PEDS: Kids and Their Tummy Aches - Hoffman Flashcards Preview

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Flashcards in PEDS: Kids and Their Tummy Aches - Hoffman Deck (34):
1

Tummy Aches - associated symtpoms

  • weight loss
  • decreased appetitie
  • nausea
  • intestinal gas
  • diarrhea
  • cough
  • wheezing
  • horase voice

2

HEADSS mnemonic

Home

Education

Activities

Drugs

Sexuality

Suicide/Depression

3

Identify this condition and describe the management:

patient is a 6 year old male with a "tummy ache"

history reveals that all he eats are poptarts and milk and only stools once a week, he doesn't like going at school

he is otherwise normally active

CONSTIPATION

exam:

  • general exam
  • abdominal exam (may be able to palpate hard stool)
  • rectal exam - visualize external exam, anal wink, digital rectal exam
  • neuro exam - lower extremity reflexes, cremasteric reflexes, tip toe/heel walking

diagnostic studies:

  • flat plate of abdomen

tx/management:

  • adequate clean-out;
  • education, maintenance, behavioral and dietary components

Stool guiac test: infants and children with abdominal pain, FTT, diarrhea or FHX of colorectal cancer

4

Encopresis

lack of voluntary control over defecation

develops as a result of long-standing constipation with enlargement of rectal vault

sensation prompting the urge to defecate is lost

large fecal masses accumulate, allowing only liquid stoll to pass

5

Treatments for Functional Constipation

GOAL: one soft stool daily, no fecal incontinence

TX: reduce after 6 months of stability, slowly taper dose

Dietary Changes

  • increase fiber and fluids

Bowl Evacuation

  • manual disimpaction
  • enema
  • laxatives
  • cathartics
  • infants: glycerin suppositories

Stool Softeners

  • smaller, more frequent stooling

Behavioral Modification

  • establish stooling routine soon after meals
  • praise successful elimination of stool

6

GERD Manifestations in Infants

  • fussiness
  • arching
  • feeding refusal or some feed more frequently
  • congestion
  • wheezing

7

GERD Manifestations in Preschool

  • on/off abdominal pain
  • decreased food intake
  • discomfort after eating
  • cough
  • wheezing

8

GERD Manifestations in Older Children Adolescents

  • burning epigastric pain
  • regurgitation
  • chest pressure
  • early satiety
  • nausea
  • bad taste in mouth (especially in AM)

9

Identify this condition and describe the management:

 

pt is a 16 year old female

she reports stomach pain usually after dinner and it wakes her up at night

she also notes that this gets worse before her AP history exams

GERD

other clinical manifestations

  • can be triggered by viral illness
  • can have dysphagia/odynophagia
  • hoarseness and stridor can occur

possible testing based on symptoms and severity

  • endoscopy
  • esophageal pH monitoring

treatment: acid supression medication

  • Ranitidine
  • Omeprazole
  • Lansoprazole
  • treat aggresively
  • trial 2 weeks, if it works 1-6 months

10

Suggested Approach for Common Clinical Scenarios:

Recurrent Vomiting or Regurgitation (older than 18 months)

  • upper GI series
  • upper endoscopy
  • acid supression trial

11

Suggested Approach for Common Clinical Scenarios:

Heartburn

  • treat empirically and do lifestyle changes
  • persistnent or recurrent symptoms should prompt referral endoscopy with biopsy

12

Suggested Approach for Common Clinical Scenarios:

Dysphagia or Odynophagia

  • barium esophagram - looking for anatomic abnormailities
  • NO empiric treatment
  • upper endoscopy is necessary

13

Suggested Approach for Common Clinical Scenarios:

Recurrent Pnemonia

  • insufficient research - trial empiric treatment
  • video fluoroscopy?

