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218 Cards in this Set

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  • Back
What is the definition of recurrent abdominal pain?
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
What is the differential diagnosis of abdominal pain?
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
How does lactase deficieny present?
Recurrent pain with the exposure to dairy food
What are the cases of abdominal pain where pain is the major symptom?
Sickle Cell disease, ulcerative colitis, Crohn's disease
What is the most common surgical cause of abdmonial pain?
How does intussusception present?
Intermitten severe pain and striking lethargy
What are causes of abdominal pain that are surgical emergencies?
incarcerated hernia, volvulus, bowel obstruction, and testicular torsion
What are examples of urologic ovstruction that can cause abdominal pain?
Urteropelvic obstruction, hydronephrosis, renal stones
What are gynecologic causes of abdominal pain?
Pregnancy, extopic pregnancy, dysmenorrhea, ovarian cysts, mittelschmerz, PID, cervicitis, endometriosis, and ovarian or adnexal torison are all potential problems in this population
What are the psychiatric causes of abdominal pain?
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
What information should be gatehered from clinical exam?
localize pain, quality, temporal characteristics, exacernbating and alleviating factors

Child has drug, food allergies or previous abdominal surgeries
How does the presentation of inflammatory pain differ from that of colicky pain?
inflammatory pain- child lies still (infected or perforated organ or viscus), colicky pain, child can not remain still (obstruction)
What is an important outcome after laparotomy?
Small bowel obstruction
What does biilious emesis indicated?
Obstruction or ileus
What does blody emesis point to?
Upper GI Source (esophagitis, gastritis, duodenitis)
What does Bloody or mucinous diarrhea suggest?
Bacterial entercolitis
What are the symptoms of urinarty tract infection?
dsyuria and abdominal pain
What are the symptoms of pharyngitis?
sore throat and abdominal pain
What are the symptoms of PID?
sexual history, vaginal discharge, fever
WHy is it important to inquire about all ill contacts when considering the differential diagnosis of abdominal pain?
Viral gastroenteritis is quite contatious and ver common
Wht is it important to inquire about family history and abdominal pain?
lactose intolerance, Crohn's disease, ulcerative colitis, irritable bowel syndrome increases the liklihood of these diagnosis because they are gnetically bassed
Why is it important to ask for social history when considering the differential diagnosis of abdominal pain?
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
What is important to exam during the PE when considering the differential of abdominal pain?
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
What are peirotneal signs found on abdominal exam?
rebound tenderness, guarding, psoas or obturator signs, rigidity of the abdominal wall
What are the diagnositc evaluations that must can ber perfomed in a patient with abdominal pain?
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
Wgat us tge treament for patients with reflux?
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
How can constipation be treated?
prune juice, senna, colace, mineral oil, lactulose, disimpactation cathartics, or enemas
What is the most common indication for abdominal surgery?
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
When does the appendix tend to perforate?
36 hours, pain diffuse
can be
What bacterial enterocolitis can minmic RLW abdominal pain and tenderness of apeendicitis?
Campylobacter and Yersinia
What is the treatment of an appendicits?
laparotomy and appenedectomy before perforation
When appendicitis results in perforation what should the patient be given?
Ampicillin, gentamycin, and metronidazole (Flagyly) to treat peritonitis from intestinal flora
When does intussusception result?
telescoping of one part of the intestin into another causing impaired venous return, bowel edema, ischemia, necrosis and perforation
When is intussusception most comon?
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
What are lead points that can lead to intussusception?
Meckels diverticulum, intestinal polyp, lymphoma, or a forein body
What has henoch-Schonlein Purpura been associated with?
Ileal ileal intuscception
How does intuscception present?
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
what is the treatmennt for intussception?
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
What can be the cause of bilious emesis and abdominal pain?
Intestinal Obstruction
What can be a cause of emesis and syncope?
What are signs of increased intracranial pressure?
Bulging fontanelle or papilledema
What are the important things to concentrate on initial asssment with a child with emesis?
Vital signs and hydration status
What might cause emesis and be associated with crackles or asymemetric examination?
pneumonia in the lung fields
What may be the cause of emesis and vaginal discharge in the female adolescent?
warrangs pelvic examination
What may be the causes of Hypoactive bowel?
Ileus or obstruction
What may be the cause of hyperactive bowel?
