E2: peds - GI

benign self-limiting recurrent or prolonged periods of crying and irritability that occur > 3 hrs/day for > 3 days/wk and persists > 3 wks in an otherwise healthy infant

colic → resolves by 3 months of age

treatment for colic?

1st line → reassurance

dietary changes

simethicone and dicyclomine

tummy massage

5 S's → swaddle, side/stomach, swinging, shhh, sucking

what are non-organic causes of generalized abd pain?

functional pain

what are organic causes of generalized abd pain?

PUD, gastritis, dyspepsia, pancreatitis, IBD, IBS, choledocholithiasis

what is the difference btw visceral and somatic/parietal abdominal pain?

visceral = poorly localized; dull and crampy

parietal = localized to involved viscera; steady and sharp

what is the MCC of acute abd pain?

acute gastroenteritis

sudden onset = obstruction, perforation, ischemia or torsion

what are causes of acute abdominal pain in < 2 y/o?

trauma, incarcerated hernias, intestinal malrotation, volvulus, Hirschsprung's

what are causes of acute abd pain in 2-5 y/o

sickle cell anemia, lower left PNA, UTI, intussusception

inflammation of the appendix secondary to appendicolith or fecalith causing features of:

- periumbilical pain w migration to RLQ

- +tenderness, guarding

- rebound tenderness, +Rovsings

appendicitis

treatment for appendicitis?

IV ABX, analgesics

surgery

what are complications of appendicitis?

abscess

perforation

peritonitis

sepsis

adhesions, intestinal obstruction

ileus

what condition has features:

- small intestine invaginate into another section of the small bowel and telescopes

- occurs age 2m-2y

- pain develops suddenly, intermittent, severe and is accompanied by inconsolable crying w drawing of legs toward abdomen

- early sx → N/V. (bile/green color)

- late sx → rectal bleeding (currant jelly stool)

intussusception → will feel sausage shaped mass in upper mid abdomen

target or doughnut sign seen on ultrasound

intussusception

treatment for intussusception?

air contrast enema (dx and tx)

incomplete rotation of the intestine during embryogenesis (normally duodenojejunal junction) typically caused by external compression from Ladds bands

volvulus with intestinal malrotation

which condition has features:

- sudden onset bilious vomiting

- severe abdominal pain

- abdominal distention

- left threatening emergency

volvulus with intestinal malrotation

corkscrew appearance and "double bubble" sign on abdominal x-ray

volvulus with intestinal malrotation

what is the diagnostic test for volvulus with intestinal malrotation?

upper GI w SBFT

treatment for volvulus with intestinal malrotation?

STAT surgery → Ladds procedure

what are causes of chronic abdominal pain?

IBS, lactose intolerance, inorganic causes (stressors, new school, exams, family death)

what criteria is diagnostic for chronic abdominal pain?

3+ episodes of pain over a 3-month period severe enough to affect activities

what condition has features:

- recurrent episodes of acute incapacitating, periumbilical pain

- will have sx free periods (wks to months)

- anorexia

- N/V

abdominal migraine → remove triggers to tx

which condition has features:

- recurrent abdominal pain without an organic cause

- MC type of abd pain in children

- loss of daily activity

- 1x/wk for at least 2 months and occurs over weeks to months

- pain usually lasts < 1hr and resolves spontaneously

- can be assoc w anxiety/depression

functional abdominal pain

treatment for functional abd pain?

reassurance

supportive → distraction, counseling

pharm → cyproheptadine

anxiety → SSRI

what condition has features:

- abd pain and altered bowel habits in the absence of alarm sxs

- 1x per week over course of 2 months

- no organic causes identified

IBS

treatment for IBS?

dietary changes

TCA/SSRI

pain in the upper abdomen; no signs of gastritis on endoscopy

dyspepsia

passage of gastric contents into the esophagus (postprandial); peaks at 4 months of age, disappears by age 1

GER

what are esophagitis features of GER?

colic, hiccups, irritability

what are respiratory features of GER?

wheezing, coughing, recurrent PNA, aspiration, apnea, laryngospasm

what are behavioral features of GER?

dystonic posturing, Sandifer syndrome

what are severe sxs of GER?

failure to thrive

mod-sev esophagitis

hematemesis

melena

GOLD STANDARD diagnostic test for GER?

esophageal pH probe

treatment for GER?

no sxs = monitor

mild = PPI or H2 blockers x 2 wks

mod = PPI for 3-6 mos

severe = Nissen fundoplication

what condition has features:

