Pediatric (EOR): Gastrointestinal/Nutritional System (Smarty PANCE)

What is the peak age for appendicitis in children?

10-12 years old, but can occur at any age; rare in infants <1 year

What is the classic presentation of pediatric appendicitis?

Periumbilical pain migrating to RLQ (McBurney's point), anorexia, nausea/vomiting, low-grade fever, guarding

What are the atypical features of appendicitis in young children?

Diffuse abdominal pain, higher fever, rapid progression to perforation (thinner appendiceal wall), delayed diagnosis

What laboratory findings support appendicitis diagnosis?

Leukocytosis (WBC >10,000) with left shift, elevated CRP; normal labs do NOT exclude appendicitis

What imaging is preferred for suspected appendicitis in children?

Ultrasound first-line (no radiation), CT if ultrasound equivocal; MRI alternative in pregnant adolescents

What ultrasound findings confirm appendicitis?

Non-compressible appendix >6mm diameter, target sign, periappendiceal fluid, increased vascularity on Doppler

What is the treatment for uncomplicated appendicitis?

Appendectomy (laparoscopic preferred), IV antibiotics, fluid resuscitation; non-operative management emerging for select cases

What is the treatment for perforated appendicitis?

IV antibiotics, appendectomy (may be delayed 6-8 weeks in abscess cases), percutaneous drainage if abscess present

What is infantile colic defined as? Use Wessel criteria (Rule of 3s)

Crying >3 hours per day, >3 days per week, for >3 weeks in otherwise healthy infant <3 months old

What is the typical presentation of infantile colic?

Inconsolable crying episodes (late afternoon/evening), pulling legs to abdomen, clenched fists, red face, resolves spontaneously

What is the peak age for infantile colic?

Onset at 2-3 weeks of age, peaks at 6 weeks, typically resolves by 3-4 months

What are red flags that suggest colic is NOT the diagnosis?

Fever, vomiting, poor weight gain, blood in stool, lethargy, abdominal distention - requires further evaluation

What is the treatment for infantile colic?

Reassurance and parental support (self-limited condition), soothing techniques (swaddling, white noise, gentle motion), avoid overfeeding

What dietary interventions may help colic?

Trial of hypoallergenic formula if formula-fed, maternal dairy elimination if breastfed (2-week trial), probiotics (Lactobacillus reuteri) may help

What defines functional constipation in children?

≥2 of following: ≤2 stools/week, fecal incontinence, large stools, painful BMs, retentive posturing, large fecal mass in rectum

What is the most common cause of constipation in children?

Functional constipation (95% of cases) - withholding behavior often triggered by painful defecation

What are the red flags suggesting organic cause of constipation?

Onset <1 month of age, failure to pass meconium within 48 hours, ribbon stools, FTT, abdominal distention, neurologic abnormalities

What is the initial treatment for pediatric functional constipation?

Disimpaction (if needed) followed by maintenance therapy with polyethylene glycol (PEG 3350/MiraLAX) + behavioral interventions

How is fecal impaction treated in children?

Oral approach preferred: PEG 3350 1-1.5 g/kg/day for 3-6 days; alternative: mineral oil, stimulant laxatives, or enemas

What is maintenance therapy for pediatric constipation?

PEG 3350 0.4-0.8 g/kg/day, high-fiber diet, adequate fluids, scheduled toilet sitting after meals, positive reinforcement

What are the three severity classifications of pediatric dehydration?

Mild (3-5% loss), Moderate (6-9% loss), Severe (≥10% loss in infants, ≥6% in older children)

What are the clinical signs of mild dehydration in children?

Slightly dry mucous membranes, normal vital signs, normal urine output, consolable, alert

What are the clinical signs of moderate dehydration?

Dry mucous membranes, decreased skin turgor, sunken eyes/fontanelle, tachycardia, decreased urine output, irritable

What are the clinical signs of severe dehydration?