What may be the cause of emesis when associated with abdominal mass?
intussusception or malignancy
What may be the causes of emesis and tenderness of exam?
appendicitis, pancreatitis, cholecystitis, perotinitis, PID
What are the tests used to differntiate infectious cause of emesis?
cultures and CBC with manual diff
What are the tests ordered to rule out pneumonias as the cause of emesis?
chest radiograph
What are the tests ordered to rule out a surgical process as the cause of emesis?
upright and supine abdominal films should be obtained, along with complete blood count and elextrolyte and chemistry panlels
What should be sent to rule out pancratitic cause of emesis?
amylase and lipase
What tests will help guide replacement therapy if dehyration is suspected?
electrolyte tests
What tests should be sent if metabolic caueses of emesis are suspected?
ammonia level, serum amino acids, urine organic achids
What tests should be sent to r/o UTI and to assess the degree of dehyration?
UA and urine culture
What treatment is recommended for dehydrated patients with self-limited nonsurgical infectious process (viral gastroenteritis or bacterial enterocolitis)?
oral rehydration therapy
What should be ordered if ventricular-peritoneal shunt malfuntion is believed to be causing emesis?
CT of the head, shunt series, and neurosurgical consultation
What are the most common causes of emesis?
GERD, acute gastroenteritis, systemic disorders such as tonsillitis, otitis media, or UTI
What is the most important cause of gastric outlet obstruction and comiting in the first 2 months of life?
Pyloric Stenosismale 4:1 female
more common w/ family history
What therapy may prevent pyloric stenosis?
What are the carinal features of pyloric stenosis?
Projectile nonbilious vommting with dehyration and poor weight gain, hypokalemia, hypochloremic, metabolic alkalosis secondary to severe emesis in most cases
What are the classic findings of pyloric stenosis?
olive-sized, muscular, mobile nontender mass in the epigastric area, visible gastric peristaltic waves, ultrasonography reveals hypertrophic pylorus
What is the treatment of pyloric stenosis?
nasogastric tube placement and correction of dehydration, alkolosis, and electrolyte abnormalities, and pyloromyotomy
What happens in malrotation?
Small intestine abnormally rotate arount in utero, resulting in malposition in the abdomen, abnormal posterior fixation of the mesentery
What happens when the intestine attaches improperly to the mesentery?
It is at risk for twisting on the vascular supply- volvulus
What is the most common age of presentation of volvulus?
1 month
What are the clinical manifestations of malrotation and volvuluss?
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
What is the treatment of malrotation and volvulus?
operative correction because bowel ischemia, metabolic acidosis, and sepsis can progress quickly to death
How is malrtation or volvulus diagnosed?
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
What is GER?
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
What are the complications of GER?
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
What is the differential diagnosis of GER?
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
What is the most common cause of GER and what info is important to have?
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,
What are the symptoms that sugest direct aspiration?
hx of coughing, gagging, and arching of the back with extensor posturing during feeding
How is GER manifested in older child?
epigastric abdominal or chest pain esp burning that occurs after meals when the patient lies down
What is the PE in patients with GER?
most cases nl unless infants have FTT
How is GER diagnosted?
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
What should be done if the chest examination is abnl in the presence of reflux?
chest radiograph to look for aspuration pneumonia or changes due to recurrent aspiration
What is the treatment of GER?
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
What drug tx should be used to improve gastric motility and increase the rate of gastric emptying?
metoclopramide if sever GER
What should be the treatment if esophagitis is suspected secondary to GER?
H2 blocker (ranitidine) or proton pump inhibitor (omeprazole)
What is the treatment for GER if medical management fails?
Nissen fundoplication- fundus of the stomach is wrapped around the distal esophagus to increase lower ES pressure
What is the definition of diarrhea?
increase in frequency of water and content of stools
What is the most common cause of gastroenteritis?
viral gastroenteritis accounts for 70-80% of acute diarrhea in North America
What are the complications of acute diarrhea?
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
What are the most common causes of acute diarrhea in the world?
Intra-intestinal infections- viral gasatroenteritis, bacterial entercolitis, extra intesntial infections, gastrointestinal, toxic ingestion, medication induced,
What are the most commun causes of chronic recurrent diarrhea?
renal, vasculitis, Infectious, Gastroingtestinal, Allery
What information should be obtained in the history to ascertain whether the diarrhea is acute or chronic/recurrent?
frequency, appearance (bloody, mucosal, currant jelley), amount, consistency, and color of diarrhea
What may be the cause of dairrhea with recent travel?
parasitic or bacterial entercolitis
What are the medications that cause diarrhea?
antibiotics and chemotherapeutic agents
What info can be elictited in history of viral gastroenteritis?
viral gastroenteritis highly contagious, so sick contacts would be likely
What should be elicited from information from child who just ate raw poultry?
