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Peds II Unit I > Peds GI > Flashcards

Peds GI Flashcards

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1
Q

Bloody vomitus is suggestive of…

A

Maternal ingestion, esophageal varicose, foreign body

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2
Q

Bilious vomitus is suggestive of…

A

Obstruction - Urgent Eval!

Meal rotation w or w/o volvulus

Congenital intestinal atresia

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3
Q

Patients with GER can be considered to be …

A

“Happy spitters”

No complications/consequences

Normal physiologic process

Declines with age (common in infants < 6 months)

Growing well, comfortable, healthy clinically

Requires no treatment other than pt ed and reassurance

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4
Q

Patients with GERD can be considered to be …

A

“Unhappy spitters”

Complications arise
• FTT, esophagitis, respiratory complications

Fussy or irritable, dystonic neck posturing, feeding refusal

Occult blood in stool - consider food intolerance

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5
Q

Diagnosis of GERD is usually…

A

Clinical

Hemoocult (checking for hidden blood in stool)

Endoscopy, upper GI if severe Sx

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6
Q

GERD symptoms usually resolve by…

A

9-12 months (mostly because patient is now sitting up to eat)

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7
Q

First line treatment for GERD

A 
Lifestyle modification
• Upright positioning 30 min after feeds (not semi-supine)
• Trial of hypoallergenic diet
• Do not overfeed
• Avoid tobacco smoke exposure
• Thickened feeds (1-2 tsp cereal/oz)

Medications hold a limited role due to risk vs benefit
• Consider in patient with refractory Sx
• Complicated disease (underlying condition)
• Short term PPI (omeprazole) vs H2 blocker (ranitidine)

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8
Q

Hypertrophy of the pylorus, which can progress to near-complete obstruction of gastric outlet

A

Infantile hypertrophic pyloric stenosis

Genetic predisposition and environmental factors (ie maternal smoking)

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9
Q

Predisposing factors for pyloric stenosis

A

Environmental factors (maternal smoking)

Associated with use of macrolide abx during first few weeks of life

M>F (4:1), classic first born male, family history (genetic factors)

2-4/1,000

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10
Q

Classic presentation of pyloric stenosis

A

3-6 week old infant with forceful vomiting

Nonbilious “projectile” emesis (b/c obstruction is before the biliary tree)
• Immediately after feeding (postprandial)
• “Hungry vomited” (vs. GER - “Happy vomiter”)
• FTT and dehydration may occur as the disease progresses

Phys exam: “Olive-like” mass in RUQ (indicates hypertrophy)

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11
Q

Test of choice for diagnosing pyloric stenosis

A

Ultrasound —> elongation and thickening of the pylorus

If ultrasound is non-diagnostic, do an Upper GI Barium contrast study —> string sign (narrowed lumen)

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12
Q

Definitive management of pyloric stenosis is via…

A

Surgery (pyloromyotomy)

IV fluid and electrolyte resuscitation important too

Prognosis is excellent

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13
Q

Absence or obstruction of one or more segments of bowel at birth

A

Congenital intestinal atresia

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14
Q

Congenital intestinal atresia can occur at any point in the GI tract but ________ is the most commonly affected site

A

Duodenum

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15
Q

Intestinal atresia is more common in patients with …

A

Cystic Fibrosis and Down Syndrome

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16
Q

When is congenital intestinal atresia usually diagnosed?

A

At birth at Sx onset

May also be Dx via prenatal U/S

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17
Q

Clinical presentation of congenital intestinal atresia depends upon…

A

Degree of obstruction (partial vs complete)

Vomiting (may be bile-stained) within first 48 hours of life

Abdominal distinction

Failure to pass meconium (+/-)

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18
Q

Double bubble sign on plain film xray is indicative of …

A

Congenital intestinal atresia

Due to gas and dilation in both stomach and duodenum

If jejunoileal/colonic atresia —> dilated loops of bowel with air fluid levels

Upper GI and contrast enema may be used for confirmation or to further identify obstruction

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19
Q

Management of congenital intestinal atresia consists of …

A

Feedings withheld (IV fluids, correct electrolytes)

