GI POTPOURRI. What is the best diagnostic test? Presentation #1: Vomiting. I have no disclosures

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1 I have no disclosures GI POTPOURRI Andi Marmor, MD Associate Professor, Pediatrics UCSF, San Francisco General Hospital Presentation #1: Vomiting Caraway, a 3 week old boy, is brought to your walk-in clinic with vomiting On further history, he has been vomiting since this AM, 1-2 minutes after each feed, and it looks like milk Otherwise he appears well, and is ravenously hungry What do you think he has? What is the best diagnostic test? A. Upper GI series B. KUB (abdominal film) C. Abdominal ultrasound D. Barium enema E. Abdominal CT

2 Pyloric Stenosis Pyloric Stenosis: Diagnosis Classic story: 3-5 weeks, males (4:1) Projectile, immediate post-prandial, nonbilious vomiting. Exam: ravenous, olive? Stabilization Typical lab abnormalities: Hypochloremic, metabolic alkalosis hypokalemia Normal Pylorus: Width: 3 mm Length: 14mm 4 mm 16 mm Vomiting: Neonate Spit up GERD Volvulus Other: CNS infection/trauma Inborn error of metabolism UTI Congenital obstruction Fast Facts: GERD in infants Extremely common in infants < 1 year Usually benign/mild (infant thriving) Pathologic = Poor wt gain, anemia, recurrent pneumonia, severe discomfort (Sandifer syndrome) Consider GI obstruction ALTE in young infants

3 GERD: Management If benign/mild Positioning, education, reassurance Consider trial of hypo-allergenic diet If severe/pathologic Consider upper GI for anatomic abnormality Trial of milk/soy-free diet in infant/mother Trial of thickened formula Trial of H2-blocker/PPI Fast Facts: Volvulus Twisting of small bowel around SMA Malrotation the biggest risk factor > 50% present with volvulus at <1 mo Bilious vomiting (90%) Distension, illappearance Malrotation: a risk factor for volvulus Diagnosis: Upper GI (85-95% sensitivity) Mesenteric attachment Normal Malrotated Images: Up to Date Images from Univ of Hawaii: Radiology Cases in Pediatric Emergency Medicine

4 Vomiting: Infant/Toddler Most likely: AGE Others: Post-tussive vomiting Ingestion/foreign body CNS infection/trauma Infection (pneumonia, UTI) Anaphylaxis AGE in infants/toddlers Typical course: Low grade fever, crampy abd pain~24 hrs (relieved by vomiting), Diarrhea for up to 2 weeks MOST children respond to PO hydration in small quantities PO ondansetron safe, single dose sufficient Diarrhea: encourage low-sugar drinks, protein, starches and yogurt! IV fluids in kids: A quick reminder Rehydration (bolus fluids): normal saline 20cc/kg repeat as needed 10cc/kg if cardiac, pulm or renal disease Prevent dehydration (maintenance): D5 ¼ NS < 20kg, D5 ½ NS > 20 kg 4cc/kg/hour for 1 st 10 kg + 2cc/kg/hour for 2 nd 10 kg + 1cc/kg/hour for remaining kg Vomiting: Child/Teen Most likely: AGE Others: Pyelonephritis Pregnancy Migraines DKA Liver, GB, Pancreas

5 Presentation #2: Abdominal Pain Sumac, a 6 yo girl, comes in with 3 wks of abdominal pain Pain is chronic, but intermittently worsening, able to sleep at night Missed 3 days of school, but complains on weekend as well. Normal appetite, no vomiting, dysuria, fever Denies constipation, has actually had a few episodes of diarrhea while playing What do you think she has? Fast Facts: Constipation Diagnostic challenge! Causes/management age-specific Functional (95%) Dietary Behavioral Organic (5%) Poor motility Structural abnormalities Constipation in neonates Consider obstruction, Hirschsprung s, CF Management Increase intake (H2O with caution) Prune juice Polyethylene glycol/lactulose are safe Glycerin suppositories if needed Constipation in infants/toddlers Diet Reduce milk/starch Increase fiber/juice, Behavioral Reduce discomfort Stool softeners, osmotic laxatives Create routine Once daily BM the goal

6 Constipation in older kids/teens Etiologies Diet Bathroom avoidance /embarrassment Dieting Sexual assault/rape Common cause of voiding dysfunction/uti Abdominal Pain: Neonate Colic Gas Volvulus Pretty much anything else (trauma, sepsis, UTI, etc) Abdominal Pain: Infant/Toddler AGE Intussusception Ingestion Non-accidental trauma Respiratory infection/asthma Abdominal Pain: Child/Teen Appendicitis Functional abdominal pain Other infections (pneumonia, UTI, strep) Henoch-Schonlein Purpura

7 Fast Facts: Pediatric Appendicitis Most common indication for pediatric emergency surgery 1-8% of kids evaluated for abd pain Diagnosis often delayed in younger children Most have symptoms for > 2 days Rupture highest in younger kids (<4) <5% of cases in kids < 5 years of age Appendicitis: H and P NO single history/exam finding is sufficient Up to 50% LACK anorexia, RLQ pain, rebound Exam tips Perform when child is comfortable, Observe position of comfort, response to movement Generalized tenderness could mean rupture Labs Elevated WBC, ANC, CRP may add to certainty Scoring tools may be helpful in unclear cases (Pediatric Appendicitis Score, Alvarado Score) Appendicitis: Imaging If history, exam, labs ALL concerning Consult surgery for appendectomy If history OR exam OR labs concerning Obtain ultrasound If concern remains moderate/high CT or MRI Protocols using U/S first are cost-effective, fewer missed appys, less radiation If history, exam, labs ALL reassuring Home with close follow up Presentation #3: GI bleed Nasturtium, a 7 week old girl, brought in by dad for flecks of blood in her stool. She is breast-feeding well, no vomiting or fever, and has been gaining weight well. Stools are soft, tinged with blood, Abd is soft and non-tender, and there are no anal fissures seen on exam.

8 What is the most likely diagnosis? A. Milk allergy B. Swallowed maternal blood C. H. Pylori D. Volvulus E. Food protein colitis Fast Facts: Food Protein Colitis Not a true allergy Inflammation of rectum/distal colon Milk>egg> corn>soy More common in breast fed infants! Resolves in 50% by 6mo, 95% by 9 mo Does NOT predict development of food allergies Food Protein Colitis: Management Breastfeeding infant: Continue breastfeeding! Eliminate ALL milk from mother s diet Milk or Soy formula-fed infant: Switch to protein hydrolysate formula Bleeding should improve within 3-4 days of removal of food from infant/mother s diet Allergy testing NOT recommended GI Bleed: Neonates Upper: Ingested maternal blood NG tube trauma Lower: Rectal fissure Necrotizing enterocolitis Volvulus Any cause of upper GI bleed

9 GI bleed: Infant/Toddler Upper Nose bleed Mallory-Weiss tear FB ingestion/toxic ingestion Lower Polyps Intussusception Constipation Meckel s diverticulum Fast Facts: Meckel s Diverticulum Incomplete obliteration of omphalomesenteric duct Bleeding from ectopic gastric tissue (50%) Rule of 2 s: 2% of population 2:1 male:female ratio 2 feet from ileocecal valve 2 inches long 2% experience a complication 60% of those with complications are < 2 yrs GI Bleed: Child/Teen Upper: Nosebleed Mallory-Weiss tear GI ulcer/h. Pylori Lower Polyps (2-8 years) Inflammatory Bowel Disease (peaks 15-25) Growth failure more likely in younger children THE END

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