Pediatrics Blueprints Chp 8 Gastroenterology

At least three episodes within 3 months, it occurs in about 10% of chldren 5-15 years old and leass than 10% of these cases result from an organic cause

Infectious conditions (including bacterial and viral gastroenteritis) most common, Mesenteric lymphadenitis may cause persistent pain following an infection, Group A streptococcal infections, UTI, and lower lobe pneumonias may also present iwth abdominal pain, PID in adolexcent females, Viral Heptaitis, Infectious mononucleosis, Herpes Zoster

Cholecystitis, pancreaitits, gastritis, peptic ulcer disease, uncommon in children but warrant consideration, Henochl Schonlen Purpura, Kawasaki's disease, polyarteritis nodosa, lupus erythematous

Rare causes: abdnominal migraines, seizures, Hirschsprung's disease, malignancy, leukemia and solid tumors

Recurrent pain with the exposure to dairy food

Sickle Cell disease, ulcerative colitis, Crohn's disease

appendicitis

Intermitten severe pain and striking lethargy

incarcerated hernia, volvulus, bowel obstruction, and testicular torsion

Urteropelvic obstruction, hydronephrosis, renal stones

Pregnancy, extopic pregnancy, dysmenorrhea, ovarian cysts, mittelschmerz, PID, cervicitis, endometriosis, and ovarian or adnexal torison are all potential problems in this population

Uncommon in children
malingering- conversion disorder
experience abdominal pain in setting of stress, especially in the context of school, and mild intermittent pain, can also be seen in children with depression

localize pain, quality, temporal characteristics, exacernbating and alleviating factors

Child has drug, food allergies or previous abdominal surgeries

inflammatory pain- child lies still (infected or perforated organ or viscus), colicky pain, child can not remain still (obstruction)

Small bowel obstruction

Obstruction or ileus

Upper GI Source (esophagitis, gastritis, duodenitis)

Bacterial entercolitis

dsyuria and abdominal pain

sore throat and abdominal pain

sexual history, vaginal discharge, fever

Viral gastroenteritis is quite contatious and ver common

lactose intolerance, Crohn's disease, ulcerative colitis, irritable bowel syndrome increases the liklihood of these diagnosis because they are gnetically bassed

Because changes in the child's environment (home, friends, school) or behavior ( poor school performance, argumentative), may suggest that the abdominal pain is not the result of the organic disase

seeing the child walk and climb into the bed, abdomen examned, inspected, auscultated, and paplated

Rectal examination to dectec tenderness or hard stool and to obtain stool for guiac testing

If female, pelvic examination should be performed

rebound tenderness, guarding, psoas or obturator signs, rigidity of the abdominal wall

depends on history and findings of PE:
if pain thought to be surgical than surgical consultation should be obtained (most likely if pain is chronic or recurrent)

complete blood count with manual differential, serum electrolytes and chemistries, amylase, lipase, stool guiac examination, urinalysis,

radigraphic studies if history of trauma or acute surgical condition

barium swalllow for upper GE exam

pH probe or endoscopic examination may be used to evaluate for reflux

Urine/stool Cultures, UA

small frequent meels rather than infrequent large ones, sitting upright at 45% angel afte eating, avoiding late meals, prokinetic agents and H2 blocker and or proton pump antagonist

prune juice, senna, colace, mineral oil, lactulose, disimpactation cathartics, or enemas

appendicitis from bacterial invasion which occurs when lumen is obstructed by fecalith, parasite or lymphnote occure frequently in patients between 10-15 yrs and presents with fever, emesis, anorexia, diffuse periumbilical pain, RLQ and parietal peritoneum inflamation

+ Guarding, rebound ternerness, obturator and psoas sign

atypical pain if retroceceal appendicitis

moderately elevated WBC, left shift

Plane film demonstrate fecalith, abdominal ultrasound and CT inflamed appendiz

36 hours, pain diffuse
can be

Campylobacter and Yersinia

laparotomy and appenedectomy before perforation

Ampicillin, gentamycin, and metronidazole (Flagyly) to treat peritonitis from intestinal flora

telescoping of one part of the intestin into another causing impaired venous return, bowel edema, ischemia, necrosis and perforation

most common intestinal obstruction in infancy, at the eliecolic valve and junction

