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Peds Blueprint: GI/Nutritional

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What is dehydration?
AKA hypovolemia or volume depletion. Dehydration occurs when fluid is lost from the extracellular space at a rate that exceeds intake. Children are at a higher risk for dehydration.
What electrolyte imbalance is associated with dehydration?
Hypernatremia
What are the most common sites for extracellular fluid loss that leads to dehydration?
Gastrointestinal tract (eg, diarrhea, vomiting, bleeding)
Skin (eg, fever, burns)
Urine (eg, glucosuria, diuretic therapy, diabetes insipidus)
How do patients clinically present with moderate hypovolemia?
Thirsty
Decreased urinary output
Tachycardia
Fatigue
Muscle cramps
Dizziness
Hypotension
Dry mucous membranes
Decreased skin turgor
If severe: ischemia, shock, lethargy, AMS
What labs confirm hypovolemia? (4)
Hct - will be high
Serum albumin - high
Urinary Na - decreased
Urea - increased
How do you treat mild hypovolemia? Severe?
Mild - increase salt and water intake
Severe - oral fluids with electrolytes, glucose, amino acids. IV fluids should only be used in patients who can't tolerate oral intake.
What is Esophageal atresia?
Blockage of the esophagus - associated with tracheoesophageal fistulae
Clinical presentation of esophageal atresia?
Presents in newborns with excessive saliva, choking, or coughing with attempts to feed
Dx of esophageal atresia?
Inability to pass an NG tube is diagnostic
Tx for esophageal atresia?
Surgery
Make NPO
DDx for abdominal pain: CAMPER HIT
DDx for abdominal pain:
Constipation, Colic, Cholecystitis, Celiac Disease
Adenitis, Appendicitis
Mono, Mesenteric Lymphadenitis
Pancreatitis, Pneumonia, PID, Pregnancy
Esophageal reflux
Renal (UTI, stones)
Hepatitis
Infection (strep, gastroeneritis), IBS, IBD, Intussusception, Intolerance (lactose)
Trauma
What are the most common causes of chronic abdominal pain?
Constipation
IBS
What is functional abdominal pain?
Pain that occurs almost daily, lasts longer than 3 months, and is usually worse in the mornings. Age of onset is usually between 6-14.
What are clinical features of functional abdominal pain?
Not relieved by eating or defecation
Physical and psychological stressors exacerbate the pain
No weight loss
Normal PE
Normal labs and cultures
What should be on your Ddx with chronic abdominal pain?
IBS
Chronic pancreatitis
Gallstones
Peptic disease
Lactose intolerance
IBD (Crohn's and UC)
Constipation
Celiac Disease
What are red flag signs for underlying illness in children?
Fever
Night pain
Bilious Emesis
Failure to Thrive
Weight loss
Blood in stools or vomit
Delayed puberty
Severe pain of rapid onset
Abnormal vital signs
Dehydration
Evidence of visceral involvement (e.g., pallor, diaphoresis, vomiting)
Family hx of peptic ulcer or IBD
What is the pathophysiology of neonatal jaundice?
Overproduction of bilirubin
Decreased rate of conjugation
What are 6 types of neonatal jaundice?
ABO incompatibility
Rh isoimmunization
Hereditary spherocytosis
G6PD deficiency
Physiologic jaundice
Breast-feeding jaundice
What are the most common causes of neonatal jaundice?
Physiologic jaundice
Prematurity
Breast-feeding jaundice
Note: 65% of infants have bilirubin>5 in the first week of life
What types of jaundice are caused by overproduction of bilirubin?
Usually secondary to hemolysis (Retic count will be elevated):
ABO incompatibility
Rh isoimmunization
Hereditary spherocytosis
G6PD deficiency
Other: Sepsis, nonhemolytic anemia
What types of jaundice are caused by decreased rate of conjugation of bilirubin?
Physiologic jaundice
Gilbert or Crigler-Najjar syndrome
Note: Retic count is normal
What is the onset of jaundice caused by ABO incompatibility? What will lab tests show? Tx?
Onset: 24 hrs after birth
Labs: +Coombs, High retic count, Low H&H
Tx: Transfusion, phototherapy
What is the onset of jaundice caused by Rh isoimmunization? What will lab tests show? Tx?
