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Flashcards in GI Deck (186):

describe the initial steps of digestion

1. Digestion starts with food being crushed and mashed into smaller pieces in the mouth.
2. Amylase from the salivary glands begins the breakdown of carbohydrates.
3. The food bolus is swallowed and propelled through the esophagus through the lower esophageal sphincter and into the stomach
4. Digestion of fats starts in the stomach with lipase from gastric glands being secreted.
5. Protein digestion begins when pepsin and HCL denature the proteins to produce large peptide fragments and some free amino acids.


Where do fats, proteins, and carbs start being digested

1. carbs- mouth from amylase in saliva
2. fats- stomach with lipase from gastric glands
3. Proteins- stomach w/ pepsin and HCL


It is that about ___ after you start to eat, that your body initiates a gastro-colic reflex where your colon, rectum and anus are stimulated to evacuate.

15-20 minutes


Where are vitamin B1, B2, B3, B5, B6, folic acid, vitamin C, zinc and iron absorbed

-Vitamins B1, B5, B6 are absorbed in the jejunum and ileum.

-Vitamins B2, and B3 are absorbed throughout the small intestine.

-Folic Acid absorbed in the proximal jejunum.

-Vitamin C absorbed in the distal small intestine.

-Iron is absorbed primarily in the proximal intestine.

-Zinc is absorbed mainly in the ileum.


describe digestion in the SI

1. fats are combined with bile salts and pancreatic lipase to create small, mixed micelles which are ultimately absorbed into the enterocytes and through to the lacteals. Fat soluble vitamins are absorbed this way (A,D, E, K)
2. protein digestion in the duodenum
3. starches are broken down into smaller components by pancreatic amylase


describe protein digestion in the duodenum

1. Cholecystokinin is released which stimulates the pancreas to release protease zymogens (aka proenzymes) and the intestinal cells to release enterokinase.
2. Enterokinase converts trypsinogen to its active form—trypsin.
3. Trypsin activates more trypsinogen, chymotrypsinogen, proelastase and procarboxypeptidase A and B into their active forms. These enzymes are responsible for cleaving certain AA bonds thus creating smaller peptide chains that can be better absorbed.
4. These peptide chains are further broken down by the brush border enzymes into single, di and tripeptides which are then transported in to the enterocyte.
5. Intracellular peptidases will continue to convert these small peptides into individual amino acids that will be absorbed into the circulatory system.


describe starch break down in the SI

Starches are broken down into smaller components by pancreatic amylase. These disaccharides are further broken down by brush border enzymes such as lactase, sucrase, maltase, isomaltase, and trehalase and then transported into the cell. Highest activity of these enzymes in the proximal intestine.


Chronic abdominal pain is abdominal pain lasting longer than ___

6 months


HPI questions that will help you sort through your differential diagnosis when seeing a child for chronic abdominal pain

1. Stooling pattern. How often are they stooling? What does the stool look like? Do they see blood and/or mucous in the stool? You’ll also want to know if stooling makes the pain better or worse?
2. You’ll want to ask about the location of the pain.
3. Are there signs that indicate something organic is taking place—vomiting, weight loss/weight gain, fevers, waking at night because of pain or symptoms, etc?
4. Does food make the pain better/worse? Does stress seem to exacerbate the pain?


PMH questions to help you assess abdominal pain

1. Did the child pass meconium within the first 48 hours?
2. Does the child have other associated medical conditions that increase the risk of certain GI diseases—atopy (allergies/asthma/eczema), cystic fibrosis, diabetes, down’s syndrome, etc?
3. Is the child on medications that can contribute to abdominal pain, and/or diarrhea and constipation (iron, antibiotics, antidepressants, ADHD meds, psych meds, etc)?
4. What kind of surgeries has the child had—imperforate anus repair, tethered cord release, spina bifida, intestinal resections, etc?


Fhx questions to ask to help you asses abdominal pain

1. Is there a family history of other GI conditions?
2. Atopic family history?
3. Autoimmune family history?


2 main GI conditions you'll see in infants

2. Milk protein intolerance


Who do we see milk protein intolerance most commonly in

-in infants anywhere from 1-2 weeks of age to about 9-10 months of age.
-Typically it occurs in breastfed infants who present with fussiness anytime throughout the day and not just in the evenings.


Presentation of milk protein intolerance

1. fussiness anytime throughout the day- not just PM
2. Bright red blood or mucous in their stools
3. Growing well- eating and gaining weight appropriately


what is milk protein intolerance due to?

