Peds GI

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Pediatric GI complaints

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Case #1

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Case #1

4 month-old infant presents for visit c/ofrequent crying episodes lasting 3 hours at atime

Ongoing for 4 weeks and occurs 5 days perweek.

Often starts in the afternoon, face turns red,

fists clench, pulls knees to chest. Tried switching to say formula and

simethicone neither helped at all.

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Case #1

Parents are both radiologists

Birth history is NSVD

Eating about 3oz formula 8x/day (24 ounces) No fevers, rashes, vomiting, or colds

Seems like he needs to poop, but stool is soft

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Case #1 (exam)

Afebrile, P=140, RR=30,

Following 50% wt/age growth curve

Lungs CTA, heart RRR, abd +BS, soft, nomasses

GU: nl male, circumcised

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Case #1

What is the most likely diagnosis?

What one piece of information is

inconsistent with the diagnosis?

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Infantile Colic

Crying in an otherwise healthy infant>3hours/day; >3days/week x > 3 weeks

Starts around 2 weeks, peaks at 6 weeks and

ends by 4 months Incidence = 12-20% (80% of parents report their

child had colic)

Afebrile and normal PE. Screen for weight loss.

Weak evidence to screen for UTI in infants withprolonged crying, no other studies indicated

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Infantile Colic

Treatment is reassurance for parents.

Almost always resolves by 3 months

Avoid changing formulas as this may impartthe perception that infant is allergic or ill in

some way.

Consider hospitalization in cases where cryingis so intractable infant is at risk for abuse.

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Case#2 the 4 Month WCC

At the 4 month WCC your medical studentsays she is concerned.

Patient has known trisomy 21 and is falling off

Downs growth curve Had a recent cold

Taking about 15 ounces of formula/ day

Sleeping about 10 hours every night Wet diaper about every 3-4 hours

Responds normally to sound

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Case#2 the 4 month WCC

Mom reports decreased PO with fat belly

BM once per 5 days and she sometimes has touse her finger to get stool out

Epic reveals 5 BMs in the first 72 hours of life

Vitals: afebrile, RR= 36, P = 110

slightly distended abdomen, non-tender,

tympanic Anus appears normal

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Case#2 the 4 month WCC

Whats the most likely diagnosis?

What part of the story is inconsistent withthat diagnosis?

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Hirschsprungs disease

(Congenital Megacolon)

absence of ganglion cells in all or part of thecolon (colon unable to relax)

90% of infants with Hirschsprungs fail to pass

meconium in the first 24 hours of life. 80% of patients present in the first 3 months

of life with:

Difficult BMs, poor feeding andprogressive abdominal distention

Disease can go undiagnosed for years.

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Major complication (25%): enterocolitis (fever,

foul-smelling diarrhea significant mortality)

Diagnosis: AXR? barium enema

Confirmation: rectal biopsy

Treatment: colectomy

http://www.aafp.org/afp/20061015/1319.html (accessed 10/29/09)
http://www.aafp.org/afp/20061015/1319.htmlhttp://www.aafp.org/afp/20061015/1319.html

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Case #3 -- Hx

28yo G1P1 Mom brings her boy for evaluation

to your clinic in Sitka, AK

CC = vomiting

4 weeks old

Describes vomiting after almost every feeding

of breastmilk. Some spitting up began at 2

weeks, but now occurs almost every time.

Seems hungry and crying all the time

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Case #3 vomit comet

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Case #3

No coughing, fever or chills

Tummy is gurgling a lot

No diarrhea FmHX: Mom has scar on abdomen from some

surgery when she was an infant.

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Case #3 -- PE

Afebrile, P = 160, RR = 24

Weight up 2% from birth weight

Infant irritable and crying in Moms arms Cor = rrr, pul = CTA; abd hyperactive BS

You observe a feeding: Vigorous feeder, but 5

minutes post feed you observe projectilevomiting that that is a bright green color.

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Case #2

Quite confident inyour diagnosis you

order an

ultrasound that

shows the

following:

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Case #2 --


What one piece of the presentation

is inconsistent with this diagnosis?

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Case #2 bonus questions

Since a storm is coming in, you call your

surgical consult in Seattle to see about

medically evacuating the infant. (Sitka does

not have a pediatric surgeon)

What test or study did the pediatric surgeon

want that changed the management plan?

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Case #2 --

Lets see what the lytes show!

NA =136 (low normal) K = 3.4 (slightly low)

Cl = 90 (low) HCO3 = 36(elevated) Cr = 0.8 (normal) BUN = 12 (normal)

WHAT metabolic abnormality do these labssuggest?

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Pyloric Stenosis

Occurs in 2-4/1000 births

More common in white children, first born

and those with MATERNAL family history

Doesnt begin until 2-8 weeks of age

NON-BILLIOUS forceful or projectile

vomiting gradually worsens

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Pyloric Stenosis

Hypertrophic Pyloric Valve can be felt in the

RUQ in about 50% of cases.

Feels like an olive

These cases proceed to surgery directly

Ultrasound is nearly 100% sensitive and

specific in skilled hands and it is the imagining

study of choice where available.

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Pyloric Stenosis is a Medical

EMERGENCY!

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Pyloric Stenosis is a Medical

EMERGENCY!

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Case #4

18 month-old male

Previously healthy

Presenting with colicky abdominal pain H/o crying and bringing knees to chest

But he appears normal on your initial exam

Afebrile. RR = 28, P=130

DO YOU THINK THIS IS COLIC?

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Case #4

NO!!!!

Can you name 2 reasons why its unlikely?

Age >3 months

Acute rather than subacute presentation

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Case #4

Phone interpreter on line: No ill contacts Vomiting this morning x 3

Light brown diarrhea x 2

Still peeing normal amount but decreasedappetite

Exam reveals no sign of dehydration, clearlungs and normal heart, slightly distended

abdomen and hyperactive BS What next?

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Case #3

Send home with good warning signs? Frequent vomiting, dehydration, lethargy, high

fever, bloody stools and bilious vomiting

Admit to hospital?

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Case #3

PO challenge? Watched him drink and he soon started screaming

Now refusing all PO

RN reports more vomiting and loose BM ; she checked

both for blood and they were both negative

More careful exam reveals a mass located in the right

side of the abdomen

Preceptor suggested a contrast enema and admission

to the hospital for observation

Your preceptor looks sort of excited, closes his

facebook account, and asks, So, what do you think

might be going on?

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Case #3


What one aspect of the case is

inconsistent with the diagnosis?

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Intussusception

Telescoping of bowel that causesprogressive edema and ischemia

1-4/1000 infants (boys> girls)

Occurs from 3 months to 3 years (peak 9months)

History:

20 minute cycles of intermittent pain,

vomiting

Heme positive stools (95% of the time.)

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Intussusception

Currant Jellystool

(mix of mucus

and blood)seen in 16-60%

of cases.

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Intussusception

Exam:

may present w/ sausage-shaped RUQ mass

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Intussusception - treatment

Contrast enemaare 95%

diagnostic

60-80%therapeutic

CI: peritonitis,

suspectedperforation,

shock

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Surgery indicatedwhen:

Suspected

performationNecrotic bowel

Post reduction U/S or

contrast study showspersistent filling defect

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Ultrasound isbecoming more

widely used to

diagnose andguide reduction

100% sensitive

in skilled handsCT scan not

recommended

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Intussusception -- Barium enema?

Thought toincrease risk of

perforation

so most useother contrast

material or air.

Documents

Peds GI