Onset: 24 hrs after birth
Labs: +Coombs, Retics, Low H&H
Tx: Transfusion, phototherapy
What is the onset of jaundice caused by Hereditary spherocytosis? What will lab tests show? Tx?
Onset: 24 hrs after birth
Labs: -Coombs, High retics, Spherocytes on peripheral smear
Tx: Transfusion, phototherapy
What is the onset of jaundice caused by G6PD deficiency? What will lab tests show? Tx?
Onset: 24 hrs after birth
Labs: -Coombs, specific test for G6PD
Tx: Phototherapy
What is the onset of jaundice caused by physiologic jaundice? What will lab tests show? Tx?
Onset: 24 hrs after birth. Peaks at 3-5 days.
Labs: Bilirubin (will increased by <5 a day)
Tx: Phototherapy when bilirubin is >15
What is the onset of jaundice caused by breastfeeding jaundice? What will lab tests show? Tx?
Onset: 2nd-3rd day of life
Labs: Increased bilirubin. May persist for 6-8 weeks
Tx: Supplement breast milk with formula; feed or pump breast milk every 2 hrs until adequate supply is established. Phototherapy if bilirubin is >15
What is Kernicterus?
Bilirubin-induced brain dysfunction caused by hyperbilirubinemia. Bilirubin is a highly neurotoxic substance. Kernicterus occurs when bilirubin levels reach 20-25 mg/dL.
What are PE signs of jaundice?
Yellowish skin (begins at head and extends to chest and extremities)
Scleral icterus and jaundiced oral mucosa
Splenomegaly with hereditary spherocytosis
Labs for jaundice?
Prental maternal blood type
Rh and antibody testing
Direct (conjugated) and indirect (unconjugated) bilirubin levels
CBC with retic count and blood smear
Direct Coombs test
What is the difference between direct Coombs and indirect Coombs test?
Direct Coombs is used to test for autoimmune hemolytic anemia. A blood sample is taken and the RBCs are washed (removing the patient's own plasma) and then incubated with anti-human globulin (also known as "Coombs reagent"). If this produces agglutination of RBCs, the direct Coombs test is positive.

Indirect Coombs test is used in prenatal testing of pregnant women and in testing blood prior to a blood transfusion. It detects antibodies against RBCs that are present unbound in the patient's serum.
Ddx for conjugated hyperbilirubinemia?
Biliary obstruction/atresia
Choledochal cyst
Hyperalimentation
Alpha1-antitrypsin deificiency
Hepatitis
Sepsis
Infections
Hypothyroidism
Inborn errors of metabolism
Cystic fibrosis
RBC abnormalities
Treatment for neonatal jaundice?
Transfusion - for ABO incompatability, Rh isoimmunization, or nonhemolytic hemolysis
Phototherapy - for all types of jaundice
Sunlight exposure - for mild hyperbilirubinemia
What are the functions of the liver?
Synthesis of plasma proteins
Detox
Storage of glycogen and iron
Destruction of RBCs
Synthesis of Vit D
Bile production
What are liver enzymes?
AST
ALT
GGT
AP
What labs are a measure of hepatic function?
Bilirubin
Albumin and total protein
PT/INR
What is the gold standard for liver disease diagnosis?
Liver biopsy
How is U/S useful to evaluate liver disease? CT? MRI?
U/S - good for looking at the gallbladder, biliary tree, hepatic mass lesions
CT - good for looking at hepatic mass lesions
MRI - good for looking at lesions and biliary system
What is Hepatitis?
Hepatocellular damage - can be acute or chronic
What is the most common cause of acute hepatitis? Second?
Viral infection; toxins
What is the most common cause of chronic hepatitis?
Viral infection (Hep B, C, D) or inherited disorders (Wilson disease, alpha1-antitrypsin deficiency)
What are classic signs/symptoms of viral hepatitis?
Note: Severity of hepatitis is highly variable
Fatigue/Malaise
Anorexia
N/V
Fever
Tea colored urine
Abdominal discomfort
How is Hep A and E transmitted?
Fecal-oral
How is Hep B, C, D transmitted?