-a combination of insufficient secretion of zymogens from the pancreas leading to incomplete protein digestion and an immature, leaky gut in the infant. The poorly digested proteins irritate the lining of the intestinal tract causing pain when the infant eats


tx of milk protein intolerance

1. includes educating the family that this is a self-limiting condition (4-10 months of age)
2. Maternal elimination diet can help
3. If soy formula does not change the condition, you can do a 2 week trial of a semi-elemental formula like Nutramigen or Alimentum where the proteins are more hydrolyzed. (not liked as much by infants so transition by milking)
4. If the child is still highly fussy, you can try a two week trial of elemental formula such as EleCare and Neocate


describe the prognosis of milk protein intolerance

-As the child grows and matures, the pancreas will reach adult secretory levels by a year of age and the tight junctions between the cells will work more effectively.
-Parents typically start to see improvement around 4-6 months of age but some kids can take up to 10 months for improvement in their symptoms.


describe how maternal elimination diet can help milk protein intolerance

-Start with a two week trial of eliminating one food at a time—dairy first, then soy and finally peanuts. If no improvement is seen after eliminating those three foods, you can do a trial of a soy formula for 2 weeks.

*Unfortunately 50% of kids that react to breast milk or regular formula will also react to soy.


One of the most common causes of chronic abdominal pain in kids is



define constipation

-a delay or difficulty in defecation present for 2 or more weeks. The average child will stool 1-2 times a day unless they are in the first few weeks of life where they can stool 1-4 times a day.


what are the peak times of constipation occurence

1. 6 months of age with the introduction of solids
2. 1-2 years of age with the introduction of cow’s milk
3. 3-5 years of age with the challenge of kids not wanting to stool at school


You will want to make sure the child passed meconium within the first ___ or you are likely dealing with a condition other than chronic constipation

48 hours


Red flags for other abdominal conditions that are not constipation/encopresis

1. not passing meconium in 1st 48 hrs
2. fever
3. vomiting
4. failure to thrive
5. anal stenosis
6. tight empty rectum on PE
7. abdominal distention


The North American Pediatric Gastroenterology, Hepatology and Nutrition association recommends one treatment regimen for kids UNDER a year of age with chronic retentive constipation:

1. Education: explain the process of constipation
2. Diet: can introduce 2-4 oz of sorbitol containing fruit juice into diet or feed pureed prunes
3. Medication: If diet and education are not helpful, consider a trial of an osmotic laxative like Lactulose or Karo syrup (1-2 tablespoons QD-BID—titrating to achieve soft pudding consistency stools)
-Can add in ½ dropper of Little Tummies laxative if necessary for 2 weeks if child is very retentive


The North American Pediatric Gastroenterology, Hepatology and Nutrition association recommends one treatment regimen For kids OVER 1 year of age with chronic retentive constipation:

1. Education: explain the process of constipation and that treatment will be a long term process (4-6 months minimum)
2. Diet: decrease milk intake; increase fiber (5+ age); increase clear fluids
3. Behavioral changes: toilet time 15-20 min after meals
4. Medication: If diet and education are not helpful, consider a trial of Lactulose or Miralax (1/2 capful/1 tablespoon-1 capful/2 tablespoons dissolved in 4-10 oz of clear fluid) QD to BID
-Can add in 1 dropper of Little Tummies laxative or ½-1 square of Chocolate Ex-lax QD to BID if necessary for 2 weeks-2 months


Be fairly aggressive in your treatment of constipation. The reason why is the possibility of a child developing ___

encopresis aka fecal incontinence


what is encopresis

-Defined as involuntary passage of fecal material in the underwear; typically the child has anywhere from 3-8 bowel movements in their underwear that they can’t control
-Due to long standing chronic retentive constipation that has gone untreated or undertreated


tx of Encopresis

1. Education: explain the process of constipation and that treatment will be a long term process (4-6 months minimum but more likely a year); explain soiling is NOT voluntary
2. Diet: increase fiber (5gm+ age); increase fluids; this is going to be the long term management plan
3. Behavioral changes: toilet time 15-20 min after meals
4. Disimpaction—remove impaction with enema followed by a bowel clean out over a 2 day period (bowel clean out consists of a clear liquid diet, Miralax 4 times a day and ExLax twice a day until the stool comes out clear liquid)
5. Medication: Following bowel clean out, give Miralax (1 capful/2 tablespoons dissolved in 6-8 oz of clear fluid BID)
-Also add in 1-2 squares of Chocolate Ex-lax BID for 2 months then wean but continue on Miralax for another 6-12 months


what is celiac disease

-an autoimmune response to the gluten protein in wheat.
-The gluten triggers an antibody response in the proximal small intestine resulting in inflammation and destruction of the villi.
-The villous atrophy leads to a loss of absorptive surface and intestinal enzymes frequently leading to malabsorption and diarrhea.

