GI

Colic

• Benign, self-limiting recurrent/prolonged periods of crying and irritability in infants.

• Cause:

  • Unknown but several hypotheses exist.

    • Possible lactose intolerance.

    • Lack of Lactobacillus acidophilus in GI flora.

    • Excessive gas production.

• Clinical Features:

  • Persistent or excessive crying.

  • Rule of 3’s:

    • Crying occurs for ≥ 3 hours per day.

    • Episodes happen on ≥ 3 days per week.

    • Symptoms persist for ≥ 3 weeks in otherwise healthy infants.

    • Symptoms typically resolve by 3 months of age.

• Treatment/Prevention:

  • 1st line: Reassurance for parents.

  • Alternative dietary changes for the breastfeeding infant:

    • Mother should avoid dairy, nuts, cheese, etc., for 2 weeks.

    • Formula-fed infants may benefit from:

    • Casein hydrolysate or whey protein formulas.

    • Consideration of probiotics.

    • Use of gripe water containing fennel or chamomile.

  • Pharmacological: simethicone (Mylicon) and dicyclomine.

  • Non-pharmacological: tummy massage and chiropractic therapy.

  • 5 S’s technique:

    • Swaddling, side/stomach positioning, swinging, shushing (auditory calming), and sucking (pacifiers).

Abdominal Pain

Generalized Abdominal Pain

• Non-organic causes:

  • Functional abdominal pain—abdominal complaint without identifiable cause common in children.

  • Chronic abdominal pain defined as pain lasting > 2 months without alarm findings, PE normal, and negative occult blood in stools.

• Organic causes:

  1. Peptic Ulcer Disease

  2. Gastritis

  3. Dyspepsia

  4. Choledocholithiasis

  5. Pancreatitis

  6. Inflammatory Bowel Disease (IBD)

  7. Irritable Bowel Syndrome

  8. Abdominal migraine

Clinical Features of Generalized Abdominal Pain

• Visceral pain:

  • Dull/crampy and poorly localized.

  • Different locations indicate different organ involvement:

  • Epigastric (liver, pancreas, biliary tree, stomach, proximal small intestine).

  • Periumbilical (distal small intestine, ascending/right colon, appendix).

  • Suprapubic (descending/left colon, urinary tract, reproductive organs).

• Somatic/Parietal pain:

  • Associated with peritoneal inflammation, localized to the area of involved viscera.

  • Characterized by steady and sharp sensations, may include voluntary guarding or involuntary rigidity.

• Referred pain:

  • Local irritation leading to pain that begins as dull and poorly localized then becomes diffuse and severe.

Acute Abdominal Pain

Causes

• Conditions leading to acute abdominal pain include:

  • Acute gastroenteritis

  • Appendicitis

  • Intussusception

  • Urinary tract infection (UTI)

  • Pneumonia

  • Viral syndrome

  • Volvulus

• Sudden onset typically suggests:

  • Obstruction by stones, perforation, torsion, ischemia.

Age-Related Causes

• < 2 years old:

  • Trauma, incarcerated hernias, intestinal malrotation, volvulus, Hirschsprung's disease, Meckel’s diverticulitis, pyloric stenosis.

• Ages 2-5:

  • Sickle cell anemia, pneumonia affecting the lower lobe, UTI, intussusception.

• Adolescents:

  • Appendicitis, gastroenteritis, viral illnesses, pancreatitis.

  • Special cases in adolescent females include:

  • Mittelschmerz, ectopic pregnancy, ovarian cysts/torsion, pelvic inflammatory disease.

Diagnostic Workup

• Standard diagnostic procedures:

  • CBC with differential.

  • Urinalysis (U/A).

  • Comprehensive metabolic panel (CMP) and liver function tests (LFTs).

  • Amylase and lipase levels.

  • Urinary HCG in females of reproductive age.

  • Chlamydia testing.

  • Imaging:

  • Abdominal X-ray (AP and lateral decubitus).

