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Pediatric GI complaints

Pediatric GI complaints. Case #1. Case #1. 4 month-old infant presents for visit c/o frequent crying episodes lasting 3 hours at a time Ongoing for 4 weeks and occurs 5 days per week. Often starts in the afternoon, face turns red, fists clench, pulls knees to chest.

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Pediatric GI complaints

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  1. Pediatric GI complaints

  2. Case #1

  3. Case #1 • 4 month-old infant presents for visit c/o frequent crying episodes lasting 3 hours at a time • Ongoing for 4 weeks and occurs 5 days per week. • 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.

  4. 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

  5. Case #1 (exam) • Afebrile, P=140, RR=30, • Following 50% wt/age growth curve • Lungs CTA, heart RRR, abd +BS, soft, no masses • GU: nl male, circumcised

  6. Case #1 • What is the most likely diagnosis? • What one piece of information is inconsistent with the diagnosis?

  7. 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 with prolonged crying, no other studies indicated

  8. Infantile Colic • Treatment is reassurance for parents. • Almost always resolves by 3 months • Avoid changing formulas as this may impart the perception that infant is “allergic” or ill in some way. • Consider hospitalization in cases where crying is so intractable infant is at risk for abuse.

  9. Case#2 – the 4 Month WCC • At the 4 month WCC your medical student says she is concerned. • Patient has known trisomy 21 and is falling off Down’s 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

  10. Case#2 – the 4 month WCC • Mom reports decreased PO with “fat belly” • BM once per 5 days and she sometimes has to use her finger to get stool out • Epic reveals 5 BM’s in the first 72 hours of life • Vitals: afebrile, RR= 36, P = 110 • slightly distended abdomen, non-tender, tympanic • Anus appears normal

  11. Case#2 – the 4 month WCC • What’s the most likely diagnosis? • What part of the story is inconsistent with that diagnosis?

  12. Hirschsprung’s disease (Congenital Megacolon) • absence of ganglion cells in all or part of the colon (colon unable to relax) • 90% of infants with Hirschsprung’s fail to pass meconium in the first 24 hours of life. • 80% of patients present in the first 3 months of life with: Difficult BM’s, poor feeding and progressive abdominal distention Disease can go undiagnosed for years.

  13. Hirschsprung’s disease (Congenital Megacolon)

  14. Hirschsprung’s disease (Congenital Megacolon) 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)

  15. 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

  16. Case #3 – vomit comet

  17. 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.

  18. Case #3 -- PE • Afebrile, P = 160, RR = 24 • Weight up 2% from birth weight • Infant irritable and crying in Mom’s arms • Cor = rrr, pul = CTA; abd hyperactive BS • You observe a feeding: Vigorous feeder, but 5 minutes post feed you observe projectile vomiting that that is a bright green color.

  19. Case #2 • Quite confident in your diagnosis you order an ultrasound that shows the following:

  20. Case #2 -- • What is the most likely diagnosis? • What one piece of the presentation is inconsistent with this diagnosis?

  21. 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?

  22. Case #2 -- • Let’s 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 labs suggest?

  23. Pyloric Stenosis • Occurs in 2-4/1000 births • More common in white children, first born and those with MATERNAL family history • Doesn’t begin until 2-8 weeks of age • NON-BILLIOUS forceful or “projectile” vomiting gradually worsens

  24. 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.

  25. Pyloric Stenosis is a Medical EMERGENCY!

  26. Pyloric Stenosis is a Medical EMERGENCY!

  27. 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?

  28. Case #4 • NO!!!! • Can you name 2 reasons why it’s unlikely? • Age >3 months • Acute rather than subacute presentation

  29. Case #4 • Phone interpreter on line: No ill contacts • Vomiting this morning x 3 • Light brown diarrhea x 2 • Still peeing normal amount but decreased appetite • Exam reveals no sign of dehydration, clear lungs and normal heart, slightly distended abdomen and hyperactive BS • What next?

  30. Case #3 • Send home with good warning signs? • Frequent vomiting, dehydration, lethargy, high fever, bloody stools and bilious vomiting • Admit to hospital?

  31. 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?”

  32. Case #3 • What is the most likely diagnosis? • What one aspect of the case is inconsistent with the diagnosis?

  33. Intussusception • Telescoping of bowel that causes progressive edema and ischemia • 1-4/1000 infants (boys> girls) • Occurs from 3 months to 3 years (peak 9 months) • History: • 20 minute cycles of intermittent pain, • vomiting • Heme positive stools (95% of the time.)

  34. Intussusception Currant Jelly stool (mix of mucus and blood) seen in 16-60% of cases.

  35. Intussusception • Exam: may present w/ sausage-shaped RUQ mass

  36. Intussusception - treatment Contrast enema are 95% diagnostic 60-80% therapeutic CI: peritonitis, suspected perforation, shock

  37. Intussusception - treatment Surgery indicated when: Suspected performation Necrotic bowel Post reduction U/S or contrast study shows persistent filling defect

  38. Intussusception - treatment Ultrasound is becoming more widely used to diagnose and guide reduction 100% sensitive in skilled hands CT scan not recommended

  39. Intussusception -- Barium enema? Thought to increase risk of perforation so most use other contrast material or air.

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