Sunken eyes/fontanelle, tented skin, delayed cap refill (>3 sec), hypotension, minimal/no urine output, lethargic/obtunded

What is the treatment for mild dehydration?

Oral rehydration therapy (ORT): 50 mL/kg over 4 hours plus replacement of ongoing losses

What is the treatment for moderate dehydration?

ORT preferred: 100 mL/kg over 4 hours; IV fluids if unable to tolerate oral (20 mL/kg NS bolus, then maintenance)

What is the treatment for severe dehydration?

IV fluid resuscitation: 20 mL/kg NS bolus, repeat until perfusion improves, then maintenance + deficit replacement over 24-48 hours

What are the indications for IV rehydration over oral?

Severe dehydration, shock, altered mental status, intractable vomiting, inability to drink, ileus, failed ORT

What is duodenal atresia?

Congenital complete obstruction of duodenum due to failure of recanalization during fetal development

What is the classic prenatal finding in duodenal atresia?

"Double bubble" sign on prenatal ultrasound (dilated stomach and proximal duodenum) with polyhydramnios

What syndrome is strongly associated with duodenal atresia?

Trisomy 21 (Down syndrome) - present in 30% of cases with duodenal atresia

What are the classic symptoms of duodenal atresia?

Bilious vomiting within first 24-48 hours of life, upper abdominal distention, no meconium or minimal passage

What X-ray finding confirms duodenal atresia?

"Double bubble" sign on abdominal X-ray (air-fluid levels in stomach and duodenum with gasless distal bowel)

What is the treatment for duodenal atresia?

Surgical repair (duodenoduodenostomy or duodenojejunostomy) after stabilization with NGT decompression and IV fluids

What is encopresis?

Voluntary or involuntary passage of stool in inappropriate places in child ≥4 years old (developmental age when continence expected)

What are the two types of encopresis?

Retentive (with constipation) - 80-95% of cases; Non-retentive (without constipation) - 5-20% of cases

What is the pathophysiology of retentive encopresis?

Chronic constipation → fecal impaction → rectal distention → overflow incontinence around impacted stool mass

What evaluation is needed for encopresis?

Detailed history, abdominal exam (palpable stool), rectal exam (if indicated), r/o red flags for organic causes

What is the treatment approach for retentive encopresis?

Disimpaction, maintenance laxatives (PEG 3350), behavioral therapy, toilet training, treat underlying constipation

What is the treatment for non-retentive encopresis?

Behavioral modification, scheduled toilet sitting, positive reinforcement, psychological evaluation if refractory

What is the most common age for foreign body ingestion?

6 months to 3 years old (peak age 1-2 years) due to oral exploration

What are the most commonly ingested foreign bodies in children?

Coins (most common), toys, batteries, magnets, bones, sharp objects

Where do most ingested foreign bodies lodge if they don't pass?

Esophagus at anatomic narrowing points: cricopharyngeus (most common), aortic arch, gastroesophageal junction

What symptoms suggest esophageal foreign body?

Dysphagia, drooling, refusal to eat, chest pain, respiratory symptoms (if tracheal compression)

What is the emergency management for button battery ingestion?

Immediate endoscopic removal if in esophagus (can cause liquefactive necrosis in 2 hours); honey 10mL Q10min until removal (if age >1)

What foreign bodies require urgent/emergent removal?

Button batteries in esophagus, multiple magnets, sharp objects in esophagus, objects causing obstruction or symptoms

What is the management of asymptomatic coin ingestion in stomach?

Observation and repeat X-ray in 2-4 weeks if not passed; most pass spontaneously within 4-6 weeks

What is the most common cause of acute gastroenteritis in children worldwide?

Rotavirus (in unvaccinated), Norovirus (most common in vaccinated populations)

What are the classic features of viral gastroenteritis?

Acute watery diarrhea, vomiting (often precedes diarrhea), low-grade fever, crampy abdominal pain

What are the features of bacterial gastroenteritis?