Broad spectrum abx to prevent post op infection

Surgical intervention - approach depends on site

Prognosis very good

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20
Q

Abnormal positioning of the intestines is referred to as

A

Midgut malformation

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21
Q

Midgut malrotation increases the risk of …

A

Volvulus - small bowel twisting around SMA —> risk of small bowel ischemia

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22
Q

Classic clinical presentation of midgut malrotation

A

VOMITING - typically bilious (green or fluorescent yellow)

Abdominal pain

Hemodynamic instability

+/- hematochezia (sign of bowel ischemia)

PE: abdominal distention and tenderness

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23
Q

How do you work up a suspected midgut malrotation

A

1st do abdominal xray to r/o bowel perforation

Gold standard: Upper GI
• Displacement of the duodenum
• Duodenal obstruction
• “Corkscrew appearance” of the duodenum

Ultrasound with barium enema = useful adjunct to UGI but not best for confirming malrotation

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24
Q

What is the Ladd procedure?

A

Main purpose: to prevent ischemia and recurrent Sx in patients with midgut malrotation

Bowel is untwisted and repositioned in abdomen which creates adhesions to “hold” bowel in place

Prognosis: Resolution of Sx in approx. 90% post op with <1% recurrence

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25
Most common cause of abdominal emergency in kids <2 years
Intussusception (telescoping of the intestine) Typically in kids aged 6 months to 36 months, and it is the most common cause of obstruction in this age group
26
Clinical presentation of intussusception
Sudden, intermittent, severe, cramps abdominal pain Inconsolable crying, draws legs to chest Vomiting common Classic triad (only 15% will have ALL three) • Abdominal pain, abdominal mass, and “Currant jelly” stools • Current jelly: combo of blood and mucous • Palpable sausage-shaped mass (swollen bowel)
27
75% of cases of intussusception are...
Idiopathic Remaining cases may be caused by “lead point” - a lesion/variation in the intestine dragged by peristalsis into a distal segment
28
Conditions that increase risk of intussusception
Meckel’s diverticula (most common cause) Polyp Tumor Cyst Underlying conditions: Crohns, Celiac, CF, viral infections (ie Gastroenteritis) Rotashield vaccine (22x increased risk of intussusception)
29
Initial test of choice for the diagnosis of intussusception
Abdominal ultrasound —> “target sign” or “coiled spring” Hydrostatic/pneumatic enema is both diagnostic and therapeutic • Treatment of choice if no perforation, ~90% success rate • U/S or fluoroscopic guided If reduction unsuccessful, must intervene surgically
30
The most common pediatric surgical emergency
Appendicitis - obstruction of the appendices lumen leading to inflammation Peaks in the 2nd decade of life, rare before 5 years
31
Clinical presentation of appendicitis
Anorexia Migrating abdominal pain (periumbilical —> RLQ, with increasing pain with movement) Vomiting after onset of pain Fever Signs of peritoneal irritation (guarding, rebound tenderness, positive rousing, obturator, or ileopsoas signs)
32
Do we do imaging on patients with suspected appendicitis?
If classic presentation, may proceed with surgical consult prior to imaging If you DO proceed with imaging: • Ultrasound (no radiation) • CT scan (low dose CT if available)
33
Treatment of appendicitis
Surgical consult —> appendectomy is treatment of choice Pre-op management should include fluids, electrolytes, abx Some indication for Nonoperative Treatment (Abx) for early appendicitis Prognosis is excellent, especially if detected and treated early
34
What is the actual definition of diarrhea?
>3 loose watery stools/day (WHO)
35
What questions are important to include in the history when dealing with diarrhea?
``` Acute vs chronic Stool characteristics and frequency Associated SSx (nausea, vomiting) Dehydration Sick contacts/exposures (daycare) Pets/animals Med history Travel Diet ```
36
DDx for acute diarrhea (>3 loose, watery stools/day x 5 days or less)