- tenderness/guarding

- tachycardia, loss of skin turgor, dry mucous membranes

- loss of dental enamel

- papilledema

- high pitched bowel sounds (obstruction) or absent bowel sounds (ileus)

vomiting

idiopathic, early AM awakening generalized abdominal pain and non bilious emesis that lasts hours followed by symptom-free periods; attacks can last 24-48 hrs up to a week; typically occurs in school-aged children

cynic vomiting syndrome

- ↑ risk in pts w h/o migraines

cyclic vomiting syndrome treatment?

zofran

prophylaxis = cyproheptadine (<5) and amitriptyline (>5)

narrowing of the pyloric channels due to hypertrophy of the pyloric muscle causing features of:

- post-prandial projectile, non bilious emesis

- persistent hunger

- constipation

- dehydration

- firm palpable "olive-shaped" mass

pyloric stenosis

what is seen on labs of pyloric stenosis?

hypokalemia

hypochloremic

metabolic alkalosis

diagnostic test for pyloric stenosis?

U/S (preferred)

abd x-ray

UGI w SBFT

treatment for pyloric stenosis?

fluid resuscitation

definitive = pyloromyotomy

what condition has features:

- bleeding that occurs proximal to the ligament of Treitz

- presents with melena or hematemesis

- HR > 20 bpm above avg

- prolonged cap refill

- drop in Hgb > 2; Hgb level < 8

- iron deficiency anemia

- guaiac positive stools on exam

upper GI bleed

causes of PUD?

NSAIDs

H. pylori

binge drinking (adolescents)

what condition has features:

- bleeding distal to the ligament of Treitz

- presents with hematochezia

- causes → polyps, anal fissure, IBD, infectious colitis, hemorrhoids

lower GI bleed

benign juvenile polyps

Hamartomas

what condition has features & what is the tx:

- occurs ages 2-10

- painless rectal bleeding, some may have mild lower abdominal pain

juvenile polyps → colonscopy w polypectomy

presence of multiple colorectal ademonas (typically > 100) due to autosomal dominant or de novo APC gene mutation and has a 100% risk of colon cancer

familial adenomatous polyposis (FAP)

what condition has features:

- multiple colorectal ademonas

- epidermoid cysts, lipomas

- supernumerary teeth

- osteomas

- APC gene mutation

- 100% of colon cancer

Gardner syndrome

autosomal dominant condition of hamartomatous polyps and mucocutaneous pigmentation located on the lips, perioral and gums

Peutz Jegher's syndrome

autosomal dominant condition of multiple hamartomatous polyps of the GI tract due to PTEN, SMAD4 or BMPR1 gene mutations

juvenile polyposis syndrome → ↑ risk for colorectal and gastric cancer, screen every 1-3 yrs

which condition has features:

- intermittent painless rectal bleeding (maroon/hematochezia)

- under the age of 2, located 2 feet from ileocecal valve

- caused by outpouching in the lower intestines (from left over umbilical cord)

- common cause of bleeding in 50% of children

Meckel's diverticulum

diagnostic test for Meckel's diverticulum?

Meckel's scan aka nuclear scintigraphy

treatment for Merkel's diverticulum?

laparoscopic Meckel's diverticulectomy

which disease has features:

- abd pain

- weight loss

- chronic diarrhea

- bloody stools

- tenesmus

- growth failure or delayed pubertal development

IBD

what are extraintestinal manifestations of IBD?

osteoarthropathy or clubbing of digits

derm → erythema nodosum, erythema multiforme, pyoderma gangrenosum

arthritis

ankylosing spondylitis

sacroiliitis

aphthous ulcers

transmural inflammation of the GI tract from mouth to anus with "skip lesions" intervening normal bowel and characterized by areas of inflammation, strictures and fistulas that may wax and wane in severity

Crohn's

which condition has features:

- growth failure/weight loss

- elevated ESR and short stature

- pubertal delay

- perianal disease → skin tags, fissures, fistulae

- extraintestinal manifestations common

Crohn's

fistula btw bowel and bladder

enterovesicular

fistula btw bowel and skin

enterocutaneous

fistula btw bowel and genitalia

enterogenital

hallmark lesions are non-caseating granulomas

thumbrinting, string sign, cobble stoning

Crohn's disease

treatment for Crohn's disease?

corticosteroids

relapsing and remitting episodes of inflammation limited to mucosal layer of the colon (spares the upper GI tract)

ulcerative colitis

what condition has features:

- blood diarrhea, tenesmus, urgency, frequency

- nocturnal stools

- extraintestinal sxs

- hypoalbuminemia

- can result in toxic megacolon

ulcerative colitis

friability, erythema, erosions, ulcerations, bleeding crypt, abscesses, crypt branching seen on colonscopy

UC

treatment for UC?