What is the most likely cause of foul-smelling diarrhea that floats in the toilet?
steatorrhea and may be the result from cystic fibrosis or fat malabsorption from other causes
What should be PE with patient with severe diarrea?
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
What can help in the diagnostic evaluation of a child with diarrhea?
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
What should be sent if history of diarreach with long-term multiple antibiotic use?
C. difficile toxin assay
What should be tested for in children with chronic diarrhea and history of foreign travel or recent camping and immumocompromised child with diarrhea?
stool ova and parasites
What should be ordered in child who appears toxic or with moderate to severe dehyrtation?
CBC with manual diff, electrolte panel, UA, UTI evaluated by urine dipstick, urine microscopy and urine culture
What is most likely in infants younger than 3 months with bacterial entercolitis?
What are the treatment recommendations for uncomplicated viral gastroenteritis withoug signficant dehyration?
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
What should be the treatment of infants who do not tolderate their regular formul and are not significantly dehyrated or toxic appearing?
orally rehydrated at home
What should be sent in infant 0-12 months old with diarrhea for more than 5 days?
suspected entercolitis or exposure to salmonella, stool culture should be formed
What should be performed in in infant younger than 3 months of age with diarreah?
blood culture
What is the treatment for infant that is afebrile, and does not appear toxic?
the infant can be reexamined and observed at home
What is the treatment if the stool culture is potive and the infant is febrile?
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
What should be the tx management of older children with viral gastroenteritis?
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
What is the tx needed for viral gastroenteritis?
no pharmacologic therapy
antidiarrheal medications are contraindicated because they may cause toxic megaolcon
What is the treatment needed for bacterial entercolitis?
not indicated for bacteiral enterocolitis with the exceptions of Salmonella typhi, Shigella, and C. difficile
What is the treatment for parasitic gastrointestinal infections?
should be treated with antimicrobrial
What is the tx for antibiotic related diarrhea?
remits when offending antibiotic is disconinued
What is the treatment needed for intussception?
hydrostatic reducting with barium enema, air enema, and or surgery
What is the defintion of constipation?
infrequent passage of hard dry stools
what can happen over time to infants with constipation?
infants fail to empty the colon complteley with bowel movments over time stretch the smooth muscle of the colon, resulting in a functional ileus
What is the term to describe the absence of bowel movemnts?
What is the most common cause of constupation beyond the neonatal period?
90-95% is voluntary with holding, noted from the very begining of toilet training and due of pain with defecation
What can happen as a result of voluntary withholding of stool?
increases the distention of the rectum which decreases rectal sensation, necessitating and even greater fecal mass to initiate the urge to defecate
What are complications of stool retention
impaction, abdominal pain, overflow diarrhea, leakage around the fecal mass, anal fissure, rectal bleeding, UTI caused by extrinsic pressure on the urethra
What is encopresis?
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
What may be the cause of encopresis?
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
What may be organic causes of failure to defecate?
decreased peristalsis, decreased explusion, and antomoic malformation
What are nonroganic causes of faulre to defecate?
functional constipation (intentional withholding), dysfunctional toilet training
What are organic causes of failure to defecate?
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)
What is the PE of patient with constipation?
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
What should be discussed to determine if volunary witholding is the most likely cause of diarrhea?
psychologic state of the child
What is the most likely diagnosis with history of diarrhea or fecal spotting alternating with periods of constipation?
hirschsprungs disease or encopresis
What can make defecation painful?
Fissure or any rectal process can make defecation painful
What is the PE?
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
What can be seen on abdominal film of patient with constipation?
Colun full of stool
What should be ordered if an endocrine cause of hypothyroidism is being considered?
Free T4, TSH, and T3RU levels
What should be ordered if hypokalemia or hypocalcemia is a potential cause of constipation?
an electrolyte and chemistry panel may be ordered
What should be ordered if Hirschysprung's disease is suscpected?
Rectal mucosal biopsy is required to make the diagnosis
What is plumbisim and one of its side effects?
plumbisim= lead poisoning
constipation one of the side effects
What should be odered if cystic fibrosis is considered as cause of constipation?
genetic testing or sweat test
What is the tx of patients with functional constipation?
