Peds E2- GI

What is Colic?

Benign, self-limiting recurrent or prolonged periods of crying and irritability

Rule of 3's for colic

Crying ≥3 hours/day, occurs on ≥3 days per week, persists for ≥3 weeks in an otherwise healthy infant

*resolves by 3 months old

What is the 1st line tx for colic?

Reassurance

What are the 5 S’s for tx colic?

swaddling, side/stomach, swinging, Shhh, Sucking

How does non-organic (functional pain) abdominal pain present?

chronic abd pain > 2 months, no alarm findings, normal physical, negative occult test

What are organic causes of abdominal pain in peds?

gastritis, PUD, pancreatitis, dyspepsia, IBD, IBS, dyspepsia, abd migraine

What type of abd pain:

Dull/crampy and poorly localized

Visceral

What type of abd pain:

peritoneal inflammation, localized to the involved area, sharp with guarding/rigidity

Somatic/parietal

What type of abd pain:

local irritation that travels along the pathway of innervation of the organ; dull & poorly localized → diffuse & severe

Referred

What is the MCC of acute abdominal pain in kids?

Acute gastroenteritis

What test would order for Appendicitis?

abd U/S or CT

How would Appendicitis present?

periumbilical pain → RLQ, anorexia, N/V/D, ± fever, tenderness or guarding, + Rebound tenderness, + Rovsing’s, obturator, heel tap, and psoas

What is the tx for Appendicitis?

NPO, IVF, IV acetaminophen, IV abx, consult surgery

What is Intussuseption?

blockage of intestine, causing the small intestine to invaginate into another section of small bowel and slide into another

How does Intussuseption present?

Currant jelly stool (thickened, blood-tinged stool), Sausage-shaped mass in the upper mid abdomen, N/V (green/bile color), sudden severe pain, inconsolable

What would you see on imaging of Intussuseption?

U/S: "Target" or "doughnut" sign

Xray: presence of dilated loops of bowel indicating obstruction

What is the mainstay tx for Intussuseption?

Air contrast enema (diagnostic AND therapeutic)

When is an air contrast enema contraindicated in when tx Intussusception?

perforation suspected

What is Volvus?

bowel twists upon itself

How does Volvus present?

sudden onset of bilious vomiting, severe abd pain, abd distension

What is the tx for Volvus w/ intestinal malrotation?

life threatening EMERGENCY!!

STAT surgery (Ladds procedure)

What would you see on an XR of Volvulus with intestinal malrotation?

"Corkscrew" appearance or "double bubble" sign on abdominal XR

What imaging is used to diagnose volvulus with intestinal malrotation?

Upper GI w/ SBFT

What is chronic abdominal pain defined as?

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

What is an Abdominal migraine?

recurrent episodes of acute incapacitating periumbilical pain, will have sx free periods; may be associated w/ HA

What is the tx for an Abdominal migraine?

resolves by adolescence, remove triggers (caffeine, nitrates, stress)

What is the MC type of abdominal pain in children?

Functional abdominal pain

What is the tx for functional abdominal pain?

reassurance, supportive, pharm: Cryoheptadine, disruptive: SSRI

What is IBS?

abd pain w/ altered bowel habits in the absence of alarm sx (NO red flags)

What is it important to differentiate IBS from?

lactose intolerance

What is Dyspepsia?

pain centered in upper abdomen (sx suggest PUD); no signs of malignancy or other dz

GER vs GERD:

Common in infancy and usually disappears by age 1

GER

GER vs GERD:

Pathologic changes

GERD

What is the Gold standard test for diagnosis of severe GER?

Esophageal pH probe

What is Cyclic vomiting syndrome?

Idiopathic, early AM awakening generalized abdominal pain, non bilious emesis, that lasts hours

What is the tx for Cyclic vomiting syndrome?

IV hydration, Ondansetron, prophylaxis (< 5 = Cyproheptadine; > 5 = Amitriptyline)

What is Pyloric stenosis?

narrowing of the pyloric channel d/t hypertrophy of the pyloric muscle

How does Pyloric stenosis present?

Firm palpable "olive-shaped" mass, Post-prandial projectile, non-bilious emesis with persistent hunger & dehydration

What are lab findings in pyloric stenosis?

Hypokalemia, hypochloremic metabolic alkalosis

What is the preferred imaging modality to confirm pyloric stenosis?

Ultrasound

What is the tx for Pyloric stenosis?

fluid resuscitation; definitive → pyloromyotomy

Lower vs Upper GI Bleed:

Commonly presents with melena (dark, tarry stools) or hematemesis ("coffee ground" or red blood)

Upper GI bleed

Where does bleeding occur in an Upper GI bleed?

proximal to the ligament of Treitz

What causes PUD in children?

NSAIDs, H. pylori, Binge drinking -in adolescents

Lower vs Upper GI Bleed:

Commonly presents with hematochezia (bright red blood per rectum)

Lower GI bleed

Where does a lower GI bleed occur?

distal to the ligament of Treitz

What are Hamartomas?

Benign juvenile polyps

What is associated with 100% risk of colon cancer & APC gene mutations?

Familial adenomatous polyposis (FAP) and Gardner syndrome

What should you be considered about in a patient with Familial adenomatous polyposis (FAP) and/or Gardner syndrome?

Colon cancer

What is Gardner syndrome?

