PEDS: Kids and Their Tummy Aches - Hoffman Flashcards Preview

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Tummy Aches - associated symtpoms

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


HEADSS mnemonic








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



  • 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


  • 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



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


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


GERD Manifestations in Infants

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


GERD Manifestations in Preschool

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


GERD Manifestations in Older Children Adolescents

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


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


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


Suggested Approach for Common Clinical Scenarios:

Recurrent Vomiting or Regurgitation (older than 18 months)

  • upper GI series
  • upper endoscopy
  • acid supression trial


Suggested Approach for Common Clinical Scenarios:


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


Suggested Approach for Common Clinical Scenarios:

Dysphagia or Odynophagia

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


Suggested Approach for Common Clinical Scenarios:

Recurrent Pnemonia

  • insufficient research - trial empiric treatment
  • video fluoroscopy?


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


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


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



Signs of Volume Depletion

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



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



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


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


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)


fecal-oral route

self limited; tx administer oral rehydration solution


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


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


Acute Diarrhea: Infectious Gastroenteritis


frequent, watery stools

common in day cares

self-limited in healthy kids

can become chronic in the immunocompromised

no effective therapy


Acute Diarrhea: Infectious Gastroenteritis

Isospora Belli

protozoan infection cuasing diarrhea in AIDS patients

treated with TMP-SMZ


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


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


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



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


  • 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


E. Coli 0157:H7

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


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


To Treat or Not to Treat . . .

that is the question



E. Coli

E. Coli 0157:h7


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