Nova Southeastern University - NURSING 4110 Medsurg 2 FINAL EXAM Study Guide.

PEDIATRIC GASTROENTEROLOGY 1. Pediatric GI problems (bolded are more common) a. GER / “reflux” b. Vomiting c. Constipation/Diarrhea d. Pyloric stenosis e. Peptic ulcer disease f. Obstruction i. Malrotation/volvulus ii. Intussusception iii. Atresias/Webs g. Meckel's Diverticulum h. Hirschprung disease i. GI bleeding j. IBS k. Inflammatory bowel l. Appendicitis 2. Approaching the problem a. Functional i. Sxs without pathologic correlate (diagnosis of exclusion) ii. Lab tests/ work up negative iii. Variant of normal 1. Example constipation b. Organic i. Sxs caused by a distinct pathological entity ii. Labs and workup indicative of underlying pathology iii. Disease state -requires intervention 3. My tummy hurts a. 10% healthy school-aged children 5-15yo will experience recurrent episodes of unexplained abdominal pain. – usually functional problem bc unexplained 4. Symptoms a. Pain i. OPQRST: Sharp, Dull, cramping? changing? Progressing? Radiating? ii. Abdominal Pain -Think outside the GI tract as well (organ system above and below), very vague 1. Strep Throat = Headache and stomachache for some 2. UTI 3. Kidney stone 4. Ovarian cyst, ectopic pregnancy, endometriosis b. Vomiting i. Effortless? Projectile (pyloric stenosis, malrotation)? bilious (green/yellow)? Bloody? With nausea or without? No nausea – think CNS/tumor c. Stool – frequency, consistency, color i. Constipation 1. Hard, Encopresis, No stool ii. Diarrhea 1. Bloody, watery d. Other sxs? 5. A good history a. Exacerbating (diet, activity, position) & relieving factors b. Does the patient have a good appetite; are they feeding well? c. Any dysuria or urinary frequency? d. Is the patient passing a normal volume of urine? i. Monitor for dehydration ii. (In babies, are diapers wet?) e. Any recent illnesses (specifically ask about coughs, colds, sore throats, & GI upset)? f. In older girls take a menstrual history (sexual hx for males & females) 6. The Acute Abdomen a. Refers to sudden, severe abdominal pain i. In many cases, it is a medical/surgical emergency ii. Requires emergent & specific diagnosis b. Causes 2 i. Young Children 1. Malrotation, intussusception, incarcerated hernia, congenital anomalies (usually result of obstruction or ischemia) ii. Older Children 1. Appendicitis, mesenteric adenitis (usually result of obstruction, ischemia, or infection) 7. Chronic Abdominal Pain 3 months Acute abdominal pain: 1-month Persistent abdominal pain: 1-3 months a. Chronic abdominal pain is functional 70-90% of time i. Constipation, Irritable Bowel Syndrome (IBS), somatization of mental health issues b. Organic 10-30% of time: (short list of causes, need to be r/o) i. Gastritis/ulcer, Lactose intolerance, Parasites, Gall bladder disease, Celiac, IBD (autoimmune dz- fam hx important) c. Tx: reassurance and explanation of functional pain i. Fluids, diet, activity, sleep, emotions 8. Lab Tests a. CBC – infection, inflammation, bleeding b. CMP i. (electrolytes + BUN/Cr) – hydration &/or electrolyte imbalances ii. Bili/ALT /AST/ Alk Phos/ GGT (liver enzymes) c. Coags: PT / PTT / Fibrinogen - to check bleeding and liver function d. Amylase / Lipase – Pancreas e. Specific testing i. Celiac disease, viral hepatitis; pregnancy f. Stool tests: Culture, Parasites, occlut blood 9. Studies a. X-ray: Gas patterns, dilation, ileus, retained stool, obstruction (air fluid levels) b. Barium Swallow or Barium Enema i. Reflux, obstruction, malrotation, ulcer, certain IBD ii. Colon size, obstruction, intussusception, US iii. Pylorus, gallbladder, appendicitis c. CT: Mass, appendicitis d. Endoscopy: Gastritis, ulcers 10. Irritable Bowel Syndrome (IBS) AKA “Recurrent Abdominal Pain Syndrome of Childhood” a. Familial association b. Abnormal electrophysiology of bowel wall (may have switching of diarrhea & constipation) i. Often have diarrhea as infants, constipation as older children ii. Abdominal pain in early school years c. Often stress-associated (type A personalities), risk of school avoidance i. Rarely, if ever, awakens at night d. Tx: education of functional pain i. Important not to “medicalize”; Behavior modification, coping skills, distraction, CBT often helpful; Balanced diet helpful – no specific food restrictions 11. Vomiting a. Causes i. Viral gastroenteritis (acute vomiting) is most common cause in childhood ii. Can be obstruction (projectile), and acute or chronic inflammation of GI tract iii. CNS inflammation, pressure or tumor - no nausea, just HA then vomit iv. Metabolic derangements: IEM, sepsis, drug intoxication b. Ddx by sxs i. Projectile – high obstruction, i.e. pyloric stenosis ii. Bilious – obstruction beyond ampulla of vater … duodenal, jejunal, ileal, colonic 1. Can be caused by malrotation iii. Bloody – Mallory weiss tear, Gastritis, Peptic ulcer disease c. Extra-GI causes i. Viral Illness; Strep pharyngitis ii. UTI (pyelonephritis); Otitis media d. Neonates – Much greater concern (obstruction, met acidosis, sepsis, IEM very important to r/o) i. Obstruction 1. Duodenal atresia and stenosis; Malrotation / volvulus; Pyloric stenosis- forceful, non-bilious ii. Metabolic Acidosis 1. Sepsis; Metabolic disorders / Inborn errors of metabolism (IEM) e. If Chronic vomiting, consider CNS tumor (no nausea) f. If with pain or bilious emesis: bowel obstruction, peptic disorders, appendicitis g. Physical Exam (extra-GI, depends on what you’re looking for) i. Development: appropriate for age? ii. General appearance, fontanelles iii. Growth Charts for height, weight, FOC- excessive vomiting could lead to FTT h. Labs: Electrolytes, BUN/Cr, CBC, UA/UC, amylase, lipase, LFTs i. Imaging 3 i. US- pyloric Stenosis, gallstones, renal stones, Hydronephrosis, biliary obstruction, pancreatitis, appendicitis, malrotation, intussusception ii. CT appendicitis j. Treatment: Treat underlying cause if identified; Management of fluid and electrolytes; Anti-emetics: very carefully