Abx associated: Clostridium difficile Bacterial: Salmonella, Shigella, E.coli, campylobacter, yersinia Viral: ROTAVIRUS, Adenovirus, Calicivirus (Norovirus) Parasitic: Giardiasis lamblia, Entamoeba histolytica, cryptosporidium
37
Most common cause of gastroenteritis
VIRAL!!!!
38
Clinical manifestations of gastroenteritis
``` Diarrhea Vomiting Fever Anorexia Headache Abdominal cramps ```
39
What are the red flags when it comes to diarrhea?
``` Fever Severe abdominal pain Blood in stool Recent abx Persistent Sx Dehydration Leukocytosis Growth/development affected ```
40
Main causes of chronic diarrhea (>1 month)
Celiac Disease Allergy (ie milk, soy) Malabsorption (ie CF) Toddler’s diarrhea
41
Immune mediated inflammatory disease of the small intestine caused by gluten sensitivity
Celiac disease Dx: IgA antibodies to tissue trans glutamine seems (TTG), small bowel bx SSx: FTT, anemia, possible foul smelling stools Tx: gluten free diet
42
Most common food allergies in children
Milk and soy Microscopic blood and mucous in stools, gassy, fussy Tx: dietary elimination - hydrolyzed or free amino acid based formula (ie Nutramigen)
43
Are stool cultures recommended for most cases of diarrhea?
No Pursue further w/u if red flags —> CBC, CMP, celiac testing, urine Cx, stool testing, imaging
44
Treatment for acute diarrhea
HYDRATION always, abx sometimes, anti-motility agents rarely Keep an eye for signs of dehydration (consider PO vs IV hydration)
45
Should antibiotics be used routinely for well-appearing children with acute bloody diarrhea?
NO No recommended for routine use unless a specific pathogen has been isolated (Risk of HUS)
46
Peak incidence for IBD
15-30 years Increasing in kids
47
Smoking is associated with a 2x increased risk for _____________ but with a 50% decreased risk for ___________
2x increased for Crohns Disease | 50% decreased for Ulcerative Colitis
48
Clinical presentation of IBD
Diarrhea, abdominal pain +/- hematochezia Growth failure, delayed puberty Nutrient deficiencies Anemia Can also have extraintestinal manifestations (mouth, skin, joints, liver, eye) sometimes developing before GI Sx
49
Differences in the pattern of inflammation between Crohn Disease and Ulcerative Colitis
Crohn: “Skip lesions” - Terminal ileus, distal descending colon, and rectum UC: Continuous colonic involvement beginning in rectum
50
What is the clinical presentation of Crohn Disease?
Presentation variable Transmural inflammation - mouth to anus (can involve entire GI tract) Skip lesions Cobblestone appearance Perianal fissures, fistulas Dx: colonoscopy
51
What is the clinical presentation of ulcerative colitis?
Involvement of rectum and large colon • Mucosal layer only • Inflammation starts at rectum and extends proximally into colon • Bloody diarrhea common • Diffuse/continuous edema, erythema, friability, ulceration of colon
52
Which IBD condition holds an increased risk of colon cancer?
Ulcerative colitis
53
Crohn Disease vs Ulcerative Colitis
Location: Mouth to Anus for CD, Rectum and Colon for UC Ulceration Pattern: Skip lesions/cobblestoning for CD, Continuous for UC Depth of inflammation: Transmural inflammation for CD, mucosal layer only for UC Etiology: Genetic, autoimmune, environmental factors for BOTH
54
Goal of treatment for IBD
Clinical and laboratory remission with mucosal healing, not just symptomatic improvement Accelerated “step-up” therapy for most vs “Top-down” therapy for high risk patients - choice of treatment varies based on severity of disease
55
5 principle components of treating IBD
Medications Surgery Nutritional rehabilitation Behavioral health support Colorectal cancer screening for older patients Treatment involves a multidisciplinary effort
56
Medications for the treatment of IBD
Aminosalicylates: 5-ASA (Sulfasalazine, Mesalamine, etc) Immunomodulating agents (Mercaptopurine, Azathioprine, Methotrexate) or Biologics (Infliximad, Remicade etc) Steroids - primary therapy for acute flare but concern for bone density, growth and development +/- antibiotics Surgical intervention for refractory cases Monitor growth, nutrition, infection risk, psychological issues and cancer surveillance
57
