Pediatric Gastrointestinal Disorders

 

 

Esophageal Foreign Bodies

There are five anatomical sites of narrowing in the pediatric esophagus, which are: the cricopharyngeus muscle level at C6; the thoracic inlet at T1; the cardioesophageal level or aortic arch at T4; the tracheal bifurcation at T6; and the gastroesophageal junction or hiatal narrowing.

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Rectal Bleeding In Peds

Infectious Colitis

Shigella

Salmonella

Enteroinvasive E. Coli

Campylobacter Jejuni

Yersinia

C. Difficile

Entamoeba histolytica

E. Coli 0157:H7

Painless Rectal Bleeding

Anal Fissure

Swallowed Maternal blood (distinguish with apt test)

Meckel’s diverticulum

Infectious gastroenteritis

Juvenile polyps

 

Common Causes Of Upper And Lower Gastrointestinal Bleeding In The Newborn. (EMP)

Upper gastrointestinal bleeding Bleeding disorders Esophagitis Swallowed maternal blood Ulcers Vascular malformationsLower gastrointestinal bleeding Anal fissure Bleeding disorders Infectious colitis Milk allergy Meckel’s diverticulum Necrotizing enterocolitis Swallowed maternal blood Volvulus

 

 

Meckel’s Diverticulum

Rules of 2.  2% of population.  2 feet proximal to terminal ileum.  2% of people with meckel’s will have problems.  Usually has ectopic gastric mucosal.

true diverticulum causing painless rectal bleeding

Can be the focus of a volvulus or intussusception

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Surgical Emergencies

Get fingerstick, UA, Icon (if appropriate age and sex). drop the diaper to examine testicles, and look in the throat to avoid missing diagnoses.  If patient is a virgin female, can assess adnexa by bimanual rectal exam.

 

Malrotation (One to Two Weeks)

Surgical emergency if volvulus, surgical urgency if obstruction

Any infant with bilious vomiting, especially  in 1st week of life

double bubble sign on upright x-ray.  Absence of ligament of treitz.  Bloody stool.

blood streaking in stool

generally <1 yr of age

bilious vomitting, abdominal tenderness, palpable mass, UGI series or ultrasound can confirm dx

Pyloric Stenosis (One to Two Months)

projectile bilious vomiting from 2-6 months

firstborn males.

Examine with the infant on their back, flex their hips 90° to relax abd.  May palpate the olive by gently starting palpation with rocking motion below the liver, usually found on the right, just below the Xiphoid.  Ultrasound is the test of choice.  Will get hypochloremic, hypokalemic metabolic alkalosis.  Must correct pH and electrolytes before the OR.

Intussusception (One to Two Years)

Classic triad:  colicky intermittent abd pain, vomiting,  guiac + stools

A chart entry of, “No crampy abdominal pain pattern observed during ED stay”, would provide clinical evidence against the diagnosis of intussusception The differential of an infant presenting with lethargy should include sepsis, hypoglycemia, intussusception, Guillain-Barre syndrome, infant botulism, post-seizure lethargy and child abuse (shaken infant).

usually will have lead point such as peyer’s patches, polyps, or meckel’s

May have RUQ mass as ileocecal junction is the most common location

Neuro symptoms are associated with this disease and can include weakness, lethargy, and seizures.

Air enema or obstructive series as first test.  Can also be seen on UTS.

Appendicitis (Any Age)

can present with diarrhea.  Get CBC and UA

Compression graded UTS can be used, but CT is the better test.

In children less than 2 yrs old, symptoms may include cough, grunting, or walking with a limp. (Annals EM 36:39-51, 2000).  Diarrhea is present in up to 1/3 of children under 3 y/o with appendicitis (Am J Surg 173:80-82, 1997)

Ask the child how high they can jump, then let them show you to test rebound.

Can have white cells in urine, sometimes even bacteria (J Urol 129:1015, 1988 and Am J Surg 155(2), 1988)

Incarcerated Hernias

strangulated needs immediate op, incarcerated needs intervention.  Umbilical hernias are common, especially in African Americans.  Rarely become incarcerated.

Bowel Obstruction

The identification of a pediatric bowel obstruction is best described using four parameters: 1) gas distribution, 2) bowel distention, 3) air fluid levels, and 4) orderliness. These four parameters are not as easy as they sound. Bowel distention does not refer to the diameter of the bowel, but rather, the SMOOTHNESS of the bowel walls due to loss of haustration and plications. This looks like sausages or hoses because the walls are smooth. There are two common bowel obstruction patterns seen. Paucity of gas associated with a bowel obstruction is more commonly due to intussusception as opposed to the bowel obstruction pattern with large dilated loops and air fluid levels (7).

 

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Diarrheal Illness

Neurologic Symptoms, including hallucinations can precede the diarrhea in shigellosis (J Ped 114(1):95, Jan 1989)

The results of this meta-analysis confirm those of most individual clinical trials and two smaller meta-analyses indicating that the administration of probiotics as an adjunct to rehydration reduces the duration of acute diarrhea in children by about one day. (Dig Dis Sci 47(11):2625, November 2002)

 

 

 

 

 

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