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Pediatric GI Disease Tory Davis, PA-C Table of Contents Esophagus Stomach – Pyloric stenosis, foreign bodies Intestine/Colon – Abd wall defects, intestinal atresia, intussusception Infectious/Inflammatory Abd Pain Red Flags Awakening at night with belly pain Pain localizing away from umbilicus Wt loss, growth deceleration Extraintestinal symptoms (fever, joint pain, dysuria) Blood in stool Anemia, elevated ESR + FHx PUD, IBD Esophagus Tracheoesophageal fistula- faulty separation of trach and esoph Cough, cyanosis, choking after first feed. Recurrent pneumonia, wheezing 40% with other abnormalities VATER syndrome- vertebral defects, anal atresia, TEF, radial limb dysplasia Pyloric stenosis Hypertrophic pyloric stenosis Males 1:150, females 1:750 Postprandial nonbilious projectile vomiting, ages 4-6 weeks Hypokalemic metabolic alkalosis, dehydration Olive-shaped mass, R of midline Marked peristaltic waves postprandial Dx: US TX: Pyloromyotomy Foreign Bodies My personal favorite: Bezoar- mass of ingested material that fails to pass stomach – Trichobezoar – Phytobezoar – Lactobezoar Abd pain, anorexia, vomiting, weight loss Foreign bodies Coins, marbles, button batteries, legos…you name it, they eat it Lodge in esophagus at cricopharyngeal muscle, level of aortic arch, LES Sx: cough, choking, stridor, odynophagia, drooling, or asymptomatic If in esoph, needs removal (endo, foley) – Prevent ulceration/bleeding/perforation If in stomach, this too will pass – Manage conservatively, monitor Abd Wall Defects Omphalocele- herniation of abd viscera (covered with peritoneum) thru abd wall at umbilicus. Not covered with skin. Primary closure of small defects, staged surgeries for large defects High incidence of associated malformations Abd wall defects Umbilical hernia- incomplete closure of fascia of umbilical ring Herniated omentum/bowel covered with skin Spontaneous healing with small defects – Surgical repair if defect is >1.5 cm at 2 years – Manual reduction ineffective Intestinal Atresia Failure of a portion of the intestinal tract to completely form Bilious vomiting within hours to 2 days after birth Duodenal- xray “double bubble” Jejeunal/ileal atresia- more common than duodenal Anorectal malformation 1:5000 Careful perianal exam in newborn Rectal or anal agenesis Rectal atresia Anal stenosis Imperforate anus Meckel’s Diverticulum Vestigial remnant of omphalomesenteric duct Rule of 2s – – – – – – Most often presents clinically at 2 years old 2% of population Males 2x females 2 feet from ileocecal valve 2% symptomatic 2 inches long Meckel’s Diverticulum Most common presenting symptom is painless rectal bleeding Also: – Intussusception – Volvulus – Diverticulitis (can resemble acute appendicitis) Hirschsprung Disease Congenital aganglionic megacolon Absence of normal enteric nerves in a segment of large intestine Suspect in infant failing to pass meconium in 1st 24 hours Chronic constipation Failure to thrive, abd distention, anemia, undernourished PE: Palpable stool in abd with empty rectum Hirschsprung Disease Dx- barium studies, aganglionic rectal bx Tx: “pull through” surgery Midgut Volvulus Emergent bowel obstruction in which loop of bowel has twisted on itself Caused by congenital intestinal malrotation Presents 0-30 days Bilious vomiting (from obstruction), severe pain (from bowel ischemia) Dx: UGI Tx: Surgical (Ladd’s procedure) Inguinal hernia Abdominal contents in patent processus vaginalis (thru which the testicle descends into scrotum, 50% remain patent) More common in preemies and boys Painless swelling, manually reducible Incarcerated Hernia Age 0-12 months Hard, painful non-reducible groin mass Fussy, anorexia, +/- emesis Dx by exam Tx surgical (hernioplasty) to avoid bowel necrosis Intussusception Section of bowel telescopes into distal segment Idiopathic – CF, lymphoid hyperplasia patches, Meckel diverticulum Ages 6-18 months Acute onset colicky, intermittent abd pain Intussusception Fetal position, vomiting Sausage-shaped mass in upper abd Current jelly-colored stools Dx: Barium enema (bonus- may also reduce the intussusception) Tx: if barium enema failed, or if clinical signs of perforation or peritonitis: surgical reduction Colic Periods of unexplained paroxysmal bouts of crying Rule of 3s – >3 hours/day, >3 days/week, >3 weeks in healthy, well-fed infant between age 3 weeks and 3 months Typical late afternoon, early evening bouts 15-25% of infants Multifactorial etiology-infant, parent, and environmental factors – Not necessarily GI Colic Listen to the parents! Reassure the parents! Teach the parents! Emphasize that this is self-limited Changing formula? – “The art of medicine is to amuse the patient while nature cures the disease.” • Voltaire Probiotics Phenylketonuria Autosomal recessive genetic disorder Deficiency in the enzyme phenylalamine hydroxylase (PAH) – Metabolizes phenylalamine (PA) to tyrosine Untx’d accumulation of PA leads to irreversible brain damage, MR, seizures. Screen at birth. No cure Tx by diet low in PA, high in tyrosine Yes, kids also have: IBD Crohn’s Ulcerative colitis Lactase deficiency Celiac disease Appendicitis Peptic ulcer disease GERD But you already know about those… And I know you didn’t forget it all already…. And if you did, you’ll be sure to go review….