*an underlying cause of chronic abdominal pain


sx of celiac disease

Wide range of sx
1. anything from asymptomatic results found on screening tests
2. bloating
3. abdominal pain
4. failure to thrive with diarrhea


what should you do if you suspect celiac disease

1. order a Tissue Transglutaminase Antibody blood test and also get a serum IgA level.
-If the TTG level is elevated, it is suggestive of Celiac Disease, but it is recommended to confirm the diagnosis with an upper endoscopy given the long term risks of untreated or poorly treated Celiac Disease (osteoporosis, intestinal lymphoma, infertility)


long term risks of untreated or poorly treated Celiac Disease

1. Osteoporosis
2. Intestinal lymphoma
3. infertility


tx for Celiac disease

Strict gluten free diet


Causes of chronic abdominal pain

1. constipation/encopresis
2. Celiac disease
3. IBD (Crohns, UC)
4. Functional abdominal pain (IBS)


what are the 2 types of IBD and describe their similarities

Chron's and ulcerative colitis

1. Both are autoimmune disorders
2. There can be some exam findings that will make you more suspicious for this diagnosis—anal tags or perianal fistulas
3. Typically you will see changes in the CBC indicative of anemia and you will see elevated ESR and CRP
4. Both diseases are diagnosed with endoscopy
5. Both are treated with steroids, immune modulators, and nutrition;
6. Both are periodically monitored by pediatric GI specialists


Who and WHAT does Crohn's disease effect

-Affects preteens through adults
-5 to 10 new cases per 100,000 individuals/year

-Affects any part of GI tract from mouth to anus
-PATCHY disease: most often effects terminal ileum, ileum and cecum and the colon


sx of Crohn's Disease

1. Abdominal pain (can wake from sleep)
2. weight loss
3. Diarrhea
4. Hematochezia
5. Growth failure
6. Extraintestinal manifestations (like delayed puberty)


who and WHAT does Ulcerative colitis effect

-Affects preteens to adults (peak incidence 15-25 yo)
-2.05-3.67/100, 000 per year in children

-Affects only the colon
-Diffuse, CONTINUOUS process starting at the rectum and extending more proximally into the colon


Active UC is characterized by

diffuse and continuous edema, erythema, friability, and ulceration


Sx of UC

1. Abdominal pain
2. weight loss
3. fevers
4. bloody, mucousy diarrhea
5. nocturnal diarrhea
6. Growth failure
7. Extraintestinal manifestations (like delayed puberty


Definition of Functional abdominal pain (IBS)

1. Episodic or continuous abdominal pain
2. No evidence of an inflammatory, anatomic, metabolic or neoplastic process that explains the subject’s sx
3. Some loss of daily functioning
4. Additional somatic symptoms such as headache, limb pain or difficulty sleeping


IBS cannot include what sx

1. Persistent RUQ or RLQ pain
2. dysphagia
3. persistent vomiting
4. GI blood loss
5. nocturnal diarrhea
6. family hx of IBD, celiac dz, or PUD
7. pain that wakes the child from sleep
8. arthritis
9. perirectal disease
10. involuntary weight loss
11. deceleration of linear growth
12. delayed puberty
13. unexplained fever


who does IBS affect

Children school aged to adolescents


Features of IBS

1. no discernible pattern
2. nothing seems to consistently make it better or worse
3. the child continues to grow and develop appropriately


what is IBS caused by

visceral hypersensitivity


IBS is a dx of exclusion. Before you can diagnose it, what screening labs must be normal?

Screening labs: CBC, CRP, ESR, TTG, IgA, CMP, GGT, and UA


tx of IBS

1. Education: explain what condition the patient has
2. Symptomatic:
-increased fiber and fluids;
-antispasmodics (Levsin subligual or Bentyl 10 mg QD-QID daily);
-can consider Tricyclic antidepressant—amitriptyline (10-20 mg daily);
-stress management and relaxation techniques


define nausea and regurgitation

Nausea - a sensation of impending emesis

Regurgitation - the return of small amounts of food or secretions to the hypopharynx -food is brought back to the mouth without abdominal and diaphragmatic muscular activity

*Emesis rarely occurs without nausea


define emesis and retching

Emesis (a.k.a. “vomiting”) - forceful expulsion of stomach contents through an open glottis

Retching (a.k.a. “dry heaves”) - same mechanism as vomiting but glottis remains closed

*Emesis rarely occurs without nausea


The approach to acute nausea and vomiting is based on three key questions:

1. Is immediate therapy needed due to the consequences of nausea and vomiting regardless of the underlying cause?
2. Are empiric treatment and reassurance sufficient?
3. Is expeditious work-up required to establish the cause?- Is this a more serious problem, like an anatomical issue, that requires emergent intervention?


common causes of vomiting in neonates

2. Pyloric stenosis
3. Necrotizing enterocolitis*
4. Malrotation w/ volvulus
5. Hirschsprung disease
6. Atresias*, stenoses
7. Metabolic disorders*
8. Feeding intolerance

*unique to neonatal period
*Others, such as pyloric stenosis, Hirschsprung disease, and malrotation may be picked up outside of the neonatal period, typically in early infancy.