Parenteral (Blood, sexual contact, IVDU)
Mucous membrane contact (saliva, tears)
Which hepatitis virus is self limiting and mild?
A and E
HDV is only seen as a coinfection with...
HBV
What will labs show with viral hepatitis?
Elevations of AST/ALT (indicates hepatocellular damage)
Direct bilirubin is >3
INR elevation
Hypoglycemia
Elevated GGT
Neutropenia
What is the initial serologic marker for HAV? When does it present?
IgM antibody (anti-HAV). 15-40 days. Disappears after several months
What does HAV IgG indicate?
Immunity/resolved HAV
What are the serologic markers for HBV and what do they mean?
HBsAg - acute infection
HBsAb - immunity (from past infx or vaccination)
HBcAb - present between Ag and Ab. represents somewhat recent infection but immunity is building
HBeAg - indicates active infection that is very contagious
HBeAb - indicates low viral titer
What is the earliest test that can be done to diagnose HAV? When?
Fecal HAV (2 weeks after being infected)
How do you treat acute viral hepatitis?
Supportive care
Frequent hand washing with HAV
Who should get HAV vaccine (2 dose series)?
Patients with chronic liver disease
High risk workers
Men who have sex with men
Travelers
1 yr olds
Recipients of clotting factors
IVDU
Who should get the HBV vaccine (3 doses)?
Neonates
Patients with chronic liver disease
High risk workers
Patients on hemodialysis
Sexually active men and women
Recipients of clotting factors
IVDU
HIV+
What consistency of stool and how frequent is considered diarrhea?
3+ liquid or semisolid stools daily for 2-3 consecutive days
Types of diarrhea?
Secretory - large volume without inflammation
Inflammatory - bloody diarrhea + fever
Antibiotic associated
Bacterial causes of gastroenteritis?
E. coli
Salmonella
Shigella
C.diff
Campylobacter jejuni
Tx for diarrhea?
BRAT diet - bananas, rice, applesauce, toast
Fluids
Antibiotics if indicated
What is Gastroenteritis?
An intestinal infection marked by diarrhea, cramps, nausea, vomiting, and fever. Mostly occurs in the fall and winter
What is the most common cause of gastroenteritis in children?
Rotavirus. MC in children 6mo-2yrs
What is the main complication to worry about with gastroenteritis?
Dehydration
Tx for gastroenteritis?
Supportive care
Fluids
How do you determine the difference betweeen physiologic and pathologic GERD in children?
Physiologic - normal in infants younger than 8-12 months
Pathologic - when heartburn, wheezing, coughing, dysphagia, hoarseness, weight loss/FTT, recurrent sinusitis, OM is present.
What is GERD?
Recurrent reflux of gastric contents in to the distal esophagus because of a mechanical or functional abnormality of the lower esophageal sphincter. 50% of infants have reflux but <10% have esophagitis from reflux.
What kinds of intolerance do you need to consider first before diagnosing GERD in newborns?
Milk protein intolerance
How do you diagnose GERD?
Clinical symptoms with trial of antacids
Barium Swallow - will show anatomic abnormalities and motility disorders
pH probe - will quantitate reflux episodes
Endoscopy
What is conservative therapy for GERD?
Positional therapy
Avoidance of caffeine, tobacco smoke, alcohol, spicy foods
Thickened feedings in infants
Smaller feedings
What is medical therapy for GERD?
H2 blockers - Rantidine, Cimetidine, Famotidine
PPIs - Omeprazole, Lansoprazole, Esomeprazole
What is surgical therapy for GERD?
Nissen procedure - fundus is wrapped along the LES and stitched in place, reinforcing the closure of the sphincter.
Feeding jejunostomy - useful in tube feedings. Delivers nutrients downstream preventing GERD
What is pyloric stenosis?
Hypertrophy of the pylorus with elongation and thickening leading to complete obstruction of the gastric outlet. More common in males. Administration of macrolides during pregnancy may be cause.
How does pyloric stenosis clinically present?
Symptoms occur in 3-5 weeks of age.
Post prandial, non-bilious PROJECTILE VOMITING with child still hungry after
Increasing malnutrition and dehydration
OLIVE LIKE MASS is palpable
Visible peristaltic wave in LLQ
Imaging studies for pyloric stenosis? Which is the study of choice?