Familial adenomatous polyposis (FAP) + extraintestinal manifestations

What is Peutz Jegher's syndrome?

autosomal dominant condition of hamartomatous polyps and mucocutaneous pigmentation resulting in freckling of the lips, perioral, and gums

What is Meckel’s diverticulum?

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

How does Meckel's diverticulum present?

Intermittent painless rectal bleeding (maroon/ hematochezia)

Rule of 2s for Meckel's diverticulum:

2% of the population, under age of 2, located 2 feet from the ileocecal valve

What is the diagnostic test for Meckel's diverticulum?

Nuclear scintigraphy

Crohn's disease vs Ulcerative colitis:

Transmural inflammation of the GI tract from the mouth to anus with skip lesions

Crohn's disease

Are extraintestinal manifestations more common in CD or UC?

Crohn's disease

What are symptoms of Crohn's disease?

Growth failure/weight loss, elevated ESR, short stature, perianal disease (skin tags, fistulae, fissures)

What are hallmark lesions of Crohn's disease on upper endoscopy/colonoscopy?

Non-caseating granulomas

Are medications for Crohn’s curative?

NO, they dec morbidity

Crohn's disease vs Ulcerative colitis:

Cobble stoning, thumbprinting, string sign on upper GI/SBFT

Crohn's disease

What medication induces remission in 70% of Crohn's patients but has a high relapse rate after weaning?

Corticosteroids

Crohn's disease vs Ulcerative colitis:

Relapsing and remitting episodes of inflammation limited to the mucosal layer of the colon, sparing the upper GI tract

Ulcerative colitis

What are children with ulcerative colitis are more likely to have?

Pancolitis

What are sx of Ulcerative Colitis?

bloody (mucoid, purulent) diarrhea, tenesmus, urgency, frequency, cramping, nocturnal stool

What is seen on a colonoscopy (w/ biopsy) of Ulcerative colitis?

Friability, erythema, erosions/ulcers, bleeding crypt abscesses, and crypt blanching on colonoscopy

What is the 1st line treatment for mild ulcerative colitis?

5-ASA (Mesalamine or Sulfasalazine)

What Eosinophilic esophagitis?

inflammation of esophagus d/t eosinophilic infiltration; does NOT respond to PPIs

What is Esophageal atresia?

Congenital disorder that causes the esophagus to not connect to the stomach resulting in a blind ended pouch

What is Esophageal atresia associated with?

tracheoesophageal fistula (TEF)

What are common cause of esophageal trauma?

Caustic ingestion of household cleaners, detergent, button batteries, scalding infant formula

Do acidic or alkaline agents cause more profound injury in cases of esophageal trauma? Why?

Alkaline- deep liquefaction necrosis through all layers and has no taste

What should you watch out for in esophageal trauma?

beware of esophageal perforation

When treating a child with esophageal trauma secondary to caustic ingestion, what should you AVOID doing?

DO NOT induce vomiting, perform gastric lavage, neutralization, or give oral milk/water

What are the 3 MC places where foreign bodies get lodged?

Cricopharyngeal muscle

Level of aortic arch

LES at diaphragm

Ingestion of what warrants a STAT surgical consult?

Magnets

(Small/Large) bowel obstructions are more common

Small

What would be seen on an Xray of an intestinal obstruction?

air fluid levels and dilated loops of bowel

What is the 1st symptom of cystic fibrosis?

Meconium ileus

How soon after birth is the meconium normally passed?

24-48 hrs

What is the clinical definition of constipation?

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

What should you consider in all newborns that do not pass meconium in 48 hrs?

Hirschsprung disease

What is Hirschsprung disease?

Motor disorder of the gut characterized by absence of ganglion cells in the distal colon, causing a functional obstruction

Are males or females at greater risk for Hirschsprung disease?

Males

What is the Gold standard for diagnosis of Hirschsprung disease?

Rectal biopsy

Presence of "transition zone" on contrast enema is pathognomonic for what disease?

Hirschsprung disease

What is the tx for Hirschsprung?

IVFs, surgery = definitive

Diarrhea is more than ____ watery stools per day

3

What is a common cause of diarrhea in patients 1 month-2 years of age?

Rotavirus

*get a Rotazyme stool assay

Are antidiarrheals safe to use in children?

NO

Which type of E. coli?

Caused by H7:O157

Enterohemorrhagic E. coli

Which type of E. coli?

Causes hemorrhagic colitis and hemolytic uremic syndrome

Enterohemorrhagic E. coli

Which type of E. coli?

Causes "traveler's diarrhea"

Enterotoxigenic E. coli (ETEC)

Which type of E. coli?

similar to shigellosis, causing bloody diarrhea, fever, and tenesmus

Enteroinvasive E. coli

What is “gluten-sensitive enteropathy”?

Celiac disease

How does Celiac disease present?

Bulky, pale, frothy, foul-smelling stools

What diagnostic finding has high specificity AND sensitivity for Celiac disease?

IgA antibodies against tissue transglutaminase

What is the diagnostic study for Celiac disease?

Endoscopy w/ intestinal biopsy

What is malabsorption?

diminished absorption of 1+ nutrients caused by a disorder in the intestinal process of digestion and/or transport of nutrients into the systemic circulation

Which hepatitis is self-limiting and only requires supportive treatment?

Hep A