Bloody diarrhea, high fever, severe abdominal pain, fecal leukocytes - consider Salmonella, Shigella, Campylobacter, E. coli

What is the most important complication of gastroenteritis in children?

Dehydration - assess hydration status and provide appropriate rehydration therapy

What is the first-line treatment for pediatric gastroenteritis?

Oral rehydration therapy (ORT) with electrolyte solution (Pedialyte), continue age-appropriate feeding, no routine antiemetics or antibiotics

When are antibiotics indicated for gastroenteritis?

Shigella (severe cases), Campylobacter (if early), C. difficile, parasitic (Giardia), immunocompromised patients, sepsis

What dietary recommendations should be given during gastroenteritis?

Continue breastfeeding, age-appropriate diet (BRAT diet no longer recommended), avoid high-sugar drinks, lactose-free may help temporarily

What is the role of probiotics in gastroenteritis?

May reduce duration of diarrhea by 1 day - Lactobacillus GG and Saccharomyces boulardii have best evidence

What is the difference between GER and GERD in infants?

GER: physiologic reflux without complications (spitting up); GERD: reflux with complications (poor growth, esophagitis, respiratory symptoms)

What is the peak age for physiologic infant reflux?

4 months of age, typically resolves by 12-18 months as lower esophageal sphincter matures

What are red flags suggesting pathologic GERD vs physiologic GER?

Poor weight gain/FTT, hematemesis, dysphagia, apnea, recurrent pneumonia, back arching with feeds (Sandifer syndrome)

What is Sandifer syndrome?

Abnormal posturing (head tilting, neck arching) in infants with GERD - protective mechanism to reduce reflux

What is the initial management of uncomplicated infant reflux?

Reassurance, smaller/more frequent feeds, thickened feeds (rice cereal), upright positioning after feeds, avoid overfeeding

When should pharmacologic therapy be considered for infant GERD?

Failure of conservative measures with continued symptoms, esophagitis, poor weight gain, or respiratory complications

What is the first-line medication for pediatric GERD?

H2 receptor antagonists (ranitidine - now withdrawn, famotidine) or PPIs (omeprazole, lansoprazole) for proven GERD

What diagnostic tests are used for pediatric GERD?

Upper GI series (r/o anatomic abnormalities), pH probe (gold standard), upper endoscopy (if complications suspected)

What is the most common cause of acute viral hepatitis in children?

Hepatitis A virus (HAV) - fecal-oral transmission, common in daycare settings

What are the classic symptoms of acute hepatitis in children?

Jaundice, dark urine, pale stools, hepatomegaly, abdominal pain, fatigue; children often asymptomatic (especially HAV)

How is Hepatitis A transmitted and prevented?

Fecal-oral transmission; Prevention: HAV vaccine at 12-23 months (2-dose series), good hand hygiene

What hepatitis viruses cause chronic infection?

Hepatitis B and Hepatitis C - can lead to cirrhosis and hepatocellular carcinoma

How is vertical transmission of Hepatitis B prevented?

HBIG + HBV vaccine within 12 hours of birth to infants of HBsAg-positive mothers

What laboratory findings are seen in acute hepatitis?

Markedly elevated AST/ALT (>1000 U/L), elevated bilirubin (direct and indirect), prolonged PT/INR if severe

What is the treatment for acute Hepatitis A in children?

Supportive care only - self-limited infection; post-exposure prophylaxis with HAV vaccine or immune globulin within 2 weeks

What chronic hepatitis requires treatment in children?

Chronic Hepatitis B (antiviral therapy if active disease) and Hepatitis C (direct-acting antivirals - cure rate >95%)

What is Hirschsprung disease?

Congenital absence of ganglion cells in distal colon (aganglionosis) leading to functional obstruction

What is the most common location of aganglionosis in Hirschsprung?

Rectosigmoid region (80% of cases); can extend proximally in severe cases (total colonic aganglionosis rare)

What is the classic presentation of Hirschsprung in newborns?