  • Abdominal ultrasound – preferred for pediatric patients.

  • If necessary, a CT scan can be performed.

Treatment

• Focus on treating the underlying cause.

Appendix Conditions

Appendicitis

• Cause:

  • Inflammation of the appendix, often secondary to obstruction from appendicolith or fecalith.

Clinical Features

• Initially presents with periumbilical pain that may migrate to the right lower quadrant (RLQ).

• Accompanied by:

  • Anorexia, nausea, vomiting, diarrhea, and sometimes fever.

• Typically occurs during adolescence but can present at any age.

Physical Exam Findings

• + Tenderness and guarding in the RLQ.

• May exhibit rebound tenderness and positive Rovsing’s sign.

• Additional special tests:

  • Psoas sign, obturator sign, heel tap.

Diagnostic Tests

• Imaging Modalities:

  • Abdominal ultrasound for initial evaluation.

  • CT scan for confirmation.

Treatment

• Maintain NPO (nothing by mouth).

• IV fluids for hydration.

• Pain management:

  • IV acetaminophen (Ofirmev), morphine (0.05 mg/kg), or ketorolac (Toradol).

• Administer IV antibiotics.

• Surgical consultation required.

Complications

• Possible complications from appendicitis include:

  • Abscess, perforation, peritonitis, sepsis, adhesions, intestinal obstruction, or ileus.

Intussusception

Definition

• Occurs when a segment of intestine invaginates into another segment leading to blockage and ischemia.

Clinical Features

• Typically presents between 2 months to 2 years of age.

• Sudden onset, intermittent, severe, often with inconsolable crying, drawing legs toward the abdomen.

• Initial Symptoms:

  • N/V (can be bilious with green tint).

• Late Symptoms:

  • Rectal bleeding resembling currant jelly.

Physical Examination

• Possible finding of a sausage-shaped mass in the upper mid abdomen.

Diagnosis

• Ultrasound:

  • “Target” or “doughnut” sign.

• X-ray:

  • Shows dilated loops of bowel, indicates obstruction.

Treatment

• Mainstay of treatment:

  • Air contrast enema, which is both diagnostic and therapeutic.

• If non-operative management fails:

  • Surgical intervention via laparoscopy.

• If perforation suspected, refrain from air insufflation and enema as it is contraindicated.

Volvulus with Intestinal Malrotation

Definition

• Incomplete rotation of the intestine during embryogenesis leading to twisting of the bowel upon itself, typically due to external compression from Ladd's bands.

Clinical Features

• Presents with sudden onset of bilious vomiting and severe abdominal pain.

• Often accompanied by abdominal distention.

• Considered a life-threatening emergency.

Diagnosis

• Imaging:

  • Abdominal X-ray showing a “corkscrew” appearance and “double bubble” sign.

  • Abdominal ultrasound can also be utilized.

Treatment

• Surgical intervention is immediately necessary (Ladd’s procedure).

Chronic Abdominal Pain

Causes

• Common conditions leading to chronic abdominal pain include:

  • Irritable bowel syndrome (IBS): Symptoms include nausea, diarrhea, constipation, cramping.

  • Lactose intolerance: Symptoms include bloating, gassiness, diarrhea.

  • Inorganic causes related to psychosocial stressors such as school changes.

Clinical Features

• Defined as 3 or more episodes of abdominal pain over a 3-month period, severe enough to disrupt daily activities.

Chronic Abdominal Pain Diagnostic Workup

• Recommended tests include:

  • CBC and CMP.

  • ESR and CRP.

  • Urinalysis and stool tests (occult blood, stool O&P).

  • Breath hydrogen testing post lactose challenge.

  • Upper GI series with small bowel follow-through.

  • Abdominal ultrasound and X-ray for structural issues.

Differential Diagnosis

• Abdominal migraines and functional abdominal pain.

Abdominal Migraine

Definition

• A condition characterized by recurrent episodes of acute incapacitating periumbilical pain without external signs of distress.

