Toddler GI: Abdominal Pain, Diarrhea/Gastroenteritis, Constipation Flashcards Preview

Pediatric Primary Care Exam 4 > Toddler GI: Abdominal Pain, Diarrhea/Gastroenteritis, Constipation > Flashcards

Flashcards in Toddler GI: Abdominal Pain, Diarrhea/Gastroenteritis, Constipation Deck (42):
1

Abdominal Pain Overview (8)

1. In a toddler and preschooler, there is a higher rate of pathology
-Younger the child, the more you want to worry
-The more the pain is out from the umbilicus, the more you want to worry

2. Complete history and physical is key

3. Evaluate for constipation - constipation is the #1 cause of abdominal pain

4. Get a history of stooling pattern from birth

5. Common to see this complaint as the child goes from formula to whole milk due to Casein

6. Preschoolers may have abdominal pain if they are stressed

7. Gastroenteritis can lead to abdominal pain

8. Appendicitis (while uncommon) should always be on your differential

2

Alarming Features of Abdominal Pain (14)

1. GI Blood loss
2. Perirectal disease
3. Dysphagia
4. Involuntary weight loss
5. Persistent vomiting
6. Deceleration of linear growth
7. Delayed puberty
8. Acholic stools (White or pale yellow)
9. Unexplained fever
10. Persistent right upper or lower quadrant pain
11. Pain that wakes the child from sleep
12. Nocturnal diarrhea
13. Arthritis
14. Family history of inflammatory bowel disease, celiac disease, or peptic ulcer disease

3

History Red Flags w/ Abdominal Pain (10)

1. Pain characteristics: Focal, nocturnal, severity, duration

Associated characteristic
2. Wetting when potty trained
3. Constipation
4. Prior abdominal problems
5. Not a high achiever
6. Menarche and sexual activity
7. Weight loss/abnormal growth
8. Fever
9. History of rectal bleeding

10. Family History: GERD, ulcer, IBD

4

Diagnostic Criteria for Childhood Functional Abdominal Pain (3)

Must include all of the following criteria at least once a week for at least two months prior to diagnosis

1. Continuous or episodic abdominal pain
2. Insufficient criteria for other functional GI disorders
3. No evidence of an inflammatory anatomic, metabolic, or neoplastic process that explains the subject’s symptoms

5

Function Abdominal Pain and Separation Anxiety: Risk Factors (10)

1. Genetics: Family history of anxiety or depression

2. Child temperament: Behavioral inhibition, Socioeconomic/cultural

3. Limited exposure to non-family caregivers

4. Limited participation in activities outside the family

Situation
5. Family move
6. Parent separation
7. Divorce
8. Death of family members
9. New school

10. Parental Behavior: Overprotection

6

Abdominal Pain: Work Up (4)

More recently, there is a push to do less testing and more assurance

Diagnostic testing to consider
1. CBC with diff
2. Sed Rate
3. C reactive protein
4. Urinanalysis

7

Osmotic Diarrhea (5)

1. Caused by failure to absorb luminal solutes with resulting secretion of fluids and net water retention across osmotic gradient

2. Volume <200cc

3. Fasting will result in resolution of the diarrhea

4. Lower stool sodium and chlorides

5. Osmolality greater this serum osmolality indicates osmotic diarrhea

8

Secondary Diarrhea (5)

1. Net secretion of electrolytes and fluids from intestine without compensatory absorption

2. Increased volume of stool

3. Fasting does not effect the diarrhea

4. Higher stool sodium and chloride

5. Stool osmolality Na+ K multiplied by 2

9

Dysmotility

Occurs in a setting of intact absorption but transit time is changed and time allowed for absorption is minimized
*Example short gut syndrome and small intestinal bacterial overgrowth (SIBO)

10

Inflammation

Malabsorption of dietary nutrients which cause luminal osmotic gradient
*Ex: inflammatory bowel disease

11

Chronic Diarrhea (4)

1. Lasting greater than 14 days

2. Due to nutrient malabsorption and/or excessive fluid intake of juices or fructose containing drinks

3. Use of probiotics is becoming increasing popular
*Proviotic is a great product

4. Should maintain the proper diet even after diarrhea is done

12

Viral Pathogens that can lead to gasteroenteritis (6)

1. Rotaviruses

2. Noroviruses
*School-age virus
*Notorious for school outbreaks

3. Enteric adenoviruses
*Prolonged virus

4. Caliciviruses

5. Astroviruses

6. Enteroviruses
*Includes coxsackie

13

Bacterial Pathogens that can lead to gasteroenteritis (8)

1. Campylobacter jejuni

2. Nontyphoid salmonella
*Mucopus will show up
*Ask if they ate something that could have salmonella

3. Enteropathogenic Escherichia coli
*Found in intestines of cows
*When you buy non-kosher meat you will find intestine in the beef; Inside intestines are E.coli