Common causes of vomiting in infants

1. GERD*
2. Gastroenteritis*
3. Anatomic
4. Intussusception
5. Rumination
6. Nutrient intolerances
7. Overfeeeding
8. Munchausen syndrome by proxy

*most common


Common causes of vomiting in childhood

1. Gastroenteritis
2. Infection
3. Peptic ulcer/GERD
4. Cyclic vomiting
5. Psychogenic
6. Toxic ingestion- should be considered in any child who has the motor skills to place objects in the mouth
7. Intracranial mass


Common causes of vomiting in adolescene

1. Gastroenteritis
2. Peptic ulcer/GERD
3. Psychogenic
4. Intracranial mass
5. Cyclic vomiting
6. Bulimia
7. Pregnancy
8. Drugs of abuse
9. Suicide attempt

*pschyogenic causes become more prominent


Bilious vomiting in the first months of life suggests

anatomical obstruction or other serious condition


With vomiting in neonates and infants it is important to:

1. take it seriously
2. Distinguish vomiting from regurgitation
3. Bilious versus non-bilious


"For bilious vomiting, I give ____. It has never failed in the worst cases of persistent bilious vomiting. It can be repeated in half an hour if really necessary. The results are immediate.”

one teaspoonful of table salt


how to distinguish vomiting vs reguritation

Vomiting would likely be of larger volume and would certainly be forceful.


cause of bilious vomiting in older children

bilious vomiting can occur with any syndrome with repeated bouts of vomiting. As food is expelled, all that remains in the GI tract is saliva and bile


cause of bilious vomiting in neonatal or early infancy period

-malrotation with or without volvulus


what is a malrotation

-a developmental error in the formation of the G.I. tract in which the intestine does not complete its normal rotational pattern of fetal development
-incomplete rotation of the intestine during fetal development


Malrotation can cause symptoms of __ or __ and makes the intestine susceptible to volvulus.

incomplete or intermittent obstruction


what happens with volvulus

the large intestine wraps around a segment of the small intestine causing obstructive symptoms and ischemia.
-Volvulus can be intermittent and resolve spontaneously but can also be persistent and lead within hours to strangulation of the bowel.


how does malrotation present

1. Usually presents in neonatal period with bilious emesis
2. Infants and children may present with failure to thrive, signs of intermittent obstruction characterized by intermittent episodes of severe abdominal pain
3. Malrotation can be missed in infancy and is occasionally not picked up until adolescence or later in life (25-50% of adolescents w/ malrotation are asymptomatic)


how do you diagnose malrotation

US or barium enema


tx of malrotation



how does malrotation with volvulus typically present

1. severe abdominal pain,
2. unremitting vomiting
3. presents as an acute small bowel obstruction

*Life threatening surgical emergency


complications of malrotation with volvulus

1. Significant bowel necrosis can result from compression of superior mesenteric artery
2. high risk of short bowel syndrome
3. Life threatening surgical emergency


what is intussusception

-Prolapse (telescoping) of one portion of bowel into adjacent segment, most commonly terminal ileum near the ileocecal junction
-Compression--> swelling-> obstruction


What is the presentation of intussusception

1. neonate period: Most common at 3-12 months,
2. 3:1 mal predominance
3. abdominal pain
4. vomiting (bilious or non-bilious)
5. currant jelly stools (50%)


Dx and Tx of intussusception

barium enema or air enema: both are diagnostic AND therapeutic


prognosis of intussusception

Prognosis is strongly correlated with duration before reduction
-Complicated cases require surgical treatment


what is currant jelly stool

Mucus from the inflamed segment of intestine mixed with blood causes the currant jelly stool

*seen 50% of time w/ intussusception


Non-bilious vomiting causes

1. intussusception
3. Pyloric stenosis
4. acute appendicitis


Presentation of pyloric stenosis (IHPS)

1. 4:1 male predominance
2. vomiting usually at 2-4 weeks of age, progresses to projectile vomiting
3. Vomiting is immediately post-prandial and infant will feed following emesis (“hungry vomiter”)
4. undernourished infant w/ hypocholoremic metabolic alkalosis (rarely seen now)
5. presents first 2 months of life
6. "olive sign"- palpable pylorus


what is the cause of pyloric stenosis (IHPS)

-Positive family history in 13%, first born 30%

-caused by hypertrophy of the muscles that make up the pylorus.
-As the hypertrophy increases over a span of several weeks the nature of the vomiting progresses


Dx of pyloric stenosis (IHPS)

abdominal US


tx of pyloric stenosis (IHPS)

1. Correction of fluid/electrolyte imbalance
2. followed by surgery (pyloromyotomy)


what is GERD

Passage of gastric contents into the esophagus due to transient relaxation of the LES (lower esophageal sphincter)


Presentation of GERD in neonates and infants

1. Postprandial regurgitation (rarely vomiting)
2. May have irritability
3. feeding aversion
4. back arching


How do you dx GERD in neonates and infants

*often a clinical diagnosis in which you will take an empirical treatment approach
-can use prolonged monitoring of esophageal pH to diagnose


tx of GERD in neonates and infants

-typically self-limiting, resolves 6-12 months
2. smaller feedings at frequent intervals
3. positioning w/ the head of the crib elevated
4. Meds:
-H2-receptor blockers: e.g ranitidine (Zantac)
-Proton pump inhibitors: e.g. omeprazole (Prilosec)
-Antacids(e.g. Al hydroxide) not recommended at this age


Presentation of GERD in children

1. chest pain
2. epigastric pain
3. dysphagia
4. heart burn
5. food impaction
6. vomiting
7. cough


Dx of GERD in children

Although the diagnosis is often made clinically, the gold standard for diagnosis is esophageal pH in conjunction with a symptom diary.


