Abdominal Emergencies 1

Question 1

Acute Gasteroenteritis (3)

Answer 1

1. Acute Gastroenteritis (AGE) - major cause of morbidity and mortality in the USA
2. Worldwide diarrheal disease is the leading cause of morbidity and mortality; 1.5-2.5 million deaths annually among children younger than 5
3. Even though the number of death associated to AGE worldwide is still high, a decrease has been noticed since the start of Oral Rehydration Therapy (ORT) campaigns

Question 2

Oral Rehydration Therapy Phases (2)

Answer 2

Rehydration Phase: Water and electrolytes are provided via an oral rehydration solutions (ORS) replacing existing losses

Maintenance Phase: Replacement of ongoing fluid and electrolyte losses and adequate dietary intake

Question 3

Physiologic Basis of ORT (8)

Answer 3

1. During diarrheal disease the intestinal output increases greatly, overwhelming its re-absorptive capacity
2. Studies done among patients with cholera, salmonella, E. Coli, shigella, rotavirus demonstrated an intact Na-couple solute co-transport mechanism allowing efficient salt and water reabsorption
3. The mechanism essential for the efficacy of oral rehydration solution (ORS) is the couple transport of sodium and glucose in the intestinal brush border
4. Water passively follows the osmotic gradient
5. SGLT1- sodium glucose co-transporter which moves Na and glucose from the luminal membrane into the enterocyte
6. Rehydration solutions with low osmolarity and 1:1 ration glucose to sodium perform optimally
7. GLUT2- glucose transporter, moves the glucose in the enterocyte into the blood
8. Na+ K+ ATPase provides the gradient that drives the process

Question 4

Basic Guidelines for the management of dehydration (7)

Answer 4

1. ORS should be use for rehydration
2. Oral rehydration - within 3-4 hr
3. Rapid realimentation, an age-appropriate unrestricted diet is recommended as soon as dehydration is corrected. Gut rest is not indicated
4. In breastfeed infants, nursing should continue
5. Diluted formula or special formulas-not indicated
6. Additional ORS can be administer for ongoing losses
7. No unnecessary labs or medications (i.e. antidiarrheals)

Question 5

Acute Gasteroenteritis Management (3)

Answer 5

Home Management
1. ORS is simple and enable management of uncomplicated cases at home

2. 5 cc every 5 minutes if vomiting and gradually increase over 12 hours If the patient has diarrhea, can feed and use normal amount of fluid at the same time
3. Educate regarding the signs of dehydration

Question 6

Recommendations for medical evaluation of children with Diarrheal Illness (9)

Answer 6

1. Young age (< 6 months or < 8 kg)
2. History of premature birth, chronic medical conditions or concurrent illness
3. Fever > 38°C for infants < 3 months or > 39°C aged 3-36 months
4. Blood in stool or diarrhea lasting more than 2 wks
5. High output diarrhea, including frequency and volume
6. Caregiver’s report of signs consistent with dehydration
7. Change in mental status
8. Persistent vomiting
9. Suboptimal response to ORT or inability of caregiver to provide ORT

Question 7

Dehydration Assessment (5)

Answer 7

1. Sunken anterior fontanel can be unreliable or misleading
2. Decreased BP is a late finding and it heralds shock, corresponds to >10% of fluids losses
3. Tachycardia and decrease capillary refill are more sensitive
   a. GET A HR and CAP REFILL to chek hydration
4. Decrease urine output is sensitive but nonspecific
5. Increase of urine specific gravity can indicate dehydration

Question 8

AGE Dehydration Management: Info About Phases (5)

Answer 8

1. Rehydration – fluid is replaced rapidly, over 3-4 hr
2. Maintenance – calories and fluids are administered
3. Rapid realimentation, the patient should continue an age-appropriate diet as tolerated
4. Breastfeeding should continue
5. Lactose restriction is usually not necessary

Question 9

AGE Dehydration Management: Minimal Dehydration (3)

Answer 9

1. Provide adequate fluid and age appropriate diet
2. ORS should be encouraged
3. Fluid intake should be increased to compensate for emesis or diarrhea
   i. 10 ml/kg of additional fluid per every diarrhea or 2 ml/kg per every emesis
   ii. As an alternative in children < 10 kg provide 2-4 oz of ORS per diarrhea or emesis and 4-8 oz in children > 10 kg

Question 10

AGE Dehydration Management: Mild to Moderate Dehydration (11)