Previous viral infection can cause hypertrophy of Peyer's patches or mesteric nodes with are lead points in intussusception

Meckels diverticulum, intestinal polyp, lymphoma, or a forein body

Ileal ileal intuscception

irritability, colicy pain, emesis, interspersed with normal periods, currant jelle stools (bright red blood and mucus) in 80% of patients, lethargy, large tubular mass, paucity of gass in right lower quandrant evidence of obstruction with air-flud levels, barium enema, coiled appearance of bowel, stool tested for occult blood

normal saline, lactated finger
hydrostatic reduction or pneumatic reduction if in 48 hours is susccesful but contraindicated with peritoneal signs,
laparotomy and direct reduction are indicated by enema is either unsuccesful or contraindicated

Intestinal Obstruction

Pregnancy

Bulging fontanelle or papilledema

Vital signs and hydration status

pneumonia in the lung fields

PID
warrangs pelvic examination

Ileus or obstruction

Gastroentereitis

intussusception or malignancy

appendicitis, pancreatitis, cholecystitis, perotinitis, PID

cultures and CBC with manual diff

chest radiograph

upright and supine abdominal films should be obtained, along with complete blood count and elextrolyte and chemistry panlels

amylase and lipase

electrolyte tests

ammonia level, serum amino acids, urine organic achids

UA and urine culture

oral rehydration therapy

CT of the head, shunt series, and neurosurgical consultation

GERD, acute gastroenteritis, systemic disorders such as tonsillitis, otitis media, or UTI

Pyloric Stenosismale 4:1 female
more common w/ family history

erythromycin

Projectile nonbilious vommting with dehyration and poor weight gain, hypokalemia, hypochloremic, metabolic alkalosis secondary to severe emesis in most cases

olive-sized, muscular, mobile nontender mass in the epigastric area, visible gastric peristaltic waves, ultrasonography reveals hypertrophic pylorus

nasogastric tube placement and correction of dehydration, alkolosis, and electrolyte abnormalities, and pyloromyotomy

Small intestine abnormally rotate arount in utero, resulting in malposition in the abdomen, abnormal posterior fixation of the mesentery

It is at risk for twisting on the vascular supply- volvulus

1 month

bilious emesis in older children
OE blood stained emesis or stool and shock, gas in the stomach, with paucity of air in the intestine, abnormal position of th eligament of Treitz and the cecum, positive stool guiac examination is poor prognostic sign indicating significant bowel ischemia

operative correction because bowel ischemia, metabolic acidosis, and sepsis can progress quickly to death

an upper gastrointestinal series with small bowel follow-through confirms the diagnosis by confirming the abnormal position of the ligament of treitz and the cecum

Gastroesophageal Reflux is the regurgitation of stomach contents into the esophagus due to an incompetent lower esophageal sphincter
small degree of reflux is common in all infants, and it is only infants who have moderate to severe chronic reflux that tend to come to the pediatrician's attention

a small degree of reflux is common in all infants but when lower esophageal sphincter incompetence is severe, complications include failure to thrive, aspiration pneumonia, esophagitis, choking or apneic episodes, hematemesis, anemia, and chronic fussiness

incompetence of the lower esophageal sphincter may be the result of prematurity, esphageal disease, obstructive lung disease, overdistension of the stomach caused by overeating, medication (theophylline)

In adolescentsion the diff dx for Ger includes pneumonia, costochondritis, pericarditis, PE, arrhythmias, ischemia due to an anomalous coronary artery, pancreatitis, cholecystitis, peptic ulcer disease and anxiety

most common cause of GER is overfeeding, so careful hx of formula infant eats, how much mixed, how much infant eats during each feed, and how often child is fed,

hx of coughing, gagging, and arching of the back with extensor posturing during feeding

epigastric abdominal or chest pain esp burning that occurs after meals when the patient lies down