Management of GERD in children

1. thickened feedings
2. poistioning can help in younger children
3. Older kids- weight reduction and dietary modification
4. Meds:
-H2-receptor blockers e.g ranitidine (Zantac)
-Proton pump inhibitors e.g. omeprazole (Prilosec)
-Surgical: Nissen fundoplication


what is the most common cause of acute abdomen in children

acute appendicitis


Presentation of acute appendicitis depends on



Classic presentation of acute appendicitis

1. adolescents (age 13+):
2. anorexia
3. periumbilical pain migrating to the RLQ
4. non-bilious vomiting, preceded by pain.

*. If there are prolonged bouts of vomiting, the vomitus can become bile-stained.


Neonatal presentation of acute appendicitis

1. birth - 30 d
2. Abdominal distention
3. vomiting


infant presentation of acute appendicitis

1. 30 d - 2 y
2. Vomiting
3. inconsolability
4. fever
5. Diarrhea not uncommon in first 2-3 months of life.


preschool presentation of acute appendicitis

1. 2-5 y
2. Vomiting is often the first symptom and frequently PRECEDES abdominal pain,
3. fever present in most, but not all patients.


school age presentation of acute appendicitis

1. 6-12 y
2. Abdominal pain and vomiting are present, but the
3. typical migration of periumbilical pain to RLQ may not occur.
4. Diarrhea, constipation, and dysuria can confuse the diagnosis


PE of classic acute appendicitis

1. RLQ tenderness
2. guarding
3. rebound tenderness
4. fever


PE of acute appendicitis in neonates (birth -30d)

1. Abdominal distention is common.
2. Hypothermia,
3. hypotension,
4. respiratory distress may also be seen.


PE of acute appendicitis in infants (30d-2yrs)

1. Fever
2. diffuse abdominal tenderness (due to rupture) are the most common physical findings


PE of acute appendicitis in preschool to adult

classic signs

-RLQ tenderness
-rebound tenderness


How do you score the pediatric appendicitis score (PAS)

1. Anorexia: 1 point
2. Nausea or vomiting: 1 point
3. Migration of pain: 1 point
4. Fever > 38º C (100.5º F): 1 point
5. Tenderness with cough, percussion, or hopping: 2 points
6. Right-lower-quadrant tenderness: 2 points
7. WBC count > 10,000 cells/mm3: 1 point
8. PMNs plus band forms > 7500 cells/mm3: 1 point

-Mean score 7= appendicitis
-pts w/o appendicitis had a mean score of 1.9
-score of 3-6 was indeterminate for appendicitis


Labs for of acute appendicitis

1. WBC is elevated and/or left-shifted in most (~96%) children with acute appendicitis. Poor specificity!
2. CRP may provide useful information but currently not well-validated.
3. Urinalysis: Should be part of the work-up but…Caveat: 7-25 % of children with acute appendicitis have pyuria on urine dip. NOT useful for rule out!
4. Recommended labs: WBC, urinalysis, hCG for postmenarchal females.


Imaging for acute appendicitis and when would you do it?

1. US or CT

-Children with a typical clinical presentation or PAS of 7 or greater: Consult with a pediatric surgeon BEFORE obtaining imaging

-Children with a low likelihood of appendicitis or a low PAS (1-2)can be managed without imaging and followed closely


diarrhea is defined as

an increase in frequency, fluidity, or volume of bowel movements.


Etiologies of diarrhea

1. Infectious**
2. Intolerances (formula, lactose, carbohydrate, protein)
3. Irritable bowel syndrome (IBS)
4. Inflammatory bowel disease (IBD)
5. Medication use (e.g. antibiotics)
6. Laxative abuse
7. Toxic ingestion


AAP defines acute gastroenteritis as

“diarrheal disease of rapid onset, with or without accompanying symptoms and signs such as nausea, vomiting, fever, or abdominal pain.”*


causes of acute gastroenteritis

viral, bacterial, parastic


Management of acute gastroenteritis

-Rehydration, refeeding, attention to volume status

* antidiarrheal agents are generally not recommended


In developing countries, diarrheal illnesses account for an estimated 4-5 million deaths per year in children __

under 5 years


___ alone is believed to cause over 500,000 deaths per year in children under the age of 5.


*causes acute gastroenteritis


Common Viral pathogens and the duration of illness

1. Rotavirus- avg 6 days, range 1-10d
2. Enteric adenoviruses- avg 11d, range 1-22d
3. Astrovirus- avg 5 d, range 1-5 d
4. Torovirus- avg 5 d, range 1-5 d
5. Norwalk-Like- avg 2 d, range 1-4 d

*With the exception of adenoviruses most viral pathogens cause brief bouts of illness lasting less than one week.


