Gastrointestinal Flashcards
Review of swallowing/phases
Oral phase: food mixes w/ saliva
Pharyngeal phase: palate rises, epiglottis closes, vocal cords move up and muscles propel food into esophagus
Dysphagia clinical manifestations
HPI: feeding difficulty (noisy breathing during feeds), food refusal, FTT, older children-sensation of food stuck in throat, voice changes, recurrent cough
Oral phase
Failure to initiate or maintain sucking
Prolonged feeding time
Drooling
Oral hypersensitivity
Exaggerated gag reflex
Difficulty making the transition to textured foods
Sensitivity to touch in and around mouth
Oral hyposensitivity
Retaining food in the mouth
Increased drooling
Pharyngeal phase
Coughing
Choking
Noisy breathing during feeding
Nasopharyngeal reflux
Esophageal phase
Spitting up or vomiting
Irritability or arched during feeding
Preference for liquid food
Sensation of food stuck in the throat
Dysphagia PE/ diagnostics
PE:
orofacial malformation- cleft lip/palate
newborn- check for choanal stenosis- make sure nares are patent
neuro exam- assessment of muscle tone and strength of cranial nerve function
Labs:
CBS- screening for infectious or inflammatory conditions
CMP- albumin, protein- nutrition status
Chromosomal or DNA test- if syndrome suspected
Nerve conduction studies, muscle biopsy- suspected neuromusuclar disorders
Imaging:
CXR or CT- r/o PNA from aspiration
Brain MRI- if suspected CNS injury or structural abnormality
Dysphagia diagnostic studies
Upper GI barium study- evaluate esophageal dysphagia, assess anatomy or structural abnormalities such as strictutes, fistulas, masses or intestinal rotational anomalies
Videofluorographic swallow study (VFSS) (aka modified barium study)- gold standard for assessment of oral & pharangeal phases
- Child eats foods mixed w/ barium while radiographic images are observed and recorded
Fiberoptic endoscopic evaluation of swallowing (FEES) - pharyngeal phase
- Fiberoptic endoscope is introduced into nose and advanced into laryngopharyngeal area
Esophagogastroduodenoscopy - EOE
Manometry - assess for esophageal motility disorders
Esophageal pH probe study or multiple intraluminal impedance test (MII)-
assess for presence of abnormal acid reflux
- MII- detects acid and non acid reflux episodes (preferred over just pH monitoring)
Scintigraphy - evaluation of gastric emptying, demonstrates episodes of aspiration
Pyloric Stenosis
Thickening of the antropyloric muscle (pushes food back up esophagus)
Pyloric muscle contracts when it should be relaxing → gastric content gets expelled back up
lumen of the pyloric channel is obstructed, causing progressive vomitting
Typically manifests between 2-8 weeks, peak incidence 3-6 weeks
Pyloric Stenosis HPI/PE
HPI
-parents will complain of nonbilious vomiting (progresses from small emesis in early stages to projectile vomiting in later stages)
- increased hunger immediately after emesis
- change in energy level- lethargy is concerning sign of significant dehydration
Physical findings:
- possible weight loss
- signs of dehydration- dry mucous membranes, decreased UOP (in neonate <4-5 in 24 hr period is concerning)
GI specific:
- enlarged pylorus (olive shaped) - to palpate, baby should be calm, elevate feet/flex knees to 90 degrees and palpate at RUQ, sweep towards umbillicus
- gastric contractions- fluid wave (best observed w/ bright light, directed acriss abdomen from infant’s side, examiner at foot of bed)
- hiatal or inguinal hernia
Pyloric Stenosis diagnostics/differentials
Diagnostics:
CMP- especially if signs of dehydration present
Pyoric ultrasound- measures pylroic wall thickness, diameter, and pyloric channel length
Upper GI w/ contrast- performed if u/s is not diagnsotic, findings: elongated and narrowed pyloric channel (string sign) w/ shoulders of the hypertrophied pylorus bulging into the intestinal lumen