most cases nl unless infants have FTT

characteristic hx, moderate or severe reflux confirmed by barium swallow, pH probe placement in the esophagys, Upper GI endoscopy, severe reflux or projectile emesis pyloric stenosis, intestinal duodenal stenosis or atresia, malrotation with volvulus, obstruction, abdominal ultrasound and barium swallow, confirm normal anatomy and normal gastric emptying

severe relfux hypochloremic, hypokalemic metabolic alkalosis may exist, children fail to thrive may have pyloric stenosis rather than GER

chest radiograph to look for aspuration pneumonia or changes due to recurrent aspiration

infants should receive small frequent feedings in the upright position, and be maintained in the prone head up position for at least 20 min after feeding, should be thickened feeds

metoclopramide if sever GER

H2 blocker (ranitidine) or proton pump inhibitor (omeprazole)

Nissen fundoplication- fundus of the stomach is wrapped around the distal esophagus to increase lower ES pressure

increase in frequency of water and content of stools

viral gastroenteritis accounts for 70-80% of acute diarrhea in North America

dehyration, electrolyte and acid-base disturbance, bacteremia, sepsis, maalnutrition in chronic cases

enteritis refers to small bowel inflammation, wherease colitis refers to large bowel inflammation

Intra-intestinal infections- viral gasatroenteritis, bacterial entercolitis, extra intesntial infections, gastrointestinal, toxic ingestion, medication induced,

renal, vasculitis, Infectious, Gastroingtestinal, Allery

frequency, appearance (bloody, mucosal, currant jelley), amount, consistency, and color of diarrhea

parasitic or bacterial entercolitis

antibiotics and chemotherapeutic agents

viral gastroenteritis highly contagious, so sick contacts would be likely

salmonella

steatorrhea and may be the result from cystic fibrosis or fat malabsorption from other causes

degree of dehyration ir oder to guide thereapy, abdominal examination focuses on bowel sounds and the presence of distention, tenderness or masses, hypactive bowel sounds point to intestinal obstruction, hyerpactive sounds are conistent wtih the gastroenteritis, abdominal mass with diarrhea could indicate intussusception or malignancy

inspecting the stool, hx of blood or mucous or both, bacterial cultures, rapid tests for rotavirus and adenovirus causing 65% of infant diarrhea during the winter months

C. difficile toxin assay

stool ova and parasites

CBC with manual diff, electrolte panel, UA, UTI evaluated by urine dipstick, urine microscopy and urine culture

Bacteremia

feed through the diarrhea
continuation of nl feedings result in less denudement of intestine, improved nutritional absorption, faster return to normal stooling patern

if intant is vomiting replace one feed with Rice-Lyte or Pediyte to calm the stomach and then return to nl feeds

parents give smaller feeding smore frequently to accomodate intestinal irritation from GE and to minimize emesis

orally rehydrated at home

suspected entercolitis or exposure to salmonella, stool culture should be formed

blood culture

the infant can be reexamined and observed at home

younger than 3 months, admited to the hospital- blood culture obtained, IV antibipotics started, LP and UA considered

infant older than 3 mo, admited to hospital, blood culture sent, antibiotics may be heald pending the results of the culture

anyinfant with + stool culture, or + blood culture is admitted for intravenous antibiotics, and evaluation for pyelonephritis, meningitis, pneumonia, and osteomyelitis

isotonic fluids
any fluid with high carbohydrate load should be diluted with water admission is indicated for child who is more than 5% dehydrated and cannot be effectively oraly rehydrate himself on IV rehydration

no pharmacologic therapy
antidiarrheal medications are contraindicated because they may cause toxic megaolcon

not indicated for bacteiral enterocolitis with the exceptions of Salmonella typhi, Shigella, and C. difficile

should be treated with antimicrobrial

remits when offending antibiotic is disconinued

hydrostatic reducting with barium enema, air enema, and or surgery

infrequent passage of hard dry stools

infants fail to empty the colon complteley with bowel movments over time stretch the smooth muscle of the colon, resulting in a functional ileus