14

Identify this condition and describe the management:

patient is a 8 year old, he complains of umbilical pain that has been going on for over a year

he has soft stools each day

he just is bullied at school, but otherwise enjoys his classes

Irritable Bowel Syndrome/Functional Abdominal Pain

nonorganic abdominal pain, associated with stress

often diagnosed by GI specialists after organic causes are ruled out

can be a cry for help - consider abuse

TX:

  • Eliminate Secondary Gain
  • Treat underlying negative stress
  • Relaxation techniques

15

Abdominal Alarm Findings

  • involuntary weight loss
  • deceleration of linear growth
  • GI blood loss
  • significant vomiting
  • chronic severe diarrhea
  • persistent RUQ or RLQ pain or tenderness
  • unexplained fever
  • family history of IBD
  • localized fullness or mass effect
  • Hepatomegaly or Splenomegaly
  • Costovertebral angle tenderness
  • Tenderness over the spine
  • Perianal abnormalities
  • Abnormal or unexplained physical findings

16

Diarrhea

Signs of Volume Depletion

  • thirst
  • tachycardia
  • lethargy
  • orthostasis
  • oliguria
  • tachypnea
  • dry mucous membranes
  • weight loss
  • decreased tear production
  • decreased skin turgor

17

Diarrhea

Etiologic Risk Factors

  • recent travel to an underdeveloped area
  • other family members affected
  • daycare attendance or employment
  • pets in home (turtles, snakes)
  • visiting farm or petting zoo
  • recent or regular medications
  • occupation as food handler or caregiver
  • sexual contact
  • underlying medical conditions

18

Diarrhea 

Diagnostic Studies & Microscopic Exam

Diagnostic Studies
  • gross or occult blood
  • undigested vegetable matter
  • mucus present
  • color

Microscopic Exam

  • Leukocytes - bacterial or inflammation
  • Lymphocytes - inflammatory
  • Eosinophils - food sensitivities
  • Fat - malabsorption or pancreatic enzyme insufficiency
  • O&P - ova and parasites

Labs:

  • CBC, BMP, BUN, creatinine, and UA
  • stool studies
  • rapid rotovirus test

19

Identify this condition and describe the management:

patient is a 1 year old reporting on Friday Jan. 30

he vomited on Monday and has had a temp of 99 and watery, foul-smelling diarrhea, no blood is present

Acute Diarrhea: Viral Gastroenteritis

Rotovirus is most common

  • peaks in winter
  • can live outside body longer

Norwalk Virus (norovirus)

Adenovirus

fecal-oral route

self limited; tx administer oral rehydration solution

20

Identify this condition and describe the management:

patient was on a camping trip last weekend

he reports abdominal pain, increased flatulence, and diarrhea

stool analysis reveals cysts

Acute Diarrhea: Parasitic Gastroenteritis

Giardia Lamblia

fecal-oral transmission

other symptoms: malabsorption, failure to thrive

at risk groups: IgA deficient, CF patients

tx: Flurazolidone, Metronidazole

21

Identify this condition and describe the management:

patient has loose, bloody, mucoid stools

abdominal exam revealed hepatic abscess

Acute Diarrhea: Infectious Gastroenteritis

Entamoeba Histolytica

diagnosed via: stool examination and immunoassays

tx: Furazolidone, Albendazole, Metronidazole

22

Acute Diarrhea: Infectious Gastroenteritis

Cryptosporidum

frequent, watery stools

common in day cares

self-limited in healthy kids

can become chronic in the immunocompromised

no effective therapy

23

Acute Diarrhea: Infectious Gastroenteritis

Isospora Belli

protozoan infection cuasing diarrhea in AIDS patients

treated with TMP-SMZ

24

Identify this condition and describe the management:

patient ate a cream-filled donut that was leftover from yesterday for breakfast

at lunch time patient reports: nausea, vomiting, abdominal cramping

Acute Diarrhea: Infectious Gastroenteritis

Staphylococcus Aureus

symptoms resolve spontaneously within 24 hours

25

Identify this condition and describe the management:

patient went out to the new sketchy sushi resturant for two nights ago

she now complains of nausea, vomiting and diarrhea

she is worried becuase her vision has been blurry lately

Acute Diarrhea: Infectious Gastroenteritis

Clostridium Botulinum

other CNS symptoms: dry mouth, dysphagia, blurry vision, paralysis of respiratory muscles

tx: specific antitoxin, ventilatory sport

26

Identify this condition and describe the management:

patient is a 5 month old

mom gave baby some honey and now the baby has not been stooling, has a weak sucking reflex and weak cry