Answer 10

1. The fluid losses should be estimated and rapidly replaced
2. Administer 50-100 ml of ORS/kg during 2-4 hr
3. Additional ORS should be administer for ongoing losses
4. Smaller volumes should be offered first and increase as tolerated using (i.e. 5 ml)
5. More may be offered if the child wants more, but larger amounts have been associated with vomiting
6. Children with tachycardia at discharge or with history of severe vomiting are more likely to require a second visit to the ED
7. Clinical trials support the use NG feeding for those patients with persistent vomiting
8. When compared to IV, NG feedings were found to be more cost effective and associated with fewer complications
9. Hydration status should be assess on a regular basis
10. Those children who do not improved with ORT or with high output should be held for observation
11. Must assure follow-up

Question 11

AGE Dehydration Management: Severe Dehydration (5)

Answer 11

1. Constitutes a medical emergency and requires immediate IV rehydration
2. 20 ml/kg of Normal Saline should be administered until pulse, perfusion and mental status returns to normal
3. Complete metabolic profile is not required for the diagnosis
4. Electrolytes, BUN, Cr, CO2, and glucose should be obtained
5. Vitals should be assess on a regular basis

Question 12

AGE Dehydration Management: ED Dehydration for severe dehydration (4)

Answer 12

1. Multiple administrations of fluid in a short amount of time may be necessary
2. Severe edema is rare as long as appropriate weight based amounts are provided with close observation
3. With frail or severely malnourish infants smaller amounts (10ml/kg) are recommend because of their reduced ability of increasing the cardiac output
4. If the patient does not respond to fluid boluses, think about septic shock, metabolic, cardiac or neurologic disorders

Question 13

General Info About AGE Dehydration Management (9)

Answer 13

1. In children with abdominal ileus or signs of intestinal obstruction ORT should be held until surgical evaluation
2. 1% of infants will have carbohydrate malabsorption
   * Their diarrhea may be worsen by ORS or solutions with simple sugars
3. Children receiving a solid or semisolid diet should continue their usual diet
4. Avoid foods with high simple sugars, which may cause osmotic diarrhea
5. BRAT diets are unnecessary restrictive and provide suboptimal nutrition
6. Withholding food for 24 hr is unnecessary
7. Once rehydration is achieved, age- appropriate diets can be started if not vomiting
8. Lactose-free or lactose-reduced formulas are not necessary, except in children with severe malnutrition
9. Low ph or reducing substances in the stool without symptoms is not indicative of lactose intolerance

Question 14

Functional foods to manage AGE (8)

Answer 14

1. Foods that have an effect on physiologic processes separate from their nutritional function
2. Probiotics are live microorganisms in fermented foods promote improved balance in intestinal microflora
3. Most common species studied included Lactobacilli and nonpathogenic Saccharomyces boulardii
4. Mechanism of action include, enhancing host defenses, competition of pathogenic flora for receptor sites and production of antibiotic substances
5. Probiotics – two separate meta-analysis showed the probiotics are safe and efficacious in the treatment of infections and antibiotic-associated diarrhea
   * As probiotics are not regulated by the FDA, there may be great variability, wish make an informed recommendation rather challenging
6. Prebiotics are complex carbohydrates that stimulate the growth of health promoting intestinal flora
7. The oligosaccharides contained in breast milk are the prototypic prebiotic
8. Data have associated the oligosaccharides in breast milk to the lowered incidence of acute diarrhea in the breast feed infant

Question 15

Pharmacologic Therapy in AGE: Antimicrobials (4)

Answer 15

1. Viruses are the predominant source of AGE in developed countries
2. Antimicrobials wastes resources and may increases antimicrobial resistance
3. Even when the cause is suspected to be microbial, usually antibiotics are not indicated as these disease processes tend to be self-limited
4. Children with special needs or severe disease may benefit from antibiotics if microbial etiology is suspected

Question 16

Pharmacologic Therapy in AGE: Non-Antimicrobials (4 with info)

Answer 16

1. Limited data exist about the efficacy of antimotility agents like loperamide –> Side effects are well described including
   i. Ileus
   ii. Nausea
   iii. Drowsiness
   iv. Atropine effects
   * Loperamide has been linked to cases of severe abdominal distention and even death; Do not use this!
2. Bismuth subsalicylate has limited efficacy in treating diarrhea in children
3. Ondasetron (Zofran), a serotonin antagonist antiemetic
   * Can have significant side effects but it does work
   * Effective in decreasing vomiting and facilitates ORT
   * Proven efficacious and safe in children > 6 months
   * Shown to shorten the ED stay
4. Promethazine, non-selective antihistamine; Do not use this with children
   * Promethazine had increase side effects including drowsiness, respiratory depression, dystonia and neuroleptic malignant syndrome