Failure to pass meconium within 48 hours of birth (90% of cases), abdominal distention, bilious vomiting

What is the presentation of Hirschsprung in older infants/children?

Chronic constipation since birth, failure to thrive, abdominal distention, explosive stools after rectal exam

What is the most serious complication of Hirschsprung disease?

Hirschsprung-associated enterocolitis (HAEC) - life-threatening with fever, explosive diarrhea, sepsis; high mortality if untreated

What is the gold standard diagnostic test for Hirschsprung?

Rectal suction biopsy showing absence of ganglion cells and hypertrophied nerve fibers

What contrast enema finding suggests Hirschsprung?

Transition zone between dilated proximal colon and narrow distal aganglionic segment; delayed evacuation of contrast at 24 hours

What is the definitive treatment for Hirschsprung disease?

Surgical resection of aganglionic segment with pull-through procedure (Swenson, Duhamel, or Soave procedure)

What is the incidence of inguinal hernias in premature vs term infants?

Premature infants: 13-30% incidence; Term infants: 1-5% incidence; male predominance 6:1

What is the most common type of pediatric inguinal hernia?

Indirect inguinal hernia due to patent processus vaginalis (95-97% of cases)

What is the classic presentation of pediatric inguinal hernia?

Intermittent groin/scrotal bulge with crying or straining, reducible, more prominent when upright

What are the signs of incarcerated inguinal hernia?

Tender, firm, non-reducible groin mass; irritability; vomiting; may have overlying skin erythema

What is the most serious complication of incarcerated hernia?

Strangulation with bowel necrosis and testicular infarction - surgical emergency

When should elective inguinal hernia repair be performed in children?

Soon after diagnosis (within weeks) due to high incarceration risk (especially in infants <1 year)

What is the emergency management of incarcerated inguinal hernia?

Attempt manual reduction with Trendelenburg positioning and analgesia; if successful, urgent surgery within 24-48 hours

What is intussusception?

Telescoping of proximal bowel segment into distal segment causing obstruction and vascular compromise

What is the peak age for intussusception?

6-36 months (peak at 6-9 months); 60% occur in first year of life

What is the most common type and location of intussusception?

Ileocolic intussusception (most common) - ileum telescopes into cecum at ileocecal valve

What is the classic triad of intussusception?

Colicky abdominal pain (intermittent), vomiting, and "currant jelly" stools (late finding - only 50% of cases)

What is the typical pain pattern in intussusception?

Intermittent severe colicky pain with drawing knees to chest, followed by periods of lethargy between episodes

What is the "Dance sign" in intussusception?

RLQ emptiness on palpation due to cecum being pulled into ascending colon

What is the preferred diagnostic imaging for intussusception?

Abdominal ultrasound showing "target sign" (transverse view) or "pseudokidney sign" (longitudinal view)

What is the first-line treatment for uncomplicated intussusception?

Air or contrast enema reduction (successful in 80-90%); surgery if peritonitis, perforation, or failed reduction

What are contraindications to enema reduction?

Signs of peritonitis, perforation, shock, or multiple failed reduction attempts

What is the recurrence rate after successful enema reduction?

10-15% recurrence rate, usually within 24-72 hours; may require repeat reduction or surgery

What defines physiologic jaundice in newborns?

Appears after 24 hours of life, peaks at 3-5 days, resolves by 2 weeks; caused by immature hepatic conjugation

What defines pathologic jaundice requiring evaluation?

Jaundice in first 24 hours, total bilirubin rising >5 mg/dL/day, direct bilirubin >2 mg/dL or >20% of total

What is the most serious complication of severe neonatal hyperbilirubinemia?

Kernicterus (bilirubin encephalopathy) - permanent neurologic damage from bilirubin deposition in basal ganglia

What are early signs of acute bilirubin encephalopathy?

Poor feeding, lethargy, hypotonia, high-pitched cry - requires immediate treatment