Acute Diarrhea: Infectious Gastroenteritis

Infantile Botulism

Floppy Baby Syndrome

  • hypnatremia
  • pooled oral secretions
  • cranial nerve deficits
  • generalized weakness
  • apnea

 

27

Identify this condition and describe the management:

patient is a 10 year old has a headache, nausea, abdominal pain, water diarrhea

patient just got a pet turtle 

Acute Diarrhea: Infectious Gastroenteritis

Salmonella

  • enterocyte invasion into small bowel, can also cause bacteremia
  • can have an asymptomatic carrier state
  • fecal-oral transmission
  • sources: reptiles, eggs, poultry, meat
  • infants: fever, vomiting, diarrhea
  • older kids: HA, nausea, abdominal pain
  • stools: watery, may have mucus & blood
  • diarrhea - subsides 4-5 days
  • WBC: PMN leukocytosis
  • TX: uncomplicated - no antibiotics
  • TX: Azithromycin, Ciprofloxacin or SMZ-TMP if < 3 months, immunocompromised, hemaglobinopathies

28

E. Coli 0157:H7

  • hemorrhagic colitis
  • self-limited
  • source: undercooked beef and fruit juices
  • toxin can cuase HUS
  • no antibiotics

29

Identify this condition and describe the management:

patient is a 4 year old

patient complains of diarrhea and a tummy ache, he recently started taking clindamycin

 

Acute Diarrhea: Infectious Gastroenteritis

C. Difficile

need to order C. Difficile specific culture

tx: stop antibiotic

30

To Treat or Not to Treat . . .

that is the question

Salmonella

Shigella

E. Coli

E. Coli 0157:h7

Campylobacter

C. Difficile

Salmonella: no treatment, S. Typhi (typhoid fever), sepsis, bactermia

Shigella: 3rd generation cephalosporin

E. Coli: only in infants < 3 months

E. Coli 0157:h7: do not treat

Campylobacter: macrolide within first 5 days

C. Difficile: if severe treat with metronidazole or vancomycin

31

Identify this condition and describe the management:

patient is 18 months

patient is well-nourished, and at the 75% percentiles of height, weight and head circumfrence

patient has had increased watery BM's for the past 2 months

Chronic non-specific diarrhea (Toddler’s Diarrhea)

ages: 6-24 months

can be caused by excessive fruit juice intake 

stool contains particles of undigested food

typically resolves by age 2-4 or by changing beverages

32

Identify this condition and describe the management:

patient is 2 months

patient is failing to thrive

patient has had diarrhea for a month, stools have no O/P and cultures are negative

Protracted Diarrhea of Infancy

  • significant malabsorption can occur
  • tx: administering elemental formulas, providing parental nutrition if necessary

33

Short Bowel Syndrome

  • resection of significant protions of intestine (congenital anomalies of GI tract, infalammatory or ischemic disorders)
  • malabsorption
  • diarrhea
  • growth failure
  • remaining bowel eventually adapts to maintain adequate absorption

34

Management of Diarrhea

ORAL REHYDRATION

  • oral or IV
  • fluid should have appropriate concentrations of glucose and electrolytes (Pedialyte)
  • contraindicated
    • severe dehydration
    • hemodynamic instability
    • stool output
    • ileus

REFEEDING

  • after hydration is normalized
  • re-introduction of food
    • stimulation of intestinal enzymes
    • increased mucosal cell growth
  • advance diet as tolerated