University of St. Francis - NURS 450 Pediatrics Final 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 12. Diarrhea a. Acute diarrhea nearly always infectious i. Viral (most common infectious cause) – Norovirus, enteroviruses, Rotavirus ii. Management is supportive – fluids, Na, K 1. Oral rehydration, starvation prolongs diarrhea; Avoid lactose is helpful b. Rotavirus (potent vinegar odor) i. Mainly infants 3-15mo ii. Peaks in winter - Transmitted fecal-oral route iii. Affects the small intestine iv. Vomiting first in 80-90% pt followed by low fever v. Large Volume watery diarrhea without leukocytes or blood follows vomiting vi. Pt become dehydrated / hypernatremic, metabolic acidosis, ketosis from poor intake c. Bacterial – Campylobacter, Salmonella, Shigella, E. coli, Yersinia, C diff i. Suspect if blood in stool (effect large intestine: colitis); if exposure 1. Foreign travel, contaminated water/food, sick pets ii. Shigella dysenteriae, Shigatoxin producing bacteria (E coli O157:H7) 1. Hemolytic Uremic Syndrome potential complication iii. Pseudomembranous colitis by Clostridium difficile - 0.2-10% pt taking antibiotics 1. Fever, tenesmus, abdominal pain with diarrhea 2. Tx: oral metronidazole (or vanc $$) iv. CBC, stool culture, C. dif toxin EIA v. Tx depending on cause 1. No antidiarrheal medications- ineffective, poss worsening illness 2. No treatment with antibiotics except for Cdiff (can release toxins and make things worse) d. Chronic diarrhea i. If healthy appearing – Often functional issue 1. Normal 5-8 stools /day for infants ii. If weight loss, growth failure, ill – probably organic cause iii. Functional causes 1. Irritable bowel syndrome; Toddler’s diarrhea (too much intake of fluid, sugar, or both) iv. Organic causes 1. Food allergies Inflammatory bowel dz 2. Malnutrition Hirschprung’s dz 3. Impaction Immune deficiency syndromes 4. Malabsorption a. Lactose Intolerance; Celiac disease; Cystic fibrosis; steatorrhea 13. Constipation – often functional issue (holding in their stool, hurts, hold stool even more, cyclical) a. 10% of children seek medical attention for Constipation b. 2 nd most common cause of referrals to Peds GI. c. Chronic constipation defined as 2 or more of the following for 2 months: i. 3 BM/Wk ii. 1 episode of encopresis/wk (involuntary passage of stool, especially large/hard/impacted or watery) iii. impaction of rectum with stool iv. stool that plugs toilet v. retentive posturing and fecal withholding (obvious they are holding in poop) vi. pain with defecation d. Functional – most childhood constipation i. Withholding ii. Slow transit times (Irritable Bowel Syn.) 1. Absorb more water in LI iii. Diet – high fat, low fiber. Low fluid intake e. Organic i. Hirschprung's disease (obstruction) 1. Lacking innervation of part of intestine ii. Absence of Meissner and Auerbach plexi iii. Sympathetic hyperactivity leading to tonic contraction (doesn’t relax) iv. Hypothyroidism, cystic fibrosis, anorectal malformation f. Encopresis i. Chronic constipation w/ dilatation of rectal ampulla & fecal soiling, leads to loss of peristalsis and normal bowel habits 4 Type 1 or 2: constipation Type 3 or 4: normal Type 5 or 6: diarrhea ii. Requires stool evacuation followed by chronic management to avoid reaccumulation of stool iii. Long term laxative use, stool softeners important 14. Treatment – nonpharmacological/lifestyle a. Diet i. Whole grains, fruits, and vegetables, water/fluids ii. Recommended fiber amount adds 5 to age until 15 then adult amount. iii. Sorbital-containing fluids (prune or apple juice); Consider milk elimination trial b. Behavior Modification-based on age and individual factors i. Regular sitting on toilet for 5-10minutes after meals/ gastrocolic reflex. Make sure child has a stepstool if they cannot touch the floor ii. Motivation-rewards iii. Diary/calendar with stickers 15. Treatment – Medical a. Laxatives i. Osmotic - pushes fluid into GI tract 1. Lactulose 2. Magnesium hydroxide 3. Magnesium citrate 4. PEG 3350 (polyethylene glycol, MiraLax, Glycolax)-mix in smallest amount of fluid like water or crystal light a. higher doses of medicine for cleanout. Dose can then be titrated down depending on stool consistency. Ideal consistency- Soft mushy banana or peanut butter like. 5. Osmotic enema-phosphate enemas 6. Lavage-Polyethylene glycol-electrolyte solution (GoLytely) 7. Lubricant-Mineral oil lubricate GI tract to increase mvmt 8. Stimulants – can cause cramping & abdominal pain, avoid 9. Senna-Little tummies 10. Bisacodyl 11. Glycerin suppositories – cause stimulant & osmotic effect