Obstipation

90-95% is voluntary with holding, noted from the very begining of toilet training and due of pain with defecation

increases the distention of the rectum which decreases rectal sensation, necessitating and even greater fecal mass to initiate the urge to defecate

impaction, abdominal pain, overflow diarrhea, leakage around the fecal mass, anal fissure, rectal bleeding, UTI caused by extrinsic pressure on the urethra

daytime or nighttime soiling by formed stools in children beyond the age of expected toilet training (4-5 years)

can be another complciation
of constipation, information should be asked directly because of embarassement such information might not be ellicted voluntarily

constipation can result in encopresis because these children are unable to sense the need to defecate because of stretchin of the internal sphincter by the retained fecal mass

decreased peristalsis, decreased explusion, and antomoic malformation

functional constipation (intentional withholding), dysfunctional toilet training

dietary- low fiber diet, inadequate fluid intake, gastrointestinal-functional ilues, hirschsprung's disease, anal stenosis, rectal abscess or fissure stricture following necrotizing enterocolitis (NEC), collagen vascular disease, drugs or toxins (lead, narcotics, phenothiazines, vincristine, anticholinergics), neuromuscular, meningomyelocele, tethered spinal cord, infant botulism, absent abdominal muscles (prune belly syndrome), metabolic (CF, hypothyroidism, hypokalemia, hypercalcemia), endocrine (hypothyroidism)

Abdominap paoin caused by contipation diffuse and constant, with n/v unusual, stools are hard and difficult to pass and infrequent, particular foods exacerbate constipationq

psychologic state of the child

hirschsprungs disease or encopresis

Fissure or any rectal process can make defecation painful

abdomen is diffulsely uncomfortable rather than tender, left colon may be easily paplable and full of feces, rectal examination ususally reveals a rectal valut full of stool

Colun full of stool

Free T4, TSH, and T3RU levels

an electrolyte and chemistry panel may be ordered

Rectal mucosal biopsy is required to make the diagnosis

plumbisim= lead poisoning
constipation one of the side effects

genetic testing or sweat test

dietary changes- fluid intake increased, amt of carbs decreased, increase fiber and bulk in diet, and can drink undiluted prune juice or apple juice

senna or colace should be reseved for children in whom dietary measures are insufficient, routine use of laxatives or enemas is discoraged

A rectal injection to clear out the bowel or to administer drugs or food

Any oral agent that promotes the expulsion of feces, including harsh stimulant laxatives (e.g., senna, bisacodyl), saline laxatives (e.g., magnesium citrate), stool softeners (e.g., docusate sodium), bulking laxatives (e.g., psyllium, methylcellulose), and lubricants (e.g., mineral oil). Syn: aperient.

may me manually disimpacted or may received a fleet enema with a stool softener (colace), osmotic agent (lactulose, mineral oil, Miralax), or peristalsis inucser (senna)

softening the stools, avoiding the insertion of objects in the anus (thermometer), keeping the rectum clean as possible, applying petroleum jelly locally with each diaper change

Consultation with pediatric surgeon or gastroenterologist or both

polyethylene glycol electrolyte solution which is a powerful osmotic cathartic needed for cleanouts

in children that have persistent intractable constipation (such as cystic fibrosis)

psychotherapyth

Mechanical, dynamic, or adynamic obstruction of the intestines; may be accompanied by severe colicky pain, abdominal distention, vomiting, absence of passage of stool, and often fever and dehydration.

congenital aganglionic megacolon results from the failure of the ganglion cells of the myenteric plexuses to migrate down the devleoping colon

abnormally innervated distal colon remains tonically contracted and obstructs the flow of feces

three more times more common among boys and accounts for 20% of neontatal intestinal obstruction

75% cases aganglionic segment is limited to the rectosigmoid colon, whereas 15% extend beyond the splenic felxure

In any infant who fails to pass meconium within the first 24 hours of life and who requires repeated rectal stilmulation to induce bowel movements

first month of life the nenoate develops evidence of obstruction with poor feeeding, bilious vomiting, abdominal disetenion

