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1. Morning Report July 9, 2012 Good Morning!!!

2. Semantic Qualifiers

4. Illness Script • Predisposing Conditions • Age, gender, preceding events (trauma, viral illness, etc), medication use, past medical history (diagnoses, surgeries, etc) • Pathophysiological Insult • What is physically happening in the body • Clinical Manifestations • Signs and symptoms that result from the pathophysiological insult • Use semantic qualifiers

5. Differential Diagnosis for emesis in infants • GER/GERD • Protein intolerance • Gastroenteritis • Pyloric stenosis • UTI • Malrotation with midgutvolvulus • Intestinal atresia/stenosis • Intussusception

6. GER/GERD • Predisposing conditions • Presentation in the first few months of life, peaks at 4 months • Resolves in up to ~90% by 12 months and nearly all by 24 months • Likely combination of genetic predisposition and environmental factors (liquid diet /overfeeding/horizontal body positioning) • Immature lower esophageal sphincter

7. GER/GERD • Pathophysiological insult • Passage of stomach contents into the esophagus, can be physiologic • Disease state caused by frequent or persistent episodes of esophageal exposure to caustic gastric contents that produce esophagitis/esophageal symptoms or respiratory sequelae or failure to thrive

8. GER/GERD • Clinical manifestations • Postprandial regurgitation, nonbillious • Irritability, arching, choking, gagging, feeding aversion • Failure to thrive • Respiratory symptoms of obstructive apnea, stridor, or lower airway disease • Sandifer syndrome

9. Protein-Induced Enterocolitis • Predisposing conditions • Manifests in the first several months of life • First form of allergy to affect infants and children • About 2.5% of children experience this allergy within the first 3 yrs of life • Most children “outgrow” this allergy, ~50% resolve within 3-5 years

10. Protein-Induced Enterocolitis • Pathophysiological insult • Cell-mediated hypersensitivities • Lymphocytes, primarily food allergen-specific T cells, secrete cytokines that lead to chronic inflammatory process in skin, GI tract, or respiratory tract • Most commonly provoked by cow’s milk or soy-based formulas

11. Protein-Induced Enterocolitis • Clinical manifestations • Irritability • Protracted vomiting and diarrhea that may result in dehydration • Vomiting generally occurs 1-3hrs after feeds • Prolonged exposure leads to abdominal distention, bloody diarrhea, anemia, and failure to thrive

12. Gastroenteritis • Predisposing conditions • Risks include environmental contamination , increased exposure to enteropathogens • Young age, immunodeficiency, malnutrition, lack of exclusive or predominant breast-feeding • 2nd leading cause of child mortality worldwide

13. Gastroenteritis • Pathophysiologic insult • Numerous pathogens: viral, bacterial, and parasitic • Noninflammatory diarrhea caused by enterotoxin production by some bacteria, destruction of villus cells by viruses, adherence by parasites, and adherence and/or translocation by bacteria • Inflammatory diarrhea caused by bacteria that directly invade the intestine or produce cytotoxins that cause fluid, protein and cells to enter the intestinal lumen

14. Gastroenteritis • Clinical manifestations • Acute onset of vomiting followed by diarrhea, abdominal cramps, and possible fever • Vomiting is a self-protective process that may reduce the load of infectious organisms or associated toxins/irritants • Watery versus bloody diarrhea related to etiology • Timing of symptoms related to whether preformed toxins are present and to the enteropathogen involved

15. Pyloric Stenosis • Predisposing conditions • Males affected 4 to 6 times more frequently • 1/3 of cases in first-born infants • Genetic predisposition • Use of erythromycin • Increased incidence with B and O blood types

16. Pyloric Stenosis • Pathophysiological insult • Hypertrophy and spasm of the pyloric muscle resulting in gastric outlet obstruction • Abnormal muscle innervation, elevated serum levels of prostaglandins, and infant hypergastrinemia have been implicated • Also, reduced neuronal nitric oxide might contribute to the pathogenesis

17. Pyloric Stenosis • Clinical manifestations • Typically a 3- to 6-week-old infant with progressive or intermittent vomiting after feeding • Nonbilious emesis, often projectile in nature • Infant is often hungry after vomiting • Hypochloremichypokalemic metabolic alkalosis and dehydration • Palpable small “olive-shaped mass” in right mid-epigastric area, visible gastric peristaltic wave after feeding

18. Urinary Tract Infections • Predisposing conditions • Female, uncircumcised males • Primary or secondary urinary tract obstructions • Indwelling catheters

19. Urinary Tract Infections • Pathophysiological insult • Cystitis – infection localized to the bladder • Pyelonephritis – infection of the renal parenchyma, calyces, and renal pelvis • Renal abscess – intrarenal or perinephric • Most common organism: E. coli; other organisms: Enterococcus, Pseudomonas, Klebsiella, Proteus, S. saprophyticus

