Term
| What is the etiology of gastroesophogeal reflux? |
|
Definition
-transient relaxation of the lower esophageal sphincter (LES)
-inadequate relaxation of the LES to changes in abdominal pressure (crying, coughing, defecation)
-anatomic disruption of the GE junction (hiatal hernia) |
|
|
Term
| What is the incidence of GE reflux in infants? |
|
Definition
-50% of infants < 3 mos
-67% of infants 4 mos
-5% of infants 10-12 mos |
|
|
Term
| What is the clinical presentation of GE reflux in infants? |
|
Definition
Emesis
-variable volumes
-non bloody, non bilious
-effortless to mildly forceful
Esophagitis
Anemia
Weight loss, inadequate gain
Respiratory complications
-ALTE
-apnea
-cyanosis
-wheezing
-cough
Discomfort
-irritability
-back arching
-difficult or painful swallowing
-food refusal
Abnormal neck posture
-Sandifer syndrome |
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|
Term
| What is the clinical presentation of GE reflux in preschoolers? |
|
Definition
|
|
Term
| What is the clinical presentation of GE reflux in older children and adolescents? |
|
Definition
-chronic heartburn
-regurgitation
-difficulty swallowing
-food impaction |
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|
Term
| What are key points of the hx of GE reflux in infants? |
|
Definition
-onset
-feeding hx
---coughing
---choking
---color change
-irritability
-emesis
---amount
---frequency
---presence of blood or bile
-ALTE
-elimination
---stool frequency
---color
---consistency |
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|
Term
| What are key points of the hx of GE reflux in older children? |
|
Definition
-pain (chest, substernal, epigastric)
-nighttime awakening
-regurgitation
-bad taste in mouth
-food getting "stuck"
-relationship of diet, food to symptoms
-chronic cough, hoarseness, sore throat |
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|
Term
| What are key points of the physical exam in GE reflux? |
|
Definition
-growth
-observing feeding
-rash |
|
|
Term
| What is the differential diagnosis for GE reflux? |
|
Definition
-food allergies
-eosinophilic esophagitis
-achalasia
-cyclic vomiting syndrome
-rumination |
|
|
Term
| What is the clinical presentation of food allergy? |
|
Definition
Infants
-blood in stool
-skin rash
-wheezing
-rhinorrhea
Older children
-vomiting
-abdominal pain |
|
|
Term
| What is the etiology of eosinophilic esophagitis? |
|
Definition
-chronic inflammatory d/o
-eosinophilic infiltrate of the esophageal mucosa r/t food allergy |
|
|
Term
| What is the clinical presentation of eosinophilic esophagitis? |
|
Definition
-food impaction
-known food allergy
-no improvement on reflux medication |
|
|
Term
| What is the etiology of achalasia? |
|
Definition
-motor dz
-abnormal esophagial peristalsis: LES fails to relax, upper esophagus dilates |
|
|
Term
| What is the clinical presentation of achalasia? |
|
Definition
-vomiting
-weight loss
-food impaction
-chest pain
-adults, but as early as 9 years old |
|
|
Term
| What is the clinical presentation of cyclic vomiting syndrome? |
|
Definition
-interspersed with normal states of health
-bouts of intense vomiting
-abdominal pain x hours or days
-family h/o migraines |
|
|
Term
| What is the management of cyclic vomiting syndrome? |
|
Definition
-prevention of vomiting and dehydration
-usually resolves |
|
|
Term
| What is the etiology of rumination? |
|
Definition
-chronic regurgitation of partially digested food that is either ejected or re-swallowed
-infants and young children with developmental delay, institutionalized, understimulated |
|
|
Term
| What is the clinical presentation of rumination? |
|
Definition
-halitosis
-sour taste in mouth |
|
|
Term