Question 17

summary of AGE/dehydration management (4)

Answer 17

1. The use of appropriate ORS have shown to be effective for the treatment of mild to moderated dehydration
2. Severe dehydration is a medical emergency and IV fluids should not be held
3. Continuation of age-appropriate diet is more effective for the treatment of AGE than gut rest
4. Ondasetron is safe and efficacious for the treatment of AGE in children

Question 18

Mimics of GI bleeding (6)

Answer 18

1. Red candies, juices, red dye in foods, beets

Black stools:

2. Peptobismol
3. Iron
4. Spinach
5. Blueberries
6. Licorice

Question 19

Upper vs. Lower GI Bleeding (6)

Answer 19

1. Nasogastric tube placement

Presentation:

2. Hematemesis; Is blood mixed in with stool or around it
3. Melena
4. Hematochezia
5. Streaked blood could be to small anal fissures
6. Mixed blood may be due to cows milk protein allergy, this will be continuous

Question 20

GI bleed in newborn period (3)

Answer 20

1. Swallowed maternal blood either during delivery or from cracked bleeding nipples during breast feeding
2. Neonatal blood differentiated from maternal blood by APT test
3. Mix specimen with 3-5 ml of tap water and centrifuge. Supernatant must have a pink color to proceed. To 5 parts of supernatant, add 1 part of 0.25 N (1%) NaOH.
   a. If the blood is pink – it’s the baby’s
   b. If the blood is brown – it’s the mother’s (AB = adult, brown)

Question 21

GI bleed interpretation (2)

Answer 21

1. A pink color persisting over 2 minutes indicates fetal hemoglobin.
2. Adult hemoglobin gives a pink color that becomes yellowish brown in 2 minutes or less indicating denaturation of the adult hemoglobin

Question 22

Upper GI bleed (8)

Answer 22

1. Stress
2. Vascular malformation
3. Gastric/esophageal duplication
4. Hemorrhagic gastritis
5. Esophagitis
6. Varices from portal hypertension
7. Vascular malformations
8. Bleeding diathesis from such hemorrhagic disease of the newborn

Question 23

Neonatal bleeding evaluation (4)

Answer 23

1. CBC with reticulocytes
2. Coagulation studies
3. Liver enzymes
4. Type and Cross

Question 24

Upper GI bleeding causes from 30 days to 2 years (7)

Answer 24

1. Gastritis, esophagitis, duodenitis
2. Ulcer
3. Vascular malformation
4. Foreign body
5. Ingestion
6. Esophageal varices
7. Mallory Weiss Tear; More common – small tears near where the esophagus meets the stomach/at the antrum
   * Occurs due to vigorous vomiting
   * Will also see petechiae in the upper part of the face

Question 25

Upper GI Bleeding causes from 2 years to 5 years (10)

Answer 25

1. Epistaxis 2. Gastritis 3. Esophagitis 4. Stress ulcer 5. Toxic ingestion 6. Foreign body 7. Vascular malformation; May bleed years later 8. Esophageal varices 9. Hemobilia (hemorrhage in or through biliary tract) 10. Mallory Weiss Tear

Question 26

Upper GI Bleeding from 5-15 years (11)

Answer 26

1. Gastritis 2. Mallory Weiss tear 3. Ulcers 4. Ingestions 5. Esophagitis 6. Esophageal varices 7. Inflammatory bowel disease 8. Vascular malformation 9. Hemophilia 10. Leiomyoma 11. Thrombocytopenia

Question 27

history of upper GI bleed (3)

Answer 27

1. Past history of Instrumentation 2. Family history of ulcer 3. Stool antigen H. Pylori tests

Question 28

Physical exam with upper GI bleed (4)

Answer 28

a. Look at nose and throat b. Look for signs of liver disease c. Abdominal distention d. Spider Nevi

Question 29

Upper GI bleed work-up (6)

Answer 29

Labs: 1. HGB, Hct 2. Bilirubin 3. SGOT, SGPT, albumin 4. PT, PTT 5. BUN, Cr. 6. Diagnostics --> If persistent or recurrent admission for endoscopy

Question 30

sources of GI bleeding (6)

Answer 30

1. Esophagogastrodueodenoscopy 2. Colonoscopy 3. Meckel’s scan; For Meckel’s diverticulitis * Gastric epithelium secretes stomach acid into the intestines causing an outward pouch * Will cause painless GI bleeding * Little tiny area that the stomach lining doesn’t get into the right place 4. Angiography 5. Upper GI 6. Barium Enema; Not commonly used due to interruption of the barium and radiation