20. Urinary Tract Infections • Clinical manifestations • Neonates: failure to thrive, feeding problems, direct hyperbilirubinemia • Infants: feeding problems, failure to thrive, vomiting, diarrhea, unexplained fever • >2yrs: urgency, dysuria, frequency, abdominal pain

21. Malrotation with Volulus • Predisposing conditions • Majority present in first year of life, >50% present within first month of life • Often associated with other abnormalities of the abdominal wall – such as diaphragmatic hernia, gastroschisis, and omphalocele • Also associated with heterotaxy syndrome – complex of congenital anomalies including congenital heart disease, malrotation, and either asplenia or polysplenia

22. Malrotation with Volulus • Pathophysiological insult • Nonrotation occurs when, in utero, the bowel fails to rotate after it returns to the abdominal cavity; leaving the cecum near the right upper quadrant • This results in an extremely narrow mesenteric root susceptible to volvulus • Abnormal mesenteric attachments (Ladd bands) extend from the cecum across the duodenum, causing partial obstruction

23. Malrotation with Volulus • Clinical manifestations • About ~60% of children with malrotation present with bilious vomiting during the first month of life – Could be due to duodenal obstruction by Ladd bands or volvulus • If bilious emesis due to volvulus, then venous drainage of the gut is impaired, leading to ischemia, pain, tenderness, and possibly bloody stools • If the bowel undergoes ischemic necrosis, the child may appear septic

24. Intestinal Atresia/Stenosis • Predisposing conditions • Congenital partial or complete blockage of the intestine (1:1500 live births) • Small intestine is the most common site of intestinal atresia/stenosis (~90%) • Possible prenatal history of polyhydraminos

25. Intestinal Atresia/Stenosis • Pathophysiological insult • Intrinsic causes include inherent abnormalities of intestinal innervation, mucus production, or tubular anatomy • Extrinsic causes involve compression of the bowel by vessels, organs (annular pancreas), and cysts

26. Intestinal Atresia/Stenosis • Clinical manifestations • Classic symptoms: bilious vomiting and abdominal distention • Findings more subtle if the obstruction is partial • Obstruction high in the intestinal tract results in high-volume, frequent, bilious emesis with little or no distention. Pain is intermittent and usually relieved by vomiting. • Obstruction in the distal small bowel leads to moderate or marked abdominal distention with emesis that is progressively feculent.

27. Intussusception • Predisposing conditions • Most common between 3 months – 6 years of age, Rare in neonates • Most common abdominal emergency in children <2years • Male:female ratio of 3:1 • 90% idiopathic; 2-8% with recognizable lead points • Seasonal peaks in spring and autumn • Risk factors: Lymphoid nodular hyperplasia, HSP, CF

28. Intussusception • Pathophysiological insult • Proximal intestine is telescoped into a distal portion of intestine • Most often ileocolic, less common cecocolic and rarely ileo-ileal • Constriction of the associated mesentery leads to venous congestion, edema and intestine ischemia, then mucosal bleeding

29. Intussusception • Clinical manifestations • Sudden onset of severe paroxysmal colicky pain that recurs • Painful episodes associated with legs and knees flexed • Lethargy can be associated and out of proportion to the abdominal symptoms • Vomiting occurs in most cases, nonbilious in the early phase and can be bilious in the later phase • “Currant jelly stool” • “Sausage-shaped mass” may be palpable

31. Intussusception

32. Intussusception Illness Script Predisposing Conditions • Age 6-24 months • Very rare before 3 months and after 6 years • Male: Female 3:1 • 90% - no etiology, healthy child • Sometimes associated with viral Illness or gastroenteritis • Rare cases: HSP, CF, Celiac dz, Crohn disease, leukemia

33. Intussusception Illness Script Pathophysiologic Insult • Telescoping of the intestine into an area distal to it • 95% involve the ileocecal valve • Age < 2 years: typically no etiology for lead point • Older children: 5-10% have lead point • Meckel’s, polyp, appendiceal stumps, enteric duplication, ectopic pancreas, foreign body, mass • Compressed mesentery venous obstruction intestinal mucosal ischemia  leakage of blood and mucus into lumen • Bowel ischemia can lead to release of endogenous opiods

34. Intussusception Illness Script Clinical Manifestations • Intermittent, colicky episodes of abdominal pain • Normal between episodes • Vomiting (starts non-bilious, may progress to bilious) • Bloody stool • Abdominal exam often normal • Pain over site of intussusception; “sausage mass” • Lethargy

35. Imaging • Abdominal x-rays • 25% show normal gas pattern • Crescent sign • Ultrasound • Target sign • Very accurate • Test of choice

38. Treatment • Contrast or air enema • Diagnostic and therapeutic • Surgery aware and present • More successful when symptoms present for <24hrs • 10% recur • Most within 24hours of reduction – observation • Surgical reduction warranted when contrast enema unsuccessful • 15% of patients require surgical intervention

39. Thanks for your attention!