Differentials
(other causes of gastric outlet obstruction should be considered for infants w/ nonbilious emesis)
- gastric duplication
- antral web- extra tissue in stomach
- pylorispasm
- malrotation
- annular pancrease
(if diagnosis of PS can’t be established in infant w/ persistent emesis and normal u/s)
- GERD
- intracranial disease
PS treatment
Surgical consult - pyloromyotomy- surgical incision of pyloric muscle (treatment choice)
Medical management: atropine sulfate (not done as much anymore)
0.04mg-0.225 mg/kg/day IV x 10 days, followed by 0.08-0.45 mg/kg/day PO for up to 4 mts
Increased risk d/t anticholinergic use- facial flushing,elevated ALT, tachycardia
Hospitalization
- Fluid and electrolyte deficit stabilization prior to OR
- Post op care
- Insure tolerance of feeds
- Monitor output
Degree of dehydration: minimal to no dehydration
<3% loss of body weight
Mental status: well; alert
Thirst- drinks normally, might refuse liquids,
Normal HR, pulses, breathing, eyes, cap refill
Tears present
Mouth & tongue- moist
Skin - instant recoil
Extremities- warm
Urine output- normal to decreased
Degree of drhydration: mild to moderate
3-9% loss of body weight
Mental status: normal, fatigued or restless, irritable
Thirst- eager to drink
HR- normal to increased
Pulses- normal to decreased
Breathing- normal; fast
Eyes- slightly sunken
Tears- decreased
Mouth & tongue- dry
Skin - recoil < 2 seconds
Cap refill- prolonged
Extremities- cool
Urine output-decreased
Degree of dehydration: severe
> 9% loss of body weight
Mental status: apathetic, lethargic, unconcious
Thirst- drinks poorly, unable to dtink
HR- tachycadic; bradycardic in severe cases
Pulses- weak, thready, or impalpable
Breathing- deep
Eyes- deeply sunken
Tears- absent
Mouth & tongue- parched
Skin - recoil > 2 seconds
Cap refill- prolonged, minimal
Extremities- cold, mottled, cyanotic
Urine output-minimal
Vomiting differentials
Infant
Gastroenteritis (GE)
GERD
Overfeeding
Anatomic obstruction: PS, malrotation, hirschsprung, antral web
systemic infection (SI): UTI, PNA, hepatitis
Pertussis syndrome
Child/adolescent
GE
GERD
Gastritis
Toxic ingestion
SI: UTI, pyelonephrirtis, PNA, hepatitis
Pertussis syndrome
Sinusitis, appendicitis, small bowel obstruction
Vomiting treatment
Ondansetron dosing:
- 8-15 kg: 2 mg
- 15-30kg: 4 mg
- >30 kg: 8 mg
multiple dosing not recommended, single dose
Referral if conservative treatment for vomiting not working, intractable vomiting, bilious or bloody emesis, moderate-severe dehydration
Rehydration Therapy: none-minimal dehydration
Rehydration therapy: not applicable
Replacement of ongoing losses:
* < 9kg body weight: 60-120 mL oral rehydration solution (ORS) for each diarrheal stool or vomiting episode
* >10kg body weight: 120-240 mL ORS for each stool or vomiting episode
Rehydration Therapy: mild-moderate dehydration
Rehydration therapy: ORS 50-100mL/kg body weight over 3-4 hrs
Replacement of ongoing losses:
* < 9kg body weight: 60-120 mL oral rehydration solution (ORS) for each diarrheal stool or vomiting episode
* >10kg body weight: 120-240 mL ORS for each stool or vomiting episode
Rehydration Therapy: severe dehydration
Rehydration therapy: LR or NS IV bolus of 20 mL/kg/body weight until perfusion & mental status improves, then 100 mL/kg body weight ORS over 4 hrs or 5% dextrose 1/2 NS IV at twice maintenance fluid rates
Replacement of ongoing losses:
- < 9kg body weight: 60-120 mL oral rehydration solution (ORS) for each diarrheal stool or vomiting episode
- > 10kg body weight: 120-240 mL ORS for each stool or vomiting episode
- if unable to drink, administer through NG tube or adminster 5% D 1/2 NS w/ 20 mEq/L KCl IV
GERD
Lower esophageal sphincter (LES) malfunction
Prlonged exposure to gasrtic contents in the esophagus
Stomach contents is returning from stomach through esophageal sphincter
