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GI and liver > Peds GI > Flashcards

Peds GI Flashcards

1
Q

neonate definition

A

0-28 days

term (due date) + 28 days if born premature

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2
Q

infant definition

A

1-12 months

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3
Q

child definition

A

1-12 years (or prepubescent)

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4
Q

adolescent definition

A

13-18 yeas (puberty)

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5
Q

estimating GFR***

A

eGFR (mL/min/1.73 m^2) = 0.413 (height in cm/SCr)

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6
Q

GER definition

A

Passage of gastric contents into the esophagus

aka spitting up / “happy spitter”

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7
Q

GERD definition

A

Gastric reflux causes troublesome symptoms or complications

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8
Q

regurgitation definition

A

Effortless passage of stomach contents, AKA “spitting up”

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9
Q

vomiting definition

A

forceful expulsion of stomach contents

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10
Q

epidemiology of GER/GERD

A

GER is a normal physiologic process in healthy infants,
children, and adults - 67% of 4-month-olds have at least one regurgitation episode daily, Usually resolves by 12-14 months of age
GERD symptoms affect 7% of school-age children and 8% of adolescents

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11
Q

risk factors for GER(D)

A

Genetic predisposition, Hiatal hernia, Esophageal atresia (esophagus doesn’t form completely), Obesity, Prematurity, Neurological impairment, Lung disease (especially cystic fibrosis)

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12
Q

GERD symptoms - infants

A

GI -Regurgitation*, Feeding difficulties, Hematemesis, Back arching
Extra intenstinal - Failure to thrive, Wheezing, Stridor, Persistent cough, Apnea/ALTE, Irritability

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13
Q

Gerd Sxs - children

A

GI - heartburn, feeding difficulties, hematemesis, vomiting, regurgitation, dysphagia, chest pain
extra intestinal - persisten cough, wheezing, laryngitis, stridor, asthma, recurrent pneumonia, dental erosions, anemia

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14
Q

diagnosis

A

thorough history and PE
empiric acid suppression therapy - give 4 weeks of PPI and if unsucessful, refer
esophageal or motility studies

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15
Q

management of GERD

A

goals of therapy: provide symptom relief, romote mucosal healing and weight gain, prevent GERD complications
treatment options - nonpharm therapy, pharm therapy, surgery

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16
Q

nonpharm therapy

A

feeding changes - thickening of feeds (rice cereal), increase caloric density of feeds and decrease volume, hypoallergenic diet
positioning therapy - infants should sleep in supine position
lifestyle changes - dietary mods, weight reduction, eliminate smoke exposure

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17
Q

antacids in peds

A

same role as adults
examples: magnesium hydroxide, calcium carb
**avoid aluminum containing products if possible
watch from drug interactions

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18
Q

H2RAs in peds

A

role: 1st line in mild-mod GERD, short term use
ranitidine, famotidine, cimetidine (not used IRL), nizantidine
all require renal dosing adjustment
tachypylaxis observed with chronic use

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19
Q

ranitidine dosing***

A

use in under 1 year old
IV: 1-2 mg/kg q8-12h (max = 300 mg)
PO: 4-8 mg/kg/day divided BID

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20
Q

famotidine dosing***

A

use in over 1 year old
IV: 0.5 mg/kg 1-2 times daily (max dose = 40 mg)
PO: 1 mg/kg/day divided BID (3 months to 12 years, max dose = 40 mg)

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21
Q

PPI comparison

A

all have limited data
Most data exists for: Omeprazole and Lansoprazole
Available as granules for pediatric use: Omeprazole, Pantoprazole, Esomeprazole, Rabeprazole
Available as orally disintegrating tablet: Lansoprazole
available as suspension: Lansoprazole (3 mg/mL)

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22
Q

PPI dosing

A
  • *lansoprazole: over 10 weeks: 1 mg/kg/day; 1-12 YO: under 30 kg = 15 mg QD, over 30 kg = 30 mg QD
  • *omeprazole: 1 mg/kg/day; 1-16 YO: 5-10 kg = 5 mg QD, 10-20 kg = 10 mg QD, over 20 kg = 20 mg QD
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23
Q

metoclopromide

A

prokinetic agent
neurologic AEs
black box warning for tardive dyskinesia (may be PERMANENT)