Clinical Features

• Symptom-free periods may last weeks to months.

• Accompanied by symptoms such as anorexia, nausea, and vomiting.

• Risk factors include a family history of migraines.

Treatment

• Most cases resolve by adolescence; treatment focused on dietary modification to remove known triggers (e.g., caffeine, nitrates).

Functional Abdominal Pain

Definition

• Characterized as recurrent abdominal pain without an organic cause.

Clinical Features

• Loss of daily activity.

• Occurs at least once weekly for at least 2 months, spanning over weeks to months.

• Pain is usually poorly localized, brief (lasting less than an hour), and resolves spontaneously.

• May be associated with psychological conditions like anxiety or depression.

Physical Examination

• Requires careful history and physical exam; findings may include generalized, non-specific pain without red flags (e.g., no vomiting, diarrhea).

Treatment

• Focus on reassurance and supportive management.

• Options include distraction, guided imagery, biofeedback, and counseling. If significant disruption, pharmacologic options include Cyproheptadine, and if necessary, an SSRI for anxiety.

Irritable Bowel Syndrome (IBS)

Definition

• A chronic functional gastrointestinal disorder characterized by abdominal pain and altered bowel habits without alarm symptoms.

Clinical Features

• Symptoms occur at least once a week over a two-month period without underlying organic cause and should not have red flags.

• Family history of IBS is common.

Treatment

• Supportive, may involve dietary changes (reducing sorbitol and fructose, and increasing soluble fiber) and medications (TCA, SSRI).

Stomach Concerns

Dyspepsia

Definition

• Characterized by pain located in the upper abdomen suggestive of peptic ulcer disease.

Testing

• Absence of gastritis signs on endoscopy, esophageal pH testing.

• Notable features that do not indicate dyspepsia:

  • Pain radiating to the back.

  • Bilious emesis (vomiting bile).

  • Melena (dark, tarry stools).

  • Unintentional weight loss.

  • Anemia.

Gastroesophageal Reflux (GER)

Definition

• Passage of gastric contents into the esophagus. GER is common in infancy and typically resolves by age 1, while GERD indicates pathologic changes.

Clinical Features

• Peaks around 4 months of age, often presents post-prandially.

• Symptoms associated with overeating include spitting up.

Characteristics of GERD

• Symptoms may include esophagitis leading to behavioral issues (e.g., irritability, colic) as well as respiratory complications (e.g., wheezing, recurrent pneumonia).

Severe Clinical Features

• Severe GERD may result in failure to thrive, moderate to severe esophagitis, hematemesis, and melena.

Diagnosis and Treatment

Diagnosis

• Mild cases diagnosed clinically; severe cases may require:

  • pH studies, upper GI endoscopy, and intestinal biopsy.

Treatment

1. Monitor and counsel if no symptoms.

2. For GERD with mild esophagitis, consider PPI or H2 blockers for 2 weeks.

3. For moderate to severe issues, a PPI for 3-6 months or Nissen fundoplication in high-risk cases.

Vomiting

Causes

• Can arise from endocrine (e.g., pregnancy), infectious sources (e.g., pneumonia), gastrointestinal disturbances, inner ear disorders, or metabolic issues.

Clinical Features

• Symptoms can indicate underlying inflammation (tenderness), dehydration (tachycardia, loss of skin turgor), or neoplasm (unexplained weight loss).

• Notable physical exam findings may include:

  • Dehydration: decreased skin turgor, dry mucous membranes.

  • CNS effects, such as papilledema.

  • GI findings: high-pitched bowel sounds indicating obstruction or absent bowel sounds in ileus.

Diagnostic Workup

• Recommendations include:

  • Abdominal X-ray for air fluid levels if obstruction is present.

  • Abdominal or renal ultrasound and upper endoscopy to evaluate for obstruction and ulcers.

  • MRI of the brain if increased ICP or CNS issues are suspected.