| What is the management of rumination? |
|
Definition
-behavioral therapy
-psychiatric tx |
|
|
Term
| What are diagnostic tests for GE reflux? |
|
Definition
-history and PE are diagnostic
-UGI series
-pH probe study
-scintigraphy
-endoscopy and biopsy
-impedance |
|
|
Term
| What are general management options for GE reflux? |
|
Definition
-lifestyle changes
-pharmacotherapy
-surgical therapy |
|
|
Term
| What are the management options for GE reflux in infants? |
|
Definition
-small frequent feedings with frequent burping
-thickened feedings: 1 TB rice cereal/oz or commercial antiregurgitation formula
-trial of hypoallergenic formula
-supervised prone position after eating
-avoid tight diapers and waistbands
-avoid tobacco smoke |
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|
Term
| What are the management options for GE reflux in older children and adolescents? |
|
Definition
-sleep position: left side or prone, HOB elevation
-avoid lying down immediately after eating
-avoid caffeine, chocolate, spicy food, alcohol
-avoid tight clothing
-weight loss |
|
|
Term
| What are pharmacotherapy management options for GE reflux? |
|
Definition
-antacids
-histamine-2 receptor antagonists
-proton pump inhibitors
-protokinetic agents |
|
|
Term
| What are guidelines for Histamine-2 receptor antagonists in GE reflux? |
|
Definition
-Zantac (ranitidine) 5-10 mg/kg/day or Pepcid (famotidine) 1 mg/kg/day best choice for < 1 year old
-Tagamet (cimetidine) fallen out of favor bc inhibits CP 450 system |
|
|
Term
| What are guidelines for proton pump inhibitors in GE reflux? |
|
Definition
-Prilosec (omeprazole) 0.6-1 mg/kg/day and Prevacid
-none approved for < 1 year old
-superior mucosal healing and symptom relief than H2RA |
|
|
Term
| What are guidelines for protokinetic agents in GE reflux? |
|
Definition
-Reglan (metoclopramide) 0.1-0.2 mg/kg/dose
-erythromycin 2 mg/kg/dose 20 min before meals to promote gastric emptying |
|
|
Term
| What are surgical management options for GE reflux? |
|
Definition
Nissen fundoplication
-last resort for children who have failed medical therapy with reflux, aspiration, and severe asthma
- |
|
|
Term
| What is the etiology of failure to thrive? |
|
Definition
-descriptive term, not diagnosis
-inadequate physical growth, or inability to maintain expected growth rate |
|
|
Term
| What is the incidence of failure to thrive? |
|
Definition
-10% of young children
-80% of cases in < 18 mos, usually < 3 yrs old
-increased in urban and rural low SES |
|
|
Term
| What is the diagnostic criteria for failure to thrive? |
|
Definition
-weight for age < 3rd percentile
OR
-weight crossing down 2 SDs
OR
-weight for height < 10th percentile |
|
|
Term
| What are the classifications of failure to thrive? |
|
Definition
-inadequate caloric intake
-inadequate absorption
-increased metabolism
-defective utilization |
|
|
Term
| What are causes of inadequate absorption? |
|
Definition
-Celiac dz
-CF
-cow's milk protein allergy
-vitamin or mineral deficiencies
-liver dz
-short bowel syndrome |
|
|
Term
| What are causes of increased metabolism? |
|
Definition
-hyperthyroidism
-chronic infection
-malignancy
-renal dz
-hypoxemia
---congenital heart dz
---chronic lung dz |
|
|
Term
| What are causes of defective utilization? |
|
Definition
-genetic abnormalities
-congenital infxns
-metabolic d/o
---storage dz
---amino acid d/o |
|
|
Term
| What are key points of the PE for failure to thrive? |
|
Definition
-weight, height, head circumference
-dysmorphic features
-underlying dz: clubbing, increased RR
-signs of child abuse |
|
|
Term
| What are key points of the history for failure to thrive? |
|
Definition
Medical
-birth history: complications, prematurity, SGA