When there is a short segment (less than 5cm) involvement

the diagnosis can be undetected into childhood

entercolitis with blood diarrhea, bowel perforations, sepsis and shock

stool that is palpable throught the abdomen and an empty rectum on digital examination

abdominal radiograph that shows distention of the proximal bowel and no gas or feces in the rectum

barium enema may demonstrate transition zone between the narrowed abnormally distal sement and the dilated normal proximal bowel

anal manometry demonstrates failure of the internal sphincter to relax with balloon distention of the rectum

rectal biopsy revealing no ganlgion cells and hypertrophies nerve trunks is necssary for dianosis

treated surgically in two stages
first stage creates diverting colostomy with the bowel that contains ganglion cells, thus permitting decompression of the ganglion containg bowel segment

seocn stage, the aganglionic segment is removed pulling the ganglionic segment throught the rectum

procesure is potponed until infant is 12 months old or delayed for 3-6 mo when disease diagnosised in odlder child

mortality rate is low in absence of entercolitis

major complications include anal stenosis, and incontinence

emesis of fresh or old blood from GI tract
fresh blood becomes chemically altered to a ground coffess appearance within 5 min of esposure to gastric acid

heamtochezia is the passage of fresh brigh red or dark marron blood from the rectum, the source is usually the colon although the upper GI tract blleding that has a rapid transit time can also result in hematochezia

Shiny jet black, tarry stools that are guiac positive and results usually from Upper GI bleeding, chemically altered during the passage through the gut

bleeding at a site proximal to the ligamnet of Treitz

esophatitis or gastritism portal hypertension from esophageal varices

lower GI bleeding whcih manifests as rectal bleeding

stools are streaked with blood after stool is passed are usually due to anal fissure or polyp

IBD or infectious enterocolitis- result in diarrheal stool mixed with blood

petechiea or purpura

cool or clammy skin with pallor

RLQ Crohn's disease or intussusception

epigastric tenderness suggests peptic ulcer disease

rLQ tenderness suggests Crohn's disease or infectious entercolitis

evidence of portal hypertension and risk of varices

On the thenar eminence

Most anal fissures located at 6 and 12 o clock position, best seen by spreading the buttocks and eveerting the anal canal

manual diff, coagulation studies, type and cross sent

gastric lavage to deermine whether bleeding is from the upper or lower GI tract

well lubricated nasograstric or orogastric tube of the largest bore possible should be placed and the staomach lavaged with room temerature normal salie until laage fluid is clear

may cause hyopthermia and should be avoided

NO

makes the diagnosis of Upper GI tract bleeding unlikely although occasionally duodenal ulcers may bleed only distally

upper GI bledding

active bleeding and mandates aggressive intravenous fluid management

upper or lower endoscopy

To look for WBS in the stool culture

because necrotizing entercolitis must be considered, an abdominal film and evaluaation for sepsis should be performed

the Apt test- used to dfferentiate maternal blood from the blood of the neonate

APT test is performed on the child's stolol

chest radiograph to r/o pulmonary hemorrhage

Meckel's scan

20mL/kg boluses until the patient is stable

inadequate volume replacement

hypotension

level of tachycardia

meckel's diverticulum- vestigial remnanot of the omphalomesenteric duct
present in 2-3%of population, 100cm of the ileocecal valve in the small intestine

2 years of age

heterotopic tissue, usually gastric, 10 times more common due to acid secretion and ulceration

painless rectal bleeding, 85% of patients with Meckel's diverticulum have melelna

10% develop intestinal obstruction from intussusceptio or volvulus

5% suffer from painful diverticulitis mimicking appendicitis

Meckle's Scan
Technetium-99 pertechnetate scan

preceded by preprentagatrin stimulation or a histamine H2 receptor antagonist (cimetidine)

ectopic acid-secreting cells creating the hemorrhage in the diverticulum

surgical resection

painless rectal bleeding

Crohn's disease and ulcerative colitis are both chronic inflammatory disorders of the intestines

Ulcerative Colitis produces diffuse superficial colonic ulceration and crypt abscesses

Involves the rectum in 95% of patients with or without contiguous extension higher in the colonc