The most common viral agent associated with severe diarrhea in infants and children

Rotavirus-- affects villi of SI


describe the presentation of rotavirus

1. 48 hour incubation, followed by:
2. vomiting,
3. mild fever,
4. then voluminous, watery diarrhea
5. peak in winter months (Nov-May) -- but now w/ vx pattern is less reliable
6. peak in infants under 2yrs (3-15months)

*The presentation of rotavirus gastroenteritis is similar to other viral gastroenteritides.


complications of rotavirus gastroenteritis

1. severe dehydration
2. death

Stool bicarb loss may lead to metabolic acidosis


describe the spread of rotavirus

fecal-oral route

-survives hours no the hands, days on environmental fomits


how do you dx rotavirus gastroenteritis

Clinical diagnosis if minimal or mild dehydration, no culture or other testing needed

*viral testing is often performed to monitor outbreaks.


tx of all viral gastroenteritis

1. Estimate degree of hydration
2. Rehydration is mainstay of therapy
3. AAP recommends AGAINST the use of antiemetics or antidiarrheals in acute gastroenteritis
4. Continue breast-feeding and re-initiate solid foods as as soon as rehydration is complete
5. The BRAT diet: Has NOT been shown to be more effective than normal diet, instead feed a normal diet as tolerated BUT can be used


what is the BRAT diet

Bananas, rice, applesauce, toast


How to prevent rotavirus gastroenteritis

1. Hygiene: Hand-washing with soap and water probably not sufficient; **alcohol-based gels recommended
2. Asymptomatic children should be isolated from symptomatic children, if possible
3. **RotaTeq: human-bovine reassortant vaccine approved by FDA and recommended by AAP for routine childhood immunization in 2006. Oral vaccine to be administered at 2, 4 and 6 months.
4. Rotarix: attenuated human vaccine approved in 2008. Oral vaccine, administered in two doses at 2 and 4 months.

* Immunization: RotaShield vaccine pulled from the market in 1999 following several cases of intussusception.


the most common bacterial pathogens causing diarrhea

1. Salmonella
2. Aeromonas
3. Plesimonas
4. Yersinia enterocolitica
5. C difficile
6. Listeria
7. E Coli, E Coli 0157:H7
8. Shigella


presentation of bacterial gastroenteritis depends on

causative organism


common presentation of gastroenteritis

*Depends on organism

Bloody stools common (50%), usually with more frequent, small-volume bowel movements, vomiting less common

-Febrile, non-bloody diarrhea: Usually viral
-Afebrile, non-bloody: Usually viral
-Febrile, bloody diarrhea: Usually bacterial
-Afebrile, bloody diarrhea: Usually bacterial, consider non-infectious source


w/u of gastroenteritis

1. History and exam should first focus on determining if patient is seriously ill and assessing hydration status
2. Stool culture and smear for WBCs, ova and parasites


sources of salmonella

foodborne (poultry, raw eggs)


describe the presentation of salmonella

1. Incubation of 6-72 hrs,
2. followed by abrupt onset N/V,
3. crampy abd pain,
4. then watery diarrhea,
5. sometimes blood and mucus
6. Duration: 5 days to months (chronic)


tx of salmonella

1. Supportive.
2. Antibiotics may prolong course not recommended unless pt is immune-compromised or has evidence of bacteremia or meningitis
3. Antibiotic treatment with cefotaxime or ceftriaxone if bacteremia or meningitis is present or immuno-compromised host.


presentation of Shigella

1. Uncommon before 3-6 months of age. Younger patients typically have more severe disease
2.Abrupt onset cramps,
3. urgency,
4. fever,
5. chills,
6. malaise,
7. diarrhea
8. Stool often with blood, mucus
9. Peak: SUMMER months
10. duration 5 days


how is shigella spread

fecal-oral transmission

*HIGHLY contagious


tx of shigella

1. Antibiotics:
Trimethoprim/sulfamethoxazole (TMP/SMX), Cefixime, ceftriaxone.
2. Supportive measures.


sources of E. Coli 0157:H7

uncooked meats, unpasteurized fruit juice, contaminated water


Presentation of E. coli

1. sever crampy, bloody diarrhea
2. risk for hemolytic uremic syndrome (HUS)
3. More common in children under age 4


Tx of E. coli

1. supportive

*Abx may actually worsen prognosis


sources of Giardia lamblia

1. infected feces
2. contaminated drinking water or food
3. recreational pools
4. children and employees at day care centers
5. animal hosts: beaver