US (preferred study) - shows elongated and thickened pylorus
Barium Swallow - STRING SIGN - due to obstruction at pyloric outlet
Abdominal xray - expanded stomach with diminished of absent gas in intestines
How do you treat pyloric stenosis?
IV fluids
Surgical pyloromyotomy
What is Hirschsprung disease?
Failure of neural crest cells (precusors to ganglionic cells) to migrate completely during intestinal development. Aganglionic segment of the colon fails to relax which causes a functional obstruction.
Which children are at increased risk for Hirschsprung Disease?
Patients with Down syndrome
Congenital anomalies of the kidneys and urinary tract
Where is the most common area of the intestine to be affected in Hirshsprung Disease?
Rectum and part of the sigmoid colon (but can involve any part, the whole colon, or the small intestine)
How does Hirshsprung Disease clinically present?
3 forms:
Failure to pass meconium within 24 hours
Symptoms of distal obstruction (bilious emesis, abdominal distension)
Enterocolitis - (explosive diarrhea, fever)
How do you diagnose Hirshsprung Disease?
Rectal biopsy - will show absence of ganglion cells
Barium enema and anorectal manometry
How do you treat Hirshsprung Disease?
Surgical resection of aganglionic segment of bowel
If there is distension of inflammation, do an initial colostomy
What is Intussusception?
Invagination of part of the intestine into itself. A proximal segment telescopes in to a distal segment and pulls the mesentery in with it. This causes development of venous and lymphatic congestion, then intestinal edema, then ischemia, perforation, and peritonitis.
What is the cause of intussusception?
Idiopathic
Viral
Where can intussusception occur? Where is most common?
Ileoileal
Jejunoileal
Jejunojejunal
Ielocolonic - most common
How does intussusception present?
Classic triad: Abdominal pain, vomiting, bloody (CURRANT JELLY) stools
Intermittent colicky pain
Episodes occur 2-3 times an hour
Pallor, lethargy
Diarrhea
Infants will draw up their knees
Refusal of feedings
SAUSAGE shaped mass along RUQ or epigastrium
What is the most diagnostic and therapeutic procedure for intussusception?
Barium or Air Enema. Failed reductions will result in emergency surgery
What is the most common congenital malformation of the gastrointestinal tract?
Meckel's Diverticulum
What is Meckel's Diverticulum?
Occurs when the vitelline duct fails to be obliterated leading to an outpouching of the distal ileum.
What is the clinical presentation of Meckel's Diverticulum?
GI bleed (massive, painless)
Acute abdominal pain related to obstruction
Meckel's diverticulitis
Perforation
What are the Rule of 2's for Meckel's Diverticulum?
Occurs in 2% of the population
Located within 2 feet of the ileocecal junction
Measures 2 inches in length
Measures 2 cm in diameter
2:1 male to female ratio
Usually symptomatic before age 2
What imaging is done for Meckel's Diverticulum?
Meckel's Scan (technetium scan) which labels acid-producing mucosa
How do you treat Meckel's Diverticulum?
Surgical excision is recommended in children.
Young adults - consider excision.
>50 no resection is indicated
What is the most common cause of appendicitis?
Obstruction, usually by a fecolith
What are the most specific signs of acute appendicitis?
Psoas sign - patient is supine and tries to raise leg against resistance
Obturator sign - patient is supine and attempt to flex and internally rotate the right hip with the knee bent
Rovsing sign - Rebound tenderness felt in RLQ when pressing on LLQ
"Jump Test"
What are primary signs/symptoms of appendicitis?
Initially: intermittent periumbilical or epigastric pain

After 12 hours:
Constant RLQ pain (McBurney's point)
Classic triad (Anorexia, Nausea, Vomiting)
Rebound tenderness
Pain is worsened with movement
Fever - late finding
+/- Flank pain/rectal pain
Diarrhea is not common
What is the diagnostic test of choice for acute appendicitis?
CT is preferred although largely a clinical diagnosis
What will you find on imaging with acute appendicitis?
Thickened, noncompressible appendix >6 mm in diameter
How do you treat acute appendicitis?
Appendectomy
Broad spectrum abx if perforated
What is Bowel atresia?