4. Shigella

5. Yersinia enterocolitica

6. Shiga toxin producing E. Coli

7. Salmonella typhi and S. paratyphi

8. Vibrio cholerae
*Not as common in US

14

Protozoa Pathogens that can lead to gasteroenteritis (3)

1. Cyyptosporidium
2. Giardia Lamblia
3. Entamoeba histolytica

15

Helminths Pathogens that can lead to gasteroenteritis (3)

1. Round worms
2. Hookworms
3. Whipworms

16

Acute Gastroenteritis Management (8)

1. One principle: If the gut works, use it.

Oral rehydration pearls
2. Parents love juice! Educate not to give it
3. If a patient is not vomiting use the white diet, not BRAT
4. If vomiting, sips only of clear liquid preferable a rehydration solution
5. If diarrhea, WHITE diet NOT BRAT

6. Need protein to repair the gut which is why you don’t recommend BRAT

7. Juice is worst thing to give child with diarrhea

8. Stick to white foods, bananas, apple sauce, egg whites

17

How do you treat a 3 year old who is having diarrhea only?

Stick to white foods bananas, apple sauce, egg whites

Liquids (not juice) want them to stay hydrated

18

What do you use for a 4 year old with diarrhea and vomiting? (3)

1. Rehydration solution (pedilayte) → 5cc every 4 to 5 minutes for the first hour then go up slowly

2. If this isn’t being tolerated then they should get IV bolus
*20mL/kg at bolus level and up to 1L (Normal Saline)

3. 4:2:1 maintenance (echo this)
Hourly rate of maintenance
1st hour → 4cc/hr/kg = 4cc
2nd hour → 10-20cc – 2cc/hr/kg = 20cc
3rd hour → 20-50cc – 1cc/hr/kg = 30cc

19

Diagnosing Dehydration Clinically (

First thing you look at is physical assessment: HEAR RATE
*First thing that goes up in dehydration is HR (apical rate)

Lab data does in severe dehydration isn’t to make diagnosis but to see how acidotic the patient is
*Use NS not LR

20

How do treat a child who is vomiting and will not hold down pedialyte?

Pedialyte ice pops!

21

Ondansetron (Zofran)

5-ht3 antagonist: work by blocking action of serotonin (which causes the nausea and vomiting.
*Blocks serotonin because serotonin causes you to vomit

22

Ondansentron Side Effects (5)

1. Diarrhea or constipation;

2. Weakness or tired feeling;

3. Fever;

4. Headache, dizziness, drowsiness

5. Can cause prolonged QT and lead to torsades de points which can lead to death, particularly in higher does
*Be very cautious if child is on another drug that causes prolonged QT (ex: azithromax)
*More serious side effects of prolongation of the QT interval especially at higher dosage

23

Ondansentron Dosing (2)

1. An IV dose of 0.15 mg/kg administered every 4 hours for three dose to a maximum of 16 mg
*Never give more than 16mg IV

2. Available as 4 mg and 8 mg tablets, 4 mg and 8 mg orally disintegrating tablets, and oral solution (4 mg/5 mL). Also, available as an injection for intravenous use (2 mg/mL)

24

Functional Constipation (4)

1. Difficulty or delay in defecation present for 2 or more weeks

2. Hard dry stool

3. No pathology

4. Tell children feet have to be on the floor to poop

25

Constipation Pathology (5)

1. Hirschsprungs Disease
2. Delayed meconium stool
3. Hypothyroidism
4. Imperforate anus
5. Infant botulism

26

NASPGHN Guidelines for Constipation (2)

1. A thorough history and physical examination are an important part of the complete evaluation of the infant or child with constipation
*This includes a rectal exam
*The only reason for not doing a rectal exam is not having a finger

2. Performing a thorough history and physical examination is sufficient to diagnose functional constipation in most cases.

27

Constipation: History (9)

1. Caregiver definition
2. Frequency/consistency of stools
3. Pain/bleeding/fecal soiling
4. Abdominal pain
5. Change in stooling pattern over time
6. Age at onset
7. Toilet training history
8. Wt. loss, nausea, vomiting, change in appetite
9. Medications

28

Normal BMs per week depending on age (4)

1. 0-3 months
Breastfed: 5-40
Formula fed: 5-28

2. 6-12 months: 5-28

3. 1-3 years: 4-21

4. More than 3 years: 3-14

29

Constipation: PE (8)

1. Abdominal

Perineal/perianal (look at anus!!)
2. Fissues, abscesses, dermatitis
3. Digital exam
*Sphincter tone/anal wink
*Want to make sure external sphincter works
4. Stool for occult blood

Neurological
5. Decreased LE tone
6. Dimpling/Hair tuft at lower spine
*Make sure there is none at base of spine
7. Megacolon/Hirschsprung’s
8. Look for good reflexes

