gastrointestinal disorders

pain >2months

define chronic abdominal pain

green

what color is bilious vomiting

bilious vomiting

Bilious vomiting in a neonate or infant should be assumed to be intestinal obstruction requiring urgent surgical evaluation until proven otherwise.

Think of:

• Malrotation with midgut volvulus (must not miss)

• Duodenal atresia

• Jejunal/ileal atresia

• Meconium ileus

• Hirschsprung disease with obstruction

• Incarcerated hernia

Immediate management

1. NPO

2. NG tube for decompression

3. IV fluids ± electrolyte correction

4. Urgent pediatric surgery consult

5. Abdominal X-ray → if concern for malrotation, upper GI contrast series (gold standard)

Board pearl

• Green (bilious) vomiting = obstruction distal to the ampulla of Vater until proven otherwise.

• Projectile, non-bilious vomiting in a 2–8 week-old infant instead suggests hypertrophic pyloric stenosis, which is not the same emergency.

surgery for this type of vomiting until proven otherwise

-small bowel obstruction

-volvulus

as well as …..

• Malrotation with midgut volvulus (must not miss)

• Duodenal atresia

• Jejunal/ileal atresia

• Meconium ileus

• Hirschsprung disease with obstruction

• Incarcerated hernia

differential diagnoses of bilious vomiting

small bowel obstruction

---

_{Mnemonic: SBO = 3 S's}

• _{Step-ladder air-fluid levels}

• _{Swollen (dilated) small bowel (>3 cm)}

• _{Scarce distal colonic gas}

-presents with sudden bilious vomiting, abdominal distention

NPO, NG tube for decompression

IV fluids

Emergent surgical consult

management of SBO

volvulus

Presentation: sudden onset bilious vomiting, abdominal distension, pain, rapid progression to shock

Evaluation:

Upper GI series → corkscrew appearance

u/s: whorlpool

-acute gastroenteritis

-increased intracranial pressure

-GERD

-metabolic derangements

-peptic ulcer disease

-pyloric stenosis

differential diagnoses of nonbilious vomiting

gastric ulcer isease

pain worse with food. Weight loss due to not eating. MC H. pylori or NSAIDS overuse.

____

____________________

______________________________

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duodenal ulcer disease

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_{Zollinger-Ellison Syndrome (ZES) — High Yield}

_{Definition:
A gastrin-secreting tumor (gastrinoma) → ↑ gastrin → ↑ gastric acid production → severe peptic ulcer disease.}

_{Pathophysiology}

_{Gastrinoma (usually pancreas/duodenum)
⬇
↑ Gastrin
⬇
↑ Parietal cell H⁺ secretion
⬇
Hyperacidity → recurrent ulcers + diarrhea}

pain better with food. Weight gain. H. pylori. Zollinger Ellison syndrome.

_{Zollinger-Ellison Syndrome (ZES) — High Yield}

_{Definition:
A gastrin-secreting tumor (gastrinoma) → ↑ gastrin → ↑ gastric acid production → severe peptic ulcer disease.}

_{Pathophysiology}

_{Gastrinoma (usually pancreas/duodenum)
⬇
↑ Gastrin
⬇
↑ Parietal cell H⁺ secretion
⬇
Hyperacidity → recurrent ulcers + diarrhea}

Gastrin-secreting tumor associated with ulcers

pyloric stenosis

Pt presents usually male,

2-8 weeks

was normal but now projectile vomiting.

Olive shaped mass, peristaltic waves.

noninfectious diarrhea

Clinical Presentation

Chronic (>2 weeks) or intermittent diarrhea

May be associated with weight loss, poor growth, or extraintestinal symptoms

Inflammatory bowel disease

Celiac disease

Lactose/fructose intolerance

Functional diarrhea (toddler's diarrhea)

Malabsorption syndromes (CF, pancreatic insufficiency)

ddx of noninfectious diarrhea

Functional constipation

Caused by holding feces in too long

-Has a normal transit time in the GI system, but the delay in getting stool out causes it to become hard (water gets absorbed back into body)

-most common cause of diarrhea

Hematemesis (bright red or coffee-ground emesis)

Melena if bleed is slower or more distal in upper GI tract

Signs of anemia, shock if severe

clinical presentation of upper GI bleed

Esophagitis, gastritis, PUD

Varices (portal hypertension)

Mallory-Weiss tear

Swallowed blood (epistaxis)

Ddx of upper GI bleed

Hematochezia (bright red blood per rectum)

± abdominal pain, diarrhea

presentation of lower GI bleed

Anal fissure (most common in children)

Polyps (juvenile polyp)