Blockage of the bowel. Clinical presentation is signs of obstruction.
Where is the most common site of bowel atresia to occur?
Ileum. Can also occur in duodenum, jejunum, or colon.
What is Colic?
Common, poorly understood condition of excessive crying for no apparent reason for the first 3 months of life. They cry for more than three hours per day on more than three days per week. Occurs in up to 40% of all infants.
What are possible causes of colic?
Hunger
Pain
Fatigue/overstimulation
Food sensitivities
How do you differentiate colic from crying?
The crying in colic is louder and more high-pitched Parents are often not able to comfort or soothe their baby during a bout of colic.
A baby can have a hard belly, stiff arms, or arched back during a bout of colic
Techniques to soothe a colicky infant
Use a bottle that keeps baby from swallowing too much air
Have baby sit up during feedings
Carry baby more in arms, a sling, or a front carrier
Go for a car ride
Warm bath
Baby swing
Swaddle
Background noise
Massage baby's belly
Change your baby's formula or avoid eating certain foods if breastfeeding
Dx for colic?
Clinical diagnosis
What is Constipation?
2 or less stools per week OR hard, voluntary withholding of stool and infrequent passage of large diameter, often painful stools
Dx of constipation?
Can do abdominal xray
Tx for constipation?
Increase fiber and fluid intake
Increase exercise
What is Encopresis?
Leakage of stool - common in school age kids.
How do you treat Constipation/Encopresis?
Bowel evacuation
Increase water intake and fiber
Mineral oil, stool softeners, suppositories, Miralax
Maintain 6 months of treatment until pain and accident free
What is a hernia?
When peritoneal sac and potentially peritoneal contents protrudes through a weakness or defect in the muscle or fascia of the abdominal wall
What is the most common type of hernia in children?
Indirect inguinal hernia
What is an indirect inguinal hernia?
Hernia that descends into the inguinal canal and possibly in to the scrotum
How do you perform a inguinal hernia exam?
Identify the inguinal ring by invaginating the scrotum with index finger just lateral and superior to the pubic tubercle. Have patient turn their head and cough.
What are symptoms of an indirect inguinal hernia?
Could be asymptomatic
Lump, bulge, swelling
Sudden pain while lifting was felt
Pain radiates to labia/scrotum
What will you feel on exam with an indirect inguinal hernia?
Lump, mass, or pulsation when patient strains (by coughing or bearing down)
What is an umbilical hernia?
Small (<1cm) defect in the abdominal wall due to incomplete umbilical closure at birth. Small bowel can protrude through here. Can sometimes resolve on its own.
What are symptoms of an umbilical hernia?
Bulge/lump at umbilicus
Sharp pain at umbilicus when coughing/straining
What will PE show with umbilical hernia? How do you accentuate this finding?
Bulge/mass at umbilicus - have patient lie down and lift head.
What is incarceration of a hernia?
Hernia cannot be reduced. More likely to be associated with pain, N/V
What is strangulated hernia?
Incarcerated hernia that has vascular compromise - emergency!
Tx for hernias?
Surgery
Vitamin A deficiency symptoms?
Night blindness
Dry Skin
Vit A sources and function?
Sources: Liver, fish, oils, fortified milk, eggs
Function: Vision, epithelial cell maturity, resistance to infection, antioxidant
Thiamine (B1) deficiency symptoms?
Beriberi (nervous tingling, poor coordination, edema, weakness, cardiac dysfunction)
Thiamine sources and function?
Sources: Pork, grains, dried beans, peas, brewer's yeast
Function: Carb metabolism, nerve function
Niacin (B3) deficiency symptoms?
Flushing
Niacin sources and function?
Sources: Bran, fish, chicken, beef, liver, peanuts, grains
Function: Energy, fat metabolism
B6 (pyriodoxine) deficiency symptoms?
Headache
Anemia
Seizures
Flaky skin
Sore tongue
B6 sources and function?
Sources: Animal protein, spinach, broccoli, bananas, salmon
Function: Protein metabolism, neurotransmitter synthesis, hemoglobin formation
Vitamin C deficiency symptoms?
Scurvy (poor wound healing, petechiae, bleeding gums)
Vit C sources and function?
