiple Choice Answer:

A The patient is mildly dehydrated and should be managed with oral rehydration (Pedialyte).
B The patient is moderately dehydrated and should be managed with oral rehydration (Gatorade).
C The patient should be rehydrated with clear liquids and then transitioned to a lactose-free diet until his diarrhea resolves.
D The patient is moderately dehydrated and should be bolused with 220 ccs of D5 ½ normal saline for emergency phase correction, to ensure hemodynamic stability.
E ) The work-up for infectious diarrhea for this patient should include a Wright’s stain for fecal WBCs, a stool Rotazyme, and a stool sample for culture and sensitivity.

Answer 35

E.

no tears

severe dehydration

==> bolus with NS

In addition to correcting this patient’s hydration status, a work-up for the infectious causes of this patient’s diarrhea might include a stool Wright’s stain for fecal WBCs (which would suggest a bacterial cause if this is infectious diarrhea), a Rotazyme test (given the high incidence of rotavirus in the winter months), and a stool sample for culture and sensitivity. Additional studies might include stool guaiac (for occult blood) and a check for stool C. diff toxin.

Question 36

workup for infectious gastroenteritis

Answer 36

• stool Wright’s stain for fecal WBCs (which would suggest a bacterial cause if this is infectious diarrhea)
• a Rotazyme test (given the high incidence of rotavirus in the winter months)
• stool sample for culture and sensitivity.

+/- guaiac (for occult blood)
+/- stool C. diff toxin.