Cyclic Vomiting Syndrome

Definition

• An idiopathic condition characterized by recurrent vomiting with symptom-free intervals.

Clinical Features

• Episodes last from hours to days; usually seen in school-aged children with a background of migraines.

Differential Diagnosis

• Consider organic causes from medications, CNS issues, psychological reasons, or metabolic disorders.

Treatment

• Includes IV hydration and medications such as ondansetron (Zofran). Prophylactic measures vary: Cyproheptadine for younger patients, and amitriptyline for older children.

Pyloric Stenosis

Definition

• Narrowing of the pyloric channel due to hypertrophy of the pyloric muscle, primarily seen in infants.

Clinical Features

• Typically seen in infants aged 3-5 weeks.

• Symptoms include:

  • Projectile, non-bilious vomiting after meals, persistent hunger, abdominal distention, potential dehydration, and a palpable “olive-shaped” mass.

Diagnosis

• Labs typically show:

  • Hypokalemia and hypochloremic metabolic alkalosis.

• Abdominal X-ray shows gastric distention, and ultrasound is the preferred imaging modality.

  • An abnormal pyloric channel has thickness >4mm or length >16mm.

• Upper GI with small bowel follow-through needed to rule out malrotation.

Treatment

• Fluid resuscitation is crucial, followed by definitive treatment via pyloromyotomy.

Gastrointestinal Bleeding

Upper and Lower GI Bleeding Causes

Infants and Toddlers

• Causes include:

  • Milk protein allergy.

  • Swallowed maternal blood (nursing issues).

  • Intussusception and infectious colitis.

  • Meckel's diverticulum and lymphonodular hyperplasia.

School-Aged Children

• Causes consist of:

  • Anal fissure, juvenile polyp, IgA vasculitis (Henoch-Schonlein Purpura), peptic ulcer disease, hemorrhoids.

Adolescents

• Causes include:

  • Bacterial enteritis, anal fissure, inflammatory bowel disease, Mallory-Weiss syndrome, and polyps.

Upper GI Bleeding

Presentation

• Typically manifests with melena (dark, tarry stools) or hematemesis (coffee ground or red blood).

Etiology in Children > 1 Year

• Possible causes include:

  • Esophageal varices, foreign body ingestion, esophagitis, gastric ulcers, H. pylori, duodenal ulcers, and inflammatory bowel disease.

Clinical Features

• Conditions suggesting severe upper GI bleeding include iron deficiency anemia and significant drops in hemoglobin levels.

Lower GI Bleeding

Presentation

• Characterized by hematochezia (bright red blood per rectum) and originates distal to the ligament of Treitz.

Possible Causes

• Common causes for children over 1 year of age include colonic polyps, anal fissures, intussusception, Meckel’s diverticulum, inflammatory bowel disease, infectious colitis, and hemorrhoids.

Diagnostic Workup

Recommendations

• Include:

  • CBC, ESR/CRP.

  • Stool guaiac tests for blood detection.

  • Endoscopy and possible colonoscopy.

Polyps and Polyposis Syndromes

Juvenile Polyps

Definition

• Benign growths within the gastrointestinal tract typically occurring in ages 2-10.

Clinical Features

• Characterized by painless rectal bleeding; patients often have less than five polyps.

Treatment

• Removal of polyps via colonoscopy.

Polyposis Syndromes

Familial Adenomatous Polyposis (FAP)

• Definition: Genetic condition with multiple colorectal adenomas (more than 100).

• Mutation of APC gene; nearly 100% risk of colon cancer by 60.

Gardner Syndrome

• Definition: FAP with additional features such as epidermoid cysts and lipomas; also associated with the risk of colon cancer.

Peutz-Jeghers Syndrome

• Characterized by hamartomatous polyps and mucocutaneous pigmentation with slightly increased cancer risk.

Hereditary Non-Polyposis Colon Cancer (HNPCC)

• Also referred to as Lynch Syndrome: autosomal dominant with multiple other cancer risks.