Sources: Citrus, strawberries, greens
Function: Collagen synthesis, hormone function, neurotransmitter synthesis
Vitamin D deficiency symptoms?
Rickets (Osteomalacia)
Vit D sources and function?
Sources: Sunlight, fortified milk
Function: Calcium regulation, cell differentiation
What is Lactose intolerance?
Deficiency of lactase which causes inability to digest lactose.
What populations are most affected by lactose intolerance?
Lactase production by the body stops at around 12 years for most of the world's population. Northern Europeans are some of the only that continue to make lactase.
What is the clinical presentation of lactose intolerance?
Nausea
Bloating
Flatulence
Diarrhea
Cramping
How do you treat lactose intolerance?
Dairy free trial (at least 3 days)
What is Celiac Disease?
Gluten-sensitive enteropathy. AKA Celiac sprue - injury to the lining of the small intestine because the immune system responds abnormal to gluten.
What is Gluten?
A protein found in foods such as rye, wheat, barley
What is the cause of Celiac disease?
Genetics
What are symptoms of Celiac disease?
Diarrhea which lasts for a few weeks
Constipation
Vomiting
Poor appetite
Bloating/Abdominal pain
Weight loss, FTT
Iron deficiency anemia
Changes in dentition
Skin rash
Bone thinning
Delayed puberty
How do you diagnose Celiac Disease?
Blood test for IgA antiendomysial (EMA) and anti-tTG antibodies - will be increased
Small intestine biopsy - will show flattened villi
How do you treat Celiac Disease?
Elimination of gluten from diet
Vitamin supplementation
What is Cow's Milk Protein Intolerance (CMPI)?
Abnormal immune reaction to the protein found in cow's milk
What are risk factors for CMPI?
Family hx of atopic or allergic disease
What are two kinds of CMPI?
IgE mediated - immediate rxn (within several hours)
Non IgE mediated - happens after 48 hours to a week after
What are signs/symptoms of CMPI?
Vomiting, abdominal pain, diarrhea, blood in stool
Hives, eczema, wheezing, runny nose
Irritability, facial swelling, poor growth
Reflux type symptoms
How do you diagnose CMPI?
No diagnostic test
Get a good history and PE
Trial of soy formula
How do you treat CMPI?
Eliminate cow's milk from diet
Use hydrolyzed formulas
If breastfed, mom needs to exclude all dairy
50% resolves by age 1. 90% resolves by age 6
What is phenylketonuria (PKU)?
Rare autosomal recessive disorder where there is an inability to metabolize the protein phenylalanine
What are health consequences of PKU?
Mental retardation
Movement disorders
Dx of PKU?
Screening at birth
Management of PKU?
Low phenylalanine diet and tyrosine supplementation
Strict control of protein intake for life
What denotes an inflammatory process in diarrhea?
WBCs in stool
What is the most common genetic condition in the USA?
Celiac
What are the screen tests for Celiac disease?
IgA antiendomysial and anti-tissue transglutaminase
What is the most common cause of intussusception in a child?
Viral infection
What is the presentation of intussusception?
Colicky pain
Current jelly stool
Sausage like mass
How do we both diagnose and treat intussusception in a child?
Barium or air enema
What is the most common emergency surgery?
Appendicitis
What is the initial symptom of appendicitis?
Periumbilical or epigastric pain
What represents ongoing hepatitis B infection?
Hepatitis B SURFACE antigen (HBsAg)
What represents immunity to hepatitis B?
Anti-HBs Antibody against hepatitis B surface antigen
What is the location of an indirect inguinal hernia?
Through internal inguinal ring
What is the location of a direct inguinal hernia?
Through the external ring at Hesselbach's triangle
What is the basic patient demographic for pyloric stenosis?
5 week old male
What is the radiographic finding of pyloric stenosis?
String sign
What is the disease caused by vitamin D deficiency?
Rickets
What is the disease caused by a lack of Thiamine?
Beriberi
What is the problem with phenylketonuria?
Inability to metabolize phenylalanine
What is the treatment for phenylketonuria?
Low phenylalanine diet and tyrosine supplementation
Which renal function lab is most sensitive to dehydration?
BUN