Most common congenital anomaly of the GI tract
Meckel’s Diverticulum Vitelli next duct (embryonic remnant) leads to formation of diverticulum (congenital outpouching of small intestine) Pouch is usually made of intestinal and gastric epithelium - gastric acid produced and causes damage —> bleeding occurs from mucosal ulceration
58
What is the “Rule of 2’s” with regards to Meckel’s Diverticulum
2% of the population 2:1 M:F ratio 2% develop complication (usually before age 2) 2 feet from the ileocecal valve
59
Clinical presentation of Meckel’s Diverticulum
Painless rectal bleeding Obstruction (volvulus or intussusception) Diverticulitis (can mimic appendicitis)
60
Dx study for Meckel’s Diverticulum
Technetium-99 scan (aka Meckel’s Scan) - Nuclear medicine scan identifies ectopic gastric mucosa in diverticulum Management - surgical resection (excellent prognosis)
61
________ affects 30% of children and accounts for 3-5% of all visits to the pediatrician
Constipation - regular passage of firm or hard stools or infrequent passage of stool If impacted, encopresis can occur Etiology: frequently multifactorial (r/o anatomic or biochemical cause)
62
95% of cases of constipation are considered __________ while only 5% are considered ________.
95% Functional (Psychological or Psychosomatic, Dietary) ``` 5% Organic - the “Do Not Miss” causes • Anal stenosis • Hypothyroidism • Celiac Disease • Hirschprungs • Hypercalcemia • CF ```
63
Periods during which kids are most likely to develop constipation
Intro to solid foods or cow’s milk Toilet training Start of school (high prevalence age 5-6)
64
Leakage of retained stool
Encopresis
65
Dietary suggestions for avoiding constipation
Under 2 is 5g per day and if they are older than 2 it’s their age +5-10 grams so like a 4 year old would have a range of 9-14 g/day
66
Findings that suggest an organic cause of constipation
Failure to pass meconium FTT Abdominal distension or obstructive symptoms Lumbosacral problems, neurological abnormalities Anterior placed anus/other alterations Occult blood in stool
67
Clinical presentation of constipation
+/- fecal leakage Abdominal discomfort - generalized or LLQ If impacted, bowel sounds may be hypoactive Anal fissures
68
Red flags for constipation
Weight loss, poor weight gain/growth Anorexia, fever, hematochezia, vomiting History of delayed passing of meconium (CF) Acute onset Failure to respond to conservative measures
69
Management of constipation
Fluids Gradual increase in daily fiber intake (puréed veggies, fruits) Decrease dairy intake (cow’s milk < 16 oz/day) Juice - apple, prune, or pear (infants) If encopresis, relieve impact ion if present (Polyethylene glycol aka Miralax)
70
First line treatment for encopresis/constipation
Miralax (polyethylene glycol)
71
Condition characterized by absence of ganglion cells in mucosal and muscular layers of colon
Congenital Aganglionic Megacolon or Hirschprung Disease Spasm and abnormal motility —> colon fails to relax and may lead to obstruction M>F 3:1 80% present < 6 weeks of age Patients with Down syndrome at high risk
72
Classic presentation of Hirschprung Disease
Failure to pass meconium in first 48 hours of life Bilious vomiting Abdominal distention Late presentation less common - Newborn passes meconium but develops Sx later Older children may present with chronic constipation and FTT Later the Dx, less severe disease (usually a small segment of the colon affected)
73
Physical exam findings in Hirschprung disease
Abdominal distention Tight anal sphincter —> “Squirt Sign” (explosive release of gas/stool when finger removed - relieves obstruction temporarily)
74
Gold standard for diagnosis of Hirschprung disease
Rectal biopsy to confirm absence of ganglion cells Other Dx studies: • Contrast enema unprepared to localize “transition zone” • Change from narrowed aganglionic segment to the dilated proximal colon
75
Treatment for Hirschprung disease
Surgical resection of the aganglionic segment of the colon Overall good prognosis May have some abnormal bowel function (fecal incontinence, constipation) but most have excellent quality of life

Peds II Unit I (4 decks)

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