24
Q

erythromycin

A

prokinetic agent
pyloric stenosis at antimicrobial doses (projectile vomiting is a sign)
could prolong QT or cause arrhythmias

25
Q

sucralfate in peds

A

not used in infants and typically only used for short period of time in children (7-10 days max)

26
Q

surgical options

A

Recommended in patients with: Medical therapy failure, Children at severe risk of aspiration of gastric contents, Potentially serious reflux-associated morbid conditions such as Barrett’s esophagus

27
Q

infant with regurgitation/vomiting

A

HPE
warning signs? yes - further eval, no - are there signs of GER?
signs of GERD? yes - further eval, no - happy spitter, parent education
resolution by 18 months? yes- well child, no - consult with pediatric GI specialist

28
Q

infant with regurgiation and poor weight gain

A

HPE
warning signs? yes - further eval needed, no - adequate caloric intake?
adequate caloric intake? no - education and close follow up, yes - studies: CBC, BMP, upper GI abnormality?
CBC BMP upper GI abnorm? yes - manage accordingly, no - dietary management (maternal exclusion, thickened feeding, increased caloric density)
improvement? yes - education and close follow up, no - acid suppression and/or prokinetics, NG/NJ feeding, GI consult

29
Q

older children/adolescents

A

complaint of heart burn
HPE
lifestyle modifications; PPI x 2 weeks
improvement? no - consult GI specialist, yes - continue PPI for 8-12 weeks then d/c
relapse? yes - consult GI specialist, no - observation

30
Q

vomiting pearls

A

treat underlying cause
correct dehydration and electrolyte abnormalities
avoid promethazine in children under 2

31
Q

bowel continence is expected by age..

A

4

32
Q

normal stooling patterns

A

infants: 3-4 stools/day
toddler: 2-3 stools/day
4 year old: usually have stooling patterns similar to adults
stool volume increases as number of stools declines

33
Q

withholding

A

occurs when child fails to recognize or respond to urge to defecate
repeated withholding - larger stool load - stretching and possible thinning of rectal wall
prolonged withholding leads to lots of retained stool - fecal mass becomes impacted and difficult to evacuate, soft stool leaks around impaction

34
Q

causes of constipation

A

anatomic, neurologic, obstructive, endocrine/metabolic, functional, medications (patients on high-dose opioids must have a bowel regimen!)

35
Q

“red flag” symptoms

A

delayed passage of meconium, failure to thrive, bloody stools, severe abdominal distention, perianal fistubal, absent anal wink, sacral dimple

36
Q

management of constipation in infants

A 
1st line: glycerin suppository
may adjust diet if older than 6 months
prune juice
consider increading fluid intake
AVOID: mineral oil, stimulant laxatives, phosphate enemas, home remedies containing honey
37
Q

management of constipation in children

A
  1. education
  2. disimpaction or cleanout
  3. maintenace therapy to establish regular bowel movements
  4. behavois modification to improve toileting behavior
38
Q

nonpharm options for contipation in children

A

Family/patient counseling
Reward systems such as sticker charts, toileting calendars, etc.
Dietary modification - fiber may not be effective, hydration

39
Q

step 1: disimpaction

A

PEG 3350: 1-1.5 g/kg/day x 3-6 consecutive days - Mix with 4-8 ounces of fluid
Magnesium citrate 4 mL/kg/day x 2 consecutive days
no one likes normal saline enemas
other enemas are not usually used
nasogastric (requires hospitalization): PEG w/ electrolytes 25-40 mL/kg/hr until rectal effluent is clear, *max 1000 mL/hour, may take 24-48 hours, may cause NV, consider antiemetics

40
Q

enemas

A

Outpatient use for up to 3-7 days for disimpaction
Different types
Preschool age and older need adult-size enemas
May need up to 3 in 12- to 24-hour period
Often not well tolerated due to discomfort and cramping
**AVOID: Home remedies like soap suds enemas, herbal, tap water enemas