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
What is an emema?
A rectal injection to clear out the bowel or to administer drugs or food
What is a laxative?
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.
What is the tx of child with impaction?
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)
How are nala fissures treated?
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
How should Hirschsprung's disease be managed?
Consultation with pediatric surgeon or gastroenterologist or both
What is GoLYTELY and when is it needed?
polyethylene glycol electrolyte solution which is a powerful osmotic cathartic needed for cleanouts

in children that have persistent intractable constipation (such as cystic fibrosis)
What is sometimes done for patients due to psycogenic causes of constipation?
What is ileus?
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.
What is Hirschsprung's disease?
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
When should Hirschsprung's disease be suspected?
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 can the diagnosis of Hirschsprungs disease be missed?
When there is a short segment (less than 5cm) involvement

the diagnosis can be undetected into childhood
What can be the complications of Hirschsprungs disease that occur when undetected?
entercolitis with blood diarrhea, bowel perforations, sepsis and shock
What is the PE of patient with Hirschsprungs disease?
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
What is the treatment of Hirschsprung's disease?
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
What does hematemesis refer to?
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
What does Melena refer to?
Shiny jet black, tarry stools that are guiac positive and results usually from Upper GI bleeding, chemically altered during the passage through the gut
What is the differential diagnosis for upper Gastrointestinal bleeding?
bleeding at a site proximal to the ligamnet of Treitz

esophatitis or gastritism portal hypertension from esophageal varices
What is the more common upper GI bleeding or lower GI bleeding?
lower GI bleeding whcih manifests as rectal bleeding
What are causes of minor bleeding?
stools are streaked with blood after stool is passed are usually due to anal fissure or polyp
What does the stool look like in inflammatory diseases?
IBD or infectious enterocolitis- result in diarrheal stool mixed with blood
What are dermatologic abnormalities that indicate coagulopathy?
petechiea or purpura
What are dermatologic abnormalities that indicate shock or anemia?
cool or clammy skin with pallor
What may be the cause of GI bleed that would have a mass?
RLQ Crohn's disease or intussusception
What may be the cause of tenderness that also results in GI bleeding?
epigastric tenderness suggests peptic ulcer disease

rLQ tenderness suggests Crohn's disease or infectious entercolitis
What may cause GI bleeding and result in hepatospneomegaly and caput of medusa?
evidence of portal hypertension and risk of varices
Where should capillary refil be assessed in an infant?
On the thenar eminence
Where are most anal fissures located and how are they best seen?
Most anal fissures located at 6 and 12 o clock position, best seen by spreading the buttocks and eveerting the anal canal
What are the diagnositc evaluations that must be done in a patient with a source of bleeding?
manual diff, coagulation studies, type and cross sent
What should be done if bleeding source is unclear and the patient is unstable?
gastric lavage to deermine whether bleeding is from the upper or lower GI tract
How is gastric lavage accomplished?
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
Why should iced saline be avoided when doing a lavage?
may cause hyopthermia and should be avoided
Are esophageal varices contrindcation to the placement of a nasogastric or orogastric tube?
What does the return of clear fluid on gastric lavage indicate?
makes the diagnosis of Upper GI tract bleeding unlikely although occasionally duodenal ulcers may bleed only distally
What does the return of guiac positive bright red blood or coffee grounds indicate?
upper GI bledding
What does persistent bright red blood indicate?
active bleeding and mandates aggressive intravenous fluid management
How is the precise diagnosis of gastrointestinal bleeding made?
upper or lower endoscopy
Why is methylene blue used to evaluate the stool cutlure if there is bloody diarrhea?
To look for WBS in the stool culture
What must be done in a neonate with bloody stools?
because necrotizing entercolitis must be considered, an abdominal film and evaluaation for sepsis should be performed
What is the test used to differentiate swallowed maternal blood as the cause of GI bleeding?
the Apt test- used to dfferentiate maternal blood from the blood of the neonate

APT test is performed on the child's stolol
What might be done for oral blood and a worsening pulmonary examination?
chest radiograph to r/o pulmonary hemorrhage
What can be done when Mechel's diverticulum is suspected?
Meckel's scan
What should be given to stabilize a patient with severe bleeding or hypovolemia?
20mL/kg boluses until the patient is stable
What is the most common error in management of the child with severe gastrointestinal bleeding?
inadequate volume replacement
What is a late finding in an patient with GI bleeding?