Meckel's Diverticulum

Cause

• An outpouching of the lower intestine residing from fetal development.

Acute Presentation

• Causes intermittent painless rectal bleeding, could present before 2 years of age.

Diagnostic Tests

• Meckel's scan or nuclear scintigraphy is definitive.

Treatment

• Surgical intervention via laparoscopic diverticulectomy.

Inflammatory Bowel Disease

Overview

• Two major conditions: Crohn’s disease and ulcerative colitis.

Clinical Features

• Symptoms include:

  • Abdominal pain, chronic diarrhea, bloody stools, tenesmus, weight loss, fatigue, and growth failure in children.

Extraintestinal Manifestations

• Possible skin eruptions (erythema nodosum), arthritic conditions, and ocular disturbances (iritis, uveitis).

Crohn's Disease

Pathophysiology

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

Clinical Features

• Symptoms include growth delay, perianal disease, and abscess formation.

Diagnostic Tests

• CBC may detect anemia or thrombocytosis; colonoscopy reveals classic non-caseating granulomas.

Treatment

• Corticosteroids, immunomodulators, antibiotics, and nutritional support are recommended, though they're primarily palliative.

Ulcerative Colitis

Definition

• Chronic inflammation limited to the mucosal layer of the colon, often starting in the rectum.

Clinical Features

• Manifestations include bloody diarrhea, urgency, frequency, cramping, tenesmus, and possible toxic megacolon in severe cases.

Diagnostic Tests

• Diagnosis often follows clinical evaluation alongside radiologic findings and histologic confirmation via colonoscopy.

Treatment

• First-line treatment includes 5-ASA compounds; glucocorticoids are used for moderate disease and surgery for refractory cases.

Esophageal Disorders

Eosinophilic Esophagitis

Definition

• Inflammation of the esophagus due to eosinophil infiltration.

Clinical Features

• Patients may present with dysphagia, vomiting, feeding refusal, heartburn, chest pain, or abdominal discomfort.

Diagnosis

• Determined via upper endoscopy revealing characteristic histological findings.

Treatment

• Primarily through diet modification and corticosteroids.

Esophageal Atresia

Definition

• Congenital disorder where the esophagus doesn’t connect with the stomach, often presenting with tracheoesophageal fistula.

Clinical Features

• Excessive drooling, choking, cyanotic spells.

Diagnostic Workup

• Utilizing imaging techniques to confirm structural anomalies and rule out congenital heart disease (CXR, echo).

Treatment

• Involves surgical intervention for the esophageal connection.

Esophageal Trauma

Cause

• Commonly occurs due to ingestion of caustic substances, foreign bodies, or accidental injury.

Management

• Symptomatic cases require appropriate monitoring and established surgical interventions for severe injuries.

Intestinal Concerns

Intestinal Obstruction

Definition

• Any blockage in the intestines distal to the duodenum.

Clinical Features

• Symptoms include severe abdominal pain, distention, vomiting (often fecal), constipation; possible prenatal diagnosis via ultrasound.

Differential Diagnosis

• Ileus and pseudo-obstruction conditions merit evaluation.

Treatment

• Initial management involves bowel rest, supportive care, and surgical approaches for persistent cases.

Meconium Ileus

Definition

• An obstruction at the terminal ileum typical in cystic fibrosis patients characterized by thickened meconium.

Diagnostic Workup

• Involves imaging studies, chloride sweat tests for cystic fibrosis confirmation.

Constipation

Definition

• Difficulty or infrequency in bowel movements lasting over two weeks leading to pain and discomfort.

Physical Exam

• Palpation of stool in the descending colon; diagnostic testing may involve barium enemas for therapeutic purposes.

Hirschsprung Disease

Definition

• Absence of ganglion cells causing functional obstruction in the colon.

Clinical Presentation

• Lack of meconium passage within 24-48 hours requires evaluation.

Diagnostic Workup

• Involves imaging studies revealing transition zones and rectal biopsy for definitive diagnosis.