The most common protozoan-caused diarrhea in North America

Giardia lamblia


describe the presentation of giardia

1. incubation 1-2+ weeks
2. Malodorous, greasy diarrhea, usually without blood.
2. Can cause chronic diarrhea
3. malaise,
4. other GI symptoms: Vomiting


dx of Giardia

stool O and P testing


tx of Giardia

Metronidazole 15mg/kg for 10 days


___ medications are ineffective and possibly even dangerous for smaller children for gastroenteritis .

True antidiarrheal

ex. kaopectate, loperamide, tincture of opium, diphenoxylate with atropine


meds to help with acute gastroenteritis

1. Cholestyramine (Questran) helps to bind the stools to decrease diarrhea. Rx: Questran 1/3 packet mixed with food TID until formed stools

2. Promethazine (Phenergan) suppositories: They work for vomiting, but potential for respiratory depression and toxicity when used in younger kids. Contraindicated under age 2


how can you dx dehydration by parental report

1. Vomiting, diarrhea, or decreased oral intake is useful but non-specific
2. Urine and stool output is very subjective
3. Normal tear production is useful in excluding moderate to severe dehydration


PE to assess dehydration

1. Change in body weight before and after rehydration is the standard method for diagnosis
2. To identify dehydration before treatment, many factors can be used but most are not helpful in isolation. The most useful individual signs are:
-Increased capillary refill time
-Abnormal skin turgor
-Abnormal respiratory pattern


Clinical dehydration scales based on a combination of factors are much better predictors than any individual factor. 4 factors predicted dehydration:

1. cap refill over 2 sec
2. absence of tears
3. dry mucous membranes
4. ill general appearance


Labs to assess dehydration

1. BUN
2. Creatinine
3. BUN/Creatinine ratio
4. Urine specific gravity

*NONE of the above are useful in diagnosing dehydration in children!



describe the use of skin turgor in assessing dehydration

Pinch a fold of skin on the lateral abdomen for 2 seconds and release.

-Normal: skin recoils immediately
-Moderate: Skin recoils within 2 seconds
-Severe: Skin is slow to recoil (over 2sec), “tenting”

*Do not perform on the hand!


describe the use of capillary refill in assessing dehydration

Squeeze and blanch the nail bed and count time to reperfusion.

-Normal: less than 2 seconds
-Moderate: greater than 2 seconds (2-4 sec)
-Severe: prolonged or no refill

*Performed on the sternum in neonates


clinical presentation of dehydration

1. sucken eyes and cheeks
2. decreased skin turgor
3. sunken fontanelle
4. few or no tears
5. dry mouth or tongue
6. sunken abdomin


General Signs of Mild dehydration

-Wt. loss: 3-5%
-Mental status: well, alert
-Thirst: drinks normally, might refuse liquids


General signs of moderate dehydration

-Wt. loss: 6-10%
-Mental status: normal, fatigued or restless, irritable
-Thirst: thirsty, eager to drink


General signs of severe dehydration

-Wt. loss: 11-15%
-Mental status: apathetic, lethargic, unconscious
-Thirst: drinks poorly or unable to drink


hemodynamic signs of mild dehydration

-Pulse: normal
-Cap refill: 2-3sec
-BP: nl
-Perfusion: nl


hemodynamic signs of moderate dehydration

-Pulse: slight increase
-Cap refill: 3-4 sec
-BP: nl
-Perfusion: nl


hemodynamic signs of severe dehydration

-Pulse: tachy
-Cap refill: over 4 sec
-BP: low (emergency)
-Perfusion: circulatory collapse


Assessment of fluid loss of mild dehydration

-UO: mild oliguria
-Tears: decreased
-Urine specific gravity: over 1.020


Assessment of fluid loss of moderate dehydration

-UO: oliguria
-Tears: decreased
-Urine specific gravity: over 1.020


Assessment of fluid loss of severe dehydration

-UO: anuria
-Tears: absent
-Urine specific gravity: anuria


7 Principles of fluid replacement

1. Oral rehydration solution (ORS) should be used
2. Oral rehydration should be performed rapidly (within 3-4 hours
3. Age-appropriate, unrestricted diet is recommended as soon as dehydration is corrected
4. For breastfed infants, nursing should be continued
5. For formula-fed infants, diluted formula is not recommended, special formula usually is not necessary
6. Additional ORS should be given for ongoing losses through diarrhea
7. No unnecessary laboratory tests or medications should be administered


Fluid Replacement in Children with Gastroenteritis: Caveats

1. IV Fluids not recommended in mild or moderate dehydration unless the child is not able to take ORT
2. ORT is recommended in severe dehydration only if the patient is clinically stable, alert, and taking ORT well


Fluid replacement solutions are a combination of

water, sugar, and salt in proportions that approach the osmolarity of body fluids


Sugars in the appropriate proportion are an important component of rehydration fluids because of

cellular glucose/solute co-transport, which increases the rate of rehydration.