What VS should govern fluid resucitation?
level of tachycardia
What is the most common gastrointestinal anaomaly?
meckel's diverticulum- vestigial remnanot of the omphalomesenteric duct
present in 2-3%of population, 100cm of the ileocecal valve in the small intestine
What is the peak incidence of bleeding from the diverticulum?
2 years of age
What is a common symptomatic finding in pateints with Meckel's diverticulum?
heterotopic tissue, usually gastric, 10 times more common due to acid secretion and ulceration
What are the most common presentations of Meckel's Diverticulum?
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
How is the diagnosis of Meckel's Diverticulosis made?
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
What is the definitive treatment of Meckel's Diverticulum?
surgical resection
What is the most common presentation of Meckel's Diverticulum?
painless rectal bleeding
What are the two conditions that comprise Infammatory Bowel Disease? (IBD)
Crohn's disease and ulcerative colitis are both chronic inflammatory disorders of the intestines
How does UC present?
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
What is the pathology of Crohn's disease?
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
What is the etiology of IBD?
exact not known
combination of genetic, enviormental, psychological, infectious, immunologic
In which populations are IBD more common?
whites and jews
occurs equally in males and females
most pediatric patients are adolescnets but both disease have been reported in infancy
What are the clinical manifestations of Crohns?
Crampy abdominal pain, recurrent fever, weight loss, diarrhea
How common is rectal bleeding in Crohns disease?
only 35%
How is abdominal pain different than in Crohn's disease?
tend to be more sever in crohns than in Ulcerative Colitis, may be more diffuse, frequent worse in right lower quadrant
What are some of the perianal conditions that occur in Crohns disease?
skin tags, fissures, fistuals, abscesses
What is a common side effect in patients with Crohns disease?
anorexia, poor weight gain, delayed growth in 40% patients
What are the symptoms and frequency in patients with UC?
bloody mucinous diarrheal stool (100%), abdominal pain (95%), tenesmus (75%)
What is tenesmus?
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.
What is the definition of Mild UC?
6 stools per day, no fever, no anemia, no hypoalbuminemia whereas moderate disease has greater than 6 stools per day, fever, anemia, and hypoalbunemia
What is the definition of severe UC disease?
flmnant high fever, abdominal tenderness, distention, tachycardia, leukocytosis, hemoorrhage, severe anemia, and more than 8 stools per day
What are rare complications of UC?
intestinal perforation and toxic megacolon
What are some late term complications of UC?
What are some of the extraintestinal sequelae similar in both diseses of IBD that preceded or accompnay the GI symptoms?
polyarticular arthritis, ankylosing spondylitis, primary scleosing cholangitis, chronic active hepatitis, sacroilitis, pyoderma gangrenosa, erythema nodosum, nephrolitiatis, apothous stomatitis, episcleritis, recurrent iritis, and uveitis
What are some diagnostic tools indivated in UC and crohns? And what are some of the findings?
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
What does radiographic examination with a double and contrast barium enema demonstrate in UC?
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
What is common and usually associated with iron deficiceny?
megaloblastic anemia secondary to folate and vitamin B12 deficicency may also be present
How common is an elevation of the erythrocyte sedimentation rate seen?
50% of cases of ulcerative colitis and in 80% of Crohn's disease cases
What is a common side effect of poor protein intake with patients with IBD?
Hypoalbuminemia caused by poor protein intake is common in individuals with severe symptoms
Why would one get a serum aminotransferase level in a patient with IBD?
serum aminotransferase levels are increased if hepatic inflmmation is a complicating feature
What would a stol examination reveal in patient with IBD?
blood and fecal leukocytes iwth a negative stool culture
What is the differential diagnosis of IBD?
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
What is the treatment of IBD?
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
What are some of the new geneticall engeineered drugs being used?
infliximab - antibody direct against tumor necrosis factor alpha, and it shows promise in control of significant crohn's disease
What are some some of the nutritional requirements of patients with IBD?
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
What are some of the longterm preventive exams that must be done for patients iwth UC?
patients with UC for more than 10 years need annual colonoscopy and rectal biopsy because of the high risk of colon cnacer and development
What is the rate of surgery in patients with UC and Corhns?
25% patients with UC and 70% children in Corhn's disease
When is surgery indicated in UC?
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
When is surgery performed in Corh's disease?
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