1st line = 5-ASA

mod = gulcocorticoids

refractory = surgery

others = biologics, thiopurines, ABX

inflammatory disorder of the esophagus due to eosinophilic infiltration causing features of:

- dysphagia

- vomiting

- feeding refusal

- heartburn, chest pain

- abd pain

eosinophilic esophagitis

endoscopy shows linear furrowing of the esophagus, esophageal ring formation and granularity

eosinophilic esophagitis

treatment for eosinophilic esophagitis?

diet modification

corticosteroids

congenital disorder that causes the esophagus to not connect to the stomach resulting in a blind ended pouch, assoc w tracheoesophageal fistula and causes features:

- excessive drooling

- coughing, sneezing

- choking, cyanosis

esophageal atresia

treatment for esophageal atresia?

replogle or NGT

TPN

broad spec ABX

definitive = surgery

what is the MCC of esophageal trauma?

household cleaners

do alkaline or acidic agents cause more esophageal trauma?

alkaline → deep liquefaction necrosis though all layers

should you induce vomiting or administer water/milk if a child has caustically ingested objects resulting in esophageal trauma?

NO!!

what are features of esophageal trauma due to caustic ingestion?

salvation, refusal to drink

N/V

epigastric pain

burn/ulcerations to lip/mouth

fever and leukocytosis

esophageal strictures

what are the 3 MC places foreign bodies get lodged in the esophagus?

- cricopharyngeal muscle

- level of aortic arch

- LES at the diaphragm

what are features of esophageal trauma cause by foreign body?

cough, stridor

odynophagia

↑ salivation

retrosternal pain

prefers liquids to solids

treatment for esophageal trauma due to foreign body?

surgical removal

STAT surg consult if magnets

what condition has features:

- acute abd pain

- abd distention

- vomiting (fecal vomiting)

- constipation

- caused by obstruction distal to the duodenum

intestinal obstruction → small bowel is MC

air fluid levels and dilated loops of bowel seen on abd x-ray

intestinal obstruction

treatment for intestinal obstruction?

NPO, NGT for decompression

surgery if refractory

obstruction of the small intestine at the level of the terminal ileum with thickened meconium most commonly caused by failure to pass meconium or thickened bowel proximal and narrowed distally to the ileus

meconium ileus

what is the first symptom of cystic fibrosis?

meconium ileus

diagnostic testing for meconium ileus?

cholride sweat test

abd XR

definitive = water contrast enema

delay, infrequent or difficulty passing a bowel movement for 2+ weeks that results in pain and discomfort; stools may be large, hard and dry; palpable stool in descending colon and LLQ

constipation

what is the MCC of constipation?

functional constipation → risk factor of stool withholding

diagnostic test for constipation?

barium enema (also tx)

anorectal manometry → differentiates organic causes from unction disorder

motor disorder of the gut characterized by absence of ganglion cells in the distal colon causing a functional obstruction and failure to relax

Hirschsprung disease

what diagnosis should be considered in all newborns that do not pass meconium in 48 hours?

Hirschsprung disease

what condition has features:

- failure to thrive

- absent stool in vault on rectal exam

- explosive passage on removal of finger

- distending abdomen

- absent withholding behavior

- presence of "transition zone" seen in contrast enema (pathognomonic)

Hirschsprung disease

GOLD STANDARD diagnostic test for Hirschsprung disease?

rectal biopsy

treatment for Hirschsprung disease?

IVFs

rectal irrigation

definitive = surgery

what are dietary causes of diarrhea?

lactose intolerance

milk protein allergy

gluten sensitivity

malabsorption

what are inflammatory causes of diarrhea?

salmonella, shigella, S. aureus, yersinia, campylobacter, B. cereus

what is the MCC of diarrhea in ages 1m-2y?

rotavirus → do rotazyme stool assay to confirm

should you use antidiarrheals in children?

NO!!

what is the cause of traveler diarrhea?

enterotoxigenic E. coli

what is the cause of hemolytic uremic syndrome?

E coli H7:0157 (enterohemorrhagic)

what condition has features:

- diarrhea → bulky, pale, frothy, foul-smelling

- abd distention

- proximal muscle wasting

- weight loss

- anorexia

- abd pain

- vomiting

- caused by autoimmune response to gluten

celiac disease

diagnostic test for Celiac disease?

IgA antibodies against tissue transglutaminase

intestinal biopsy → villous atrophy, crypt hyperplasia, abnorm surface epithelium