___ are appropriately formulated for rehydration.
___ are not. Why

Pedialyte and other rehydration solutions
*osmolarity ~250milliosmoles/L

Sodas and other beverages like apple juice
~2-3x the osmolarity of rehydration solutions

*those beverages can worsen dehydration and their use in the setting of acute gastroenteritis should be strongly discouraged


The basic principle of IV fluid replacement is __ followed by __

volume resuscitation followed by rehydration


describe volume resuscitation

Start with Lactated Ringer’s solution or NS at 20ml/kg IV over one hour


describe rehydration after volume resuscitation

*if electrolytes normal:
-Then administer ORT at 100 ml/kg over 3-4 hours if tolerated OR
-D5 ¼ NS IVF with 20 mEq/L potassium over 3-4 hours OR if significant stool loss
-D5 ½ NS with 20 mEq/L potassium to replace losses on top of maintanence levels


what is the recommended ORS and IV fluids for MILD dehydration in children w/ gastroenteritis

-50ml/kg over 3-4 hrs

IV fluids:
-not recommended


what is the recommended ORS and IV fluids for MODERATE dehydration in children w/ gastroenteritis

-100 ml/kg over 3-4 hours

IV fluids:
-not recommended


what is the recommended ORS and IV fluids for SEVERE dehydration in children w/ gastroenteritis

-100-150 ml/kg over 3-4 hours

IV fluids:
-20 ml/kg bolus over one hour


what is the recommended ORS and IV fluids for ON-GOING LOSSES dehydration in children w/ gastroenteritis

-10 ml/kg for each stool or emesis

IV fluids:
-10 ml/kg for each stool or emesis


describe the Holliday-Segar Method to calculate maintenance fluids

you first determine the total milliliters per day and then calculate milliliters per hour to determine the rate of IV flow. For example a 10 kg child would need 10x100 or 1000 mL of IV fluids per day or 40 mL per hour.


a pt that weights 3-10kgs needs how many ml/day and ml/hr of IV fluids?

ml/day: 100ml/kg

ml/hr: 4ml/kg/hr


a pt that weights 10-20kgs needs how many ml/day and ml/hr of IV fluids?

ml/day: 1000 + 50(wt-10kg)

ml/hr: 40 + 2(wt-10kg)


a pt that weights over 20kgs needs how many ml/day and ml/hr of IV fluids?

ml/day: 1500 + 20(wt- 20kg)

ml/hr: 60 + (wt-20kg)


Calculating Maintenance Fluids:Holliday-Segar Method Simplified for home ORT

Infants: 1 oz/hour
Toddlers: 2 oz/hour
Older children: 3 oz/hour


when should a child be hospitalized for fluid managment

1. Caregivers cannot provide adequate care at home;
2. Substantial difficulties exist in administrating ORT, including intractable vomiting, ORS refusal, or inadequate ORS intake;
3. Concern exists for other possible illnesses complicating the clinical course;
4. ORS treatment fails, including worsening diarrhea or dehydration despite adequate volumes;
5. Severe dehydration (over 9% of body weight) exists;
6. Social or logistical concerns exist that might prevent return evaluation, if necessary, or
7. Such factors as young age, unusual irritability or drowsiness, progressive course of symptoms, or uncertainty of diagnosis exist that might indicate a need for close observation.


Such factors as: _____ that might indicate a need for close observation.

1. young age
2. unusual irritability or
3. drowsiness,
4. progressive course of symptoms, or
5. uncertainty of diagnosis exist


CBC may provide evidence for

1. inflammation (WBC and platelet count)
2. poor nutrition or bleeding (Hemoglobin, RBC volume, reticulocyte counts)
3. infection (WBC and differential)


__, __, __, and __ help w/ define hydration status

serum electrolytes


___ pain results when autonomic nerves within the gut detect injury, transmitting sensation by nonmyelinated fibers



The pain is vague, dull, slow in onset, and poorly localized

visceral pain


__ pain results when overlying body structures are injured.


somatic structures include the parietal peritoneum, fascia, muscles, and skin of the abdominal wall


lab tests for infection or inflammation



lab tests for biliary or liver disease



lab tests for pancreatitis



lab tests for UTI, bleeding due to stone, trauma, or obstruction



when is plain flat or upright abdominal film best

-Bowel obstruction
-appendiceal fecalith
-free intraperitoneal air
-kidney stones


when is CT scan best

-intra-abdominal or pelvic abscess
-kidney stones


when is barium enema best



when is US best

-kidney stone


when is upper endoscopy best

-suspected peptic ulcer or eosphagitis


to determine if diarrhea is osmotic or secretory the ___ is calculate

osmotic gaps

Osmoticgap =290-2 ([Na+] + [K+])

Secretory= less than 50
Osmotic= over 50, indicates malabsored substances other than electrolyte account for fecal osmolarity


Having E. Coli O157:H puts you at risk for