Pediatric GI complaints

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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/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.

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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, P140, RR30,
• Following 50 wt/age growth curve
• Lungs CTA, heart RRR, abd BS, soft, no masses
• 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
  gt3hours/day gt3days/week x gt 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

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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.

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Case2 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
  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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Case2 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 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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Case2 the 4 month WCC

• Whats the most likely diagnosis?
• What part of the story is inconsistent with that
  diagnosis?

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Hirschsprungs disease (Congenital Megacolon)

• absence of ganglion cells in all or part of the
  colon (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 and progressive
  abdominal distention
• Disease can go undiagnosed for years.

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Hirschsprungs disease (Congenital Megacolon)
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Hirschsprungs 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)

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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 projectile vomiting
  that that is a bright green color.

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Case 2

• Quite confident in your diagnosis you order an
  ultrasound that shows the following

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Case 2 --

• What is the most likely diagnosis?
• 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 labs suggest?

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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, P130
• DO YOU THINK THIS IS COLIC?

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Case 4

• NO!!!!
• Can you name 2 reasons why its unlikely?
• Age gt3 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 decreased appetite
• Exam reveals no sign of dehydration, clear lungs
  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 is the most likely diagnosis?
• What one aspect of the case is inconsistent with
  the diagnosis?

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Intussusception

• Telescoping of bowel that causes progressive
  edema and ischemia
• 1-4/1000 infants (boysgt 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.)

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Intussusception

• Currant Jelly stool
• (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 enema are 95 diagnostic
• 60-80 therapeutic
• CI peritonitis, suspected perforation, shock

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Intussusception - treatment

• Surgery indicated when
• Suspected performation
• Necrotic bowel
• Post reduction U/S or contrast study shows
  persistent filling defect

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Intussusception - treatment

• Ultrasound is becoming more widely used to
  diagnose and guide reduction
• 100 sensitive in skilled hands
• CT scan not recommended

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Intussusception -- Barium enema?

• Thought to increase risk of perforation
• so most use other contrast material or air.