UC does not affect the small intestin

involves transmural inflammation in a discontinous pattern which results in skip lesions

may involve any part of the GI tract (moth to anus)

ileocolic 60% small intestine 30% and colon only 10%

fibrosous in transmural and strictures are common

graunulomas are observed in up to 30% patients

internal or external fistual formation occurs in up to 40% of patients

exact not known
combination of genetic, enviormental, psychological, infectious, immunologic

whites and jews
occurs equally in males and females
most pediatric patients are adolescnets but both disease have been reported in infancy

Crampy abdominal pain, recurrent fever, weight loss, diarrhea

only 35%

tend to be more sever in crohns than in Ulcerative Colitis, may be more diffuse, frequent worse in right lower quadrant

skin tags, fissures, fistuals, abscesses

anorexia, poor weight gain, delayed growth in 40% patients

bloody mucinous diarrheal stool (100%), abdominal pain (95%), tenesmus (75%)

A painful spasm of the anal sphincter with an urgent desire to evacuate the bowel or bladder, involuntary straining, and the passage of little fecal matter or urine.

6 stools per day, no fever, no anemia, no hypoalbuminemia whereas moderate disease has greater than 6 stools per day, fever, anemia, and hypoalbunemia

flmnant high fever, abdominal tenderness, distention, tachycardia, leukocytosis, hemoorrhage, severe anemia, and more than 8 stools per day

intestinal perforation and toxic megacolon

carcinoma

polyarticular arthritis, ankylosing spondylitis, primary scleosing cholangitis, chronic active hepatitis, sacroilitis, pyoderma gangrenosa, erythema nodosum, nephrolitiatis, apothous stomatitis, episcleritis, recurrent iritis, and uveitis

proctosigmoidoscopy and biopsy

visualization of the mucosoa in UC reveals diffuse supreficial ulceration and bleeding

Crohn's disease- direct visulaization and biopsy of the ileocecal area are not always possible

UC -diffuse colonic lesions and pseydopoplyp formation

Crohn's disease reveals ileal and or colonic involvement with skip lesions, rectal sparing, segmental narrowing of the ileum (string sign) and longitudinal ulcers

anemia
megaloblastic anemia secondary to folate and vitamin B12 deficicency may also be present

50% of cases of ulcerative colitis and in 80% of Crohn's disease cases

Hypoalbuminemia caused by poor protein intake is common in individuals with severe symptoms

serum aminotransferase levels are increased if hepatic inflmmation is a complicating feature

blood and fecal leukocytes iwth a negative stool culture

chronic bacterial or pasrasitic caues of diarrhea, appendicitis, hemolytic uremic syndrome, henoch-schonlein purpura, and radiation entercolitis

enteric infections include C. difficile, campylobacter jenuni, yerisinia entercolitica, amebiasis, giardiasis

treatment is aimed at control of inflammation and suppression of immune system

5-aminosalicylic compound have been used for anti-inflammatory treatment

antibiotics have a role as anti-inflammatory agents in crohn's disease

aggresive nutrional support (including tube feeding) important for growth but aslo seem to have anti-inflammatory effects and symptoms control in Crohn's disease

corticosteroids haveboth anti-inflammatory and immunospurresive effects and remain a mainstay in management

pure immunosuppresives include 6-mercaptopurine, azathiprine, cyclosporin A, and methotrexate

infliximab - antibody direct against tumor necrosis factor alpha, and it shows promise in control of significant crohn's disease

because anorexia and increased nutritient loss in stools are common in children with IBD, adequate calories and proteins are essential

Oral supplements, nasogastric tube feedings, and in some severe cases central venous hyperalimentation are necessary

vitamin and mineral supplementation, especially iron may be required

patients with UC for more than 10 years need annual colonoscopy and rectal biopsy because of the high risk of colon cnacer and development

25% patients with UC and 70% children in Corhn's disease

when there is fulminant colitis with severe blood loss or toxic megacolon, intractable disease with a high dose steriod requirement, steroid toxicity, growth failure, or colonic dysplasia

colectomy is curative

hen hemorrhage, obstruction, perforation, severe fistual formation, or ureteral obstruction

in gneral conservative management is warranted because removeal of the disease bowel is not currative and the recurrence rate of up to 50% have been reported after segmental resection