30

Physical Finding that distinguish organic constipation from Function Constipation (13)

1. Failure to thrive

2. Abdominal distention

3. Pilonidal dimple covered by tuft of hair

4. Sacral agenesis

5. Flat buttocks

6. Anterior displaced anus

7. Absent and decreased deep tendon reflexes

8. Patulous anus

9. Tight, empty rectum in presence of palpable abdominal fecal mass

10. Gush of liquid stool and air from rectum on withdrawal of finger

11. Absent anal wink

12. Absent cremasteric reflex

13. Decreased lower extremity tone

31

Constipation Diagnostics (4)

1. A stool test for occult blood is recommended in all constipated infants and in those children who also have abdominal pain, failure to thrive, diarrhea, or a family history of colon cancer or polyps.

2. In selected patients, an abdominal radiograph, when interpreted correctly, can be useful to diagnose fecal impaction.
*Done very infrequently due to high radiation

3. Rectal biopsy with histopathological examination and rectal manometry are the only tests that can reliably exclude Hirschsprung disease.

4. In selected patients, measurement of transit time using radiopaque markers can determine whether constipation in present.
*Ex: corn test

32

Nonorganic Developmental Differential Dx for Constipation (9)

1. Cognitive handicaps
2. Attention-deficit disorders
3. Situational
4. Coercive toilet training
5. Toilet phobia
6. School bathroom avoidance
7. Excessive parental interventions
8. Sexual abuse
9. Other Depression

33

Neuropathic Conditions Differential Dx for Constipation (5)

1. Spinal cord abnormalities
2. Spinal cord trauma
3. Neurofibromatosis
4. Static encephalopathy
5. Tethered cord

34

Drug Differential Dx for Constipation (10)

1. Opiates
2. Phenobarbital
3. Sucralfate
4. Antacids
5. Antihypertensives
6. Anticholinergics
7. Antidepressants
8. Sympathomimetics
9. Other Heavy-metal ingestion (lead)
10. Vitamin D intoxification l

35

Intestinal nerve or muscle disorders Differential Dx for Constipation (7)

1. Hirschsprung disease
2. Intestinal neuronal dysplasia
3. Visceral myopathies
4. Visceral neuropathies
5. Abnormal abdominal musculature
6. Prune belly
7. Gastroschisis

36

Other Differential Dx for Constipation (3)

1. Botulism
2. Cow's milk protein intolerance
3. Down syndrome

37

Connective Tissue disorders differential dx for constipation (3)

1. Scleroderma
2. Systemic Lupus erythematosus
3. Ehlers Danlos syndrome

38

Organic disorders differential dx for constipation (4)

1. Anatomic malformations
2. Imperforate anus
3. Anal stenosis
4. Anterior displaced anus (96) Pelvic mass

39

Metabolic and gastrointestinal differential dx for constipation (7)

1. Hypothyroidism
*T4 and TSH if delayed height growth
2. Hypercalcemia
3. Hypokalemia
4. Cystic fibrosis l sacral teratoma)
5. Diabetes mellitus
6. Multiple endocrine neoplasia type 2B
7. Gluten enteropathy

40

Constitutional disorders differential dx for constipation (5)

1. Colonic inertia
2. Genetic predisposition
3. Reduced stool volume and dryness
4. Low fiber in diet Dehydration
5. Underfeeding or malnutrition

41

Constipation Management in Younger Children (5)

1. In infants, rectal disimpaction can be achieved with glycerin suppositories. Enemas are to be avoided.
*Glycerine product is the best option

2. In infants, juices that contain sorbitol, such as prune, pear, and apple juices can decrease constipation.

3. Barley malt extract, corn syrup, lactulose, or sorbitol (osmotic laxatives) can be used as stool soseners.
*Can be found in things like gummy bears

4. Mineral oil and stimulant laxatives are not recommended for infants.
*Can aspirate on it
*If you use it, must shake it into something and then drink that
*Helps with passage

5. Dietary changes

42

Constipation Management Recommendations for Children (8)

1. Disimpaction can be achieved with either oral or rectal medication, including enemas.

2. In children, a balanced diet, containing whole grains, fruits, and vegetables, is recommended as part of the treatment for constipation.

3. The use of medications in combination with behavioral management can decrease the time to remission in children with functional constipation.

4. Mineral oil (a lubricant) and magnesium hydroxide, lactulose, and sorbitol (osmotic laxatives) are safe and effective medications.

5. Rescue therapy with short-term administration of stimulant laxatives can be useful in selected patients

6. Senna and bisacodyl (stimulant laxatives) can be useful in selected patients who are more difficult to treat

7. Polyethylene glycol electrolyte solution, given in low dosage, may be an effective long-term treatment for constipation that is difficult to manage.

8. Biofeedback therapy can be an effective short-term treatment of intractable constipation.
*Behavioral management → put them on the toilet after they eat