Meckel's diverticulum

IBD

Infectious colitis

Intussusception

Ddx of lower GI bleed

acetaminophen, anticonvulsants

main culprits of drug induced hepatitis

Trauma (most common in pediatrics)

Gallstones

Medications (valproate, azathioprine, steroids)

Infections (mumps)

Metabolic (hypertriglyceridemia, hypercalcemia)

Anatomic anomalies (pancreas divisum)

Ddx for acute panncreatitis causes

Pain that wakes the child from sleep

Progressive increase in severity/frequency

Localized pain away from umbilicus (especially RUQ or RLQ)

Associated systemic symptoms:

Unexplained fever

Weight loss, poor growth

Night sweats

Fatigue

GI bleeding (hematemesis, melena, hematochezia)

Persistent vomiting (especially bilious)

Chronic diarrhea

Family history of IBD, celiac disease, peptic ulcer

red flags of abdominal pain

downn syndrome

30% of cases of duodenal atresia are associated with

Duodenal atresia

What is the name for failed recanalization of the duodenum resulting in polyhydramnios, bile-containing vomitus, and a distended stomach?

double bubble sign

XR sign of duodenal atresia

abdominal pain, rectal bleeding, hiighly associated with prematurity

clinincal features of necrotizing enterocollitis

Necrotizing Enterocolitis (NEC)

-pneumatosis intestinalis on XR

failure to pass meconium

initial presentation of Hirschsprung

Malrotation with midgut volvulus

presents similarly to NEC

-associated with VACTERL anomalies

corkscrew sign

upper GI seriies finding of malrotation with midgut volvulus

intussusception

-presents at 3-24 months

-currant jelly stool-intermittent, severe abdominal pain

-RUQ mass

target sign

Ultrasound finding of intussusception

first 24-48 hrs

when does duodenal atresia present

bilious vomiting

vomiting due to issue distal to the ampulla of vater

Chronic constipation, abdominal distension, poor growth

Explosive stool passage after digital rectal exam

how does hirschsprung present in infants/children

Rectal suction biopsy → absence of ganglion cells (aganglionosis)

gold standard to diagnose hirschsprung

Stabilize: Bowel decompression, IV fluids

Definitive: Surgical resection of aganglionic segment (pull-through procedure)

Monitor for enterocolitis (can be life-threatening)

management of hirschsprung

whirpool sign on US

US finding of malrotation

intussusception

Most common cause of intestinal obstruction in children 6 mo-3 yrs

1. Intermittent colicky abdominal pain,

2. currant jelly stools (blood + mucus),

3. vomiting

classic triad off intussusception

intussusception

Sausage-shaped abdominal mass (usually RUQ)

Child may draw knees to chest during pain episodes

Lethargy can be prominent

obstruction of the lumen of the appendix (fecalith, lymphoid hyperplasia, vegetables/seeds, parasites, or neoplasm)

most common cause of appendicitis

gliadin and gluten

celiac is an autoimmune intolerance of

food protein-induced enterocolitis syndrome (FPIES)

Adverse reaction to food protein MC cows milk, soy, or grains occurring 1-4 hours after exposure.

Pt: vomiting, lethargy, pallor, watery diarrhea sometimes can be bloody.

Gastroschisis

Extrusion of abdominal content through abd fold, usually right of umbilicus. Not covered by peritoneum. Diagnosed clinically

silo: push it back in slowly

management of gastroschisis

omphalocele

extrusion of abd content through abd fold, covered by peritonium, usually midline. Diagnosed clinically.

-frequent small volume diarrhea with urgency

-bloody diarrhea

frequent features of ulcerative colitis

-diffuse inflammation in mucosa or submucosa

-crypt architecture distortion

histopath of ulcerative colitis

Antineutrophil cytoplasmic antibodies (ANCAs)

serologic marker of UC

crohns disease

-discontinuous transmural asymmetric lesions

-mainly involving ileum and right sided colon

-cobblestone appearance

-deep fissures; transmural inflammation

-granulomatous inflammation

Anti-Saccharomyces cerevisiae antibodies (ASCA)

serologic marker of crohn's disease

meconium ileus

Failure to pass meconium. Associated with CF w/ + prenatal screen or pt who never had screen.

water enema

tx of meconium ileus

umbilical hernia

Herniation of abd content through umbilical opening from failure of umbilical ring to close. Diagnosed clinically.

Most require observation and close spontaneously by age 5.

Meckel's diverticulum

outpouching of distal ileum

2% of the poppulation

M:F raio 2:1

2 ft from ileocecal valve

2 in in length

2% developing complications

2 types of heterotropic mucossa

define the rule of 2s of meckel's