41
Q

step 2: maintenance

A

Goal: Prevent recurrence of constipation and allow musculature of rectum to return to normal
Try to achieve 1 soft stools/day
Continue dietary and behavioral modifications
First-line maintenance agent is PEG 3350 1g/kg/day, can also use lactulose or magnesium hydroxide
stool softeners: docusate 5 mg/kg/day up to 400, may divide doses, avoid mineral oil
stimulant laxatives - avoid routine use, OK for intermittent

42
Q

non infectious causes of diarrhea

A 
malabsorption syndromes - CF or celiac
SBS
irritable bowel - crohn's or UC
allergic - lactose
nutrition - overfeeding, sorbitol, developmental differences in enzymes
medications
43
Q

amoxicillin/clavulanate

A

clavulanate component can cause significant diarrhea
high dose amoxicillin = 90 mg/kg/day
use 600 mg/5mL formulation if possible - has highest ratio of amoxicillin to clavulanate available - minimize risk of diarrhea

44
Q

treating dehydration

A

Patients will mild/moderate dehydration may be managed with oral replacement therapy (ORT)
Severe dehydration requires IV rehydration
In developing countries World Health Organization (WHO) and UNICEF distribute oral rehydration solution
Note that water, carbonated sports drinks, caffeinated drinks, and sweet tea are not acceptable for rehydration
• Lack electrolytes
• Hyperosmolar

45
Q

calculating fluid requirements**

A

Holliday-Segar method
up to 10 kg: 100 mL/kg
10-20 kg: 1000 ML + 50 mL/kg for every kg over 10
over 20 kg: 1500 mL + 20 mL/kg for every kg over 20

46
Q

diphenoxylate

A

opioid derivative
used in comb with atropine in help prevent abuse potential
causes ACh effects
option in chronic diarrhea
0.3-0.4 mg/kg/day (may 10 mg/day) in 4 divided doses

47
Q

loperamide

A

Another opioid derivative but does not cross blood brain barrier
Delays GI transit time and regulates chloride secretion
More useful in chronic diarrhea
Avoid in children who are malnourished, severe dehydration, or have bloody diarrhea
Dosing:
-2-5 y: 1 mg TID
-6-8 y: 2 mg BID
-9-12 y: 2 mg TID
-After initial dosing, 0.1 mg/kg after each loose stool

48
Q

cholestryamine

A

Chloride and basic quaternary ammonium anion exchange binding resin
Helpful in diarrheal disorders associated with fecal bile acids
Forms complex with bile acids - chloride ions released - chloride absorbed and water follows - decreases
water in GI lumen
Other medications will bind to resin - Give 1 hour before or 4-6 hours after cholestyramine

49
Q

SBS

A

short bowel syndrome

reduced small bowel length leading to intestinal failure

50
Q

intestinal failure

A

inadequate absorption of nutrients, water, or electrolytes

results in inability to support health, growth and development

51
Q

intestinal adaptation definition

A

ability to maintain normal growth and development without parenteral nutrition (TPN)

52
Q

epidemiology of SBS

A

SBS caused by extensive bowel resection or dysfunction
24.5 per 100,000 live births
mortality ranges from 15-25% in US

53
Q

pathophysiology of SBS

A

severity depends on extent and site of resection
regional differences in absorption
Residual intestinal length is most important prognostic factor
Term babies born with 250 to 275 cm small bowel
Adults have up to 850 cm small bowel
Patients with

54
Q

intestinal adaptation

A

After intestinal resection, adaptive changes improve function of remaining intestinal mucosa
Structural: Increase in height and diameter of microvilli, Increases absorptive area, Intestinal dilation may occur, Bowel may lengthen and thicken
Functional: Additional changes in nutrient transport, enzyme activity, transit
Adaptation can take up to 2 years
Some patients can get off TPN!

55
Q

TPN complications

A

psychosocial
central line complications - infections and malfunctions
cholestasis common, can lead to liver failure
bacterial overgrowth

56
Q

treatment of SBS

A

goals: facilitate intestinal development and optimize growth and gevelopment
TPN
enteral feeds

57
Q

H2RAs and PPIs used in SBS

A

used to prevent ulcers

GI and liver (10 decks)

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