-recent illnesses
-chronic medical conditions: anemia, asthma, CHD
-stool pattern
-vomiting, reflux
Social
-home environment
-SES
-multiple caregivers
Family
-siblings
-short stature
-mental illness
Nutrition and feeding |
|
|
Term
| What is the management for failure to thrive? |
|
Definition
-nutrition intervention: high calorie diet
-feeding behavioral modification
-followed monthly |
|
|
Term
| What are key points of the history for abdominal pain? |
|
Definition
-age at onset
-diet, appetite, satiety
-nausea, emesis, reflux
-diarrhea, constipation
-family history, travel
-interference with school, play, family |
|
|
Term
| What are key points of the physical exam for abdominal pain? |
|
Definition
-weight, height, growth velocity
-Tanner stage
-BP
-mouth: dental caries, apthous ulcers
-abdomen: rebound, mass, ascites, flank pain, liver, spleen
-perianal: skin tags, fissures, stool for occult blood
-skin: rashes, clubbing |
|
|
Term
| What are diagnostic tests for abdominal pain? |
|
Definition
-CBC with diff
-ESR or CRP
-CMP (LFTs, albumin)
-amylase and lipase
-Celiac panel: serum Iga
-UA
-stool: ova and parasite, Giardia antigen, guiac
-hydrogen breath test
-abdominal US
-UGI
-abdominal Xray |
|
|
Term
| What is the clinical presentation of organic abdominal pain? |
|
Definition
-weight loss or poor growth
-nocturnal pain
-recurrent emesis
-regular school attendance
-heme positive stool
-abnormal PE findings
-abnormal lab values: decreased albumin, increased ESR or CRP, anemia, elevated amylase/lipase |
|
|
Term
| What are the differential diagnoses for abdominal pain? |
|
Definition
-peptic d/o
-allergic, inflammatory: eosinophilic esophagus
-inflammatory: Chron's, Celiac
-functional d/o
-carbohydrate malabsorption
-constipation
-gynecological d/o |
|
|
Term
| What is the etiology of peptic d/o? |
|
Definition
Disruption of the protective mucosal barrier of the lining of the stomach
-excessive acid production
-H. pylori infection
-aspirin
-NSAIDs
-sepsis
-trauma
-stress |
|
|
Term
| What is the clinical presentation of peptic d/o? |
|
Definition
-epigastric or umbilical pain
-early morning/night arousal with pain
-reflux symptoms
-nausea
-early satiety
-postprandial pain
-positive family hx of PUD |
|
|
Term
| What is the management for peptic d/o? |
|
Definition
-H2RA or PPI for 4-6 weeks
-GI for endoscopy |
|
|
Term
| What is the incidence of H. pylori? |
|
Definition
-50% of world population infected
-more common in developing countries
-infection persists unless treated |
|
|
Term
| What conditions are associated with H. pylori? |
|
Definition
-gastritis
Adults
-peptic ulcer dz
-gastric adenoma carcinoma
-gastric MALT syndrome
Children
-gastritis
-ulcers
-gastric MALT lymphoma |
|
|
Term
| What are diagnostic tests for H. pylori? |
|
Definition
-gold standard: EGD with biopsy
-blood test (IgA and IgG don't necessarily indicate active infection)
-C-urea breath test
-H. pylori stool antigen |
|
|
Term
| What is the management for H. pylori? |
|
Definition
| -7-14 day of triple therapy: PPI + clarithromycin + amoxicillin/metroniadozole |
|
|
Term
| What is the incidence of functional abdominal pain? |
|
Definition
| -2-4% of pediatric office visits |
|
|
Term
| What is the etiology of functional abdominal pain? |
|
Definition
-alteration in brain-gut interaction
-stress and poor coping strategies
- |
|
|
Term
| What is the clinical presentation of functional dyspepsia? |
|
Definition
weekly for at least 2 months:
-persistent or recurrent pain/discomfort above the umbilicus
-not relieved by defecation
-no evidence of underlying pathology |
|
|
Term
| What is the clinical presentation of IBS? |
|
Definition
weekly for at least 2 months:
-abdominal discomfort/pain associated 25% of the time with:
---improvement with defecation
---change in stool frequency, form
-no evidence of underlying pathology |
|
|
Term
| What is the clinical presentation of abdominal migraine? |
|
Definition
-paroxysmal episodes of intense, acute, periumbilical pain that lasts at least 1 hr and is associated with 2 or more of the following:
---anorexia
---nausea
---emesis
---HA
---photophobia
---pallor
-usual health between episodes
- |
|
|
Term
| What is the clinical presentation of functional abdominal pain? |
|
Definition
weekly for at least 2 months:
-episodic or continuous abdominal pain
-insufficient evidence for other GI d/o
-no underlying pathology |
|
|
Term
| What is the clinical presentation of FAP SYNDROME? |
|
Definition
FAP with:
-loss of daily functioning
-additional somatic symptoms |
|
|
Term
| What are key points for the history of functional abdominal pain? |
|
Definition
-parental anxiety, depression, somatization
-child anxiety, depression
-school absenteeism
-decreased quality of life |
|
|
Term
| What is the management of functional abdominal pain? |
|
Definition
-reassurance
-acknowledgement of reality of pain
-encourage regular activity and diet
-behavioral therapy to manage pain: biofeedback, guided imagery
-antispasmodic medication (Hyoscyamine)
-psychological evaluation |
|
|
Term
| What is the incidence of IBD? |
|
Definition
-~1 million Americans
-~100,000 children
-25% diagnosed before 20 years old |
|
|
Term
| What is the etiology of IBD? |
|
Definition
-inherited abnormality of immune system in intestinal wall
-exaggerated response to bacteria or pathogens
-environmental factors weaken mucosal integrity of gut: infection, cigarette smoke, drugs, stress |
|
|
Term
| What is the etiology of ulcerative colitis? |
|
Definition
-only large intestine
-almost always involves rectum
-only mucosal layer |
|
|
Term
| What is the etiology of Crohn's dz? |
|
Definition
-anywhere in GI tract
-may be rectal sparing
-through full thickness of intestinal wall |
|
|
Term
| What is the clinical presentation of ulcerative colitis? |
|
Definition
-diarrhea
-rectal bleeding
-crampy abdominal pain
-tenesmus: feeling of incomplete defecation
-urgency |
|
|
Term
| What is the clinical presentation of Crohn's dz? |
|
Definition
-diarrhea
-may be bleeding
-abdominal pain
-n/v
-weight loss/no gain
-perianal dz |
|
|
Term
| What are the extraintestinal manifestations of IBD? |
|
Definition
Systemic
-growth
-fever
Joints
-arthralgias
-sacroileitis
-akylosing spondylitis
Skin
-erythema nodosum
-pyoderma gangrenosum
Ocular
-episcleritis
-uveitis
Liver
-sclerosing cholangitis
Oral
-apthous ulcers
-pyostomatitis vegetans
-GD
Other
-pulmonary
-vascular
-cardiac
-neurologic
-renal |
|
|
Term
| What are diagnostic tests for IBD? |
|
Definition
Lab
-CBC
-ESR or CRP
-CMP
-nutritional assessment
-stool: hemoccult, bacteria, O & P, C. diff
Procedure
-endoscopy
-colonoscopy
-upper endoscopy
-biopsies
Radiology
-upper GI with small bowel follow through
-abdominal CT
-abdominal MRI |
|
|
Term
| What is the incidence of constipation? |
|
Definition
-3% of general pediatric visits
-25-30% of pediatric gastroenterologist visits
-0.3-28% worldwide
-higher in LBW, CP, autism, obesity, ADD
-highest during toilet training |
|
|
Term
| What is the clinical presentation of organic constipation? |
|
Definition
-fever
-abdominal distension
-anorexia
-nausea
-vomiting
-weight loss or poor weight gain |
|
|
Term
| What are etiologies of organic constipation? |
|
Definition
-Hirshsprung dz
-anorectal malformations
-neuromuscular d/o
-Celiac dz
-CF
-metabolic conditions leading to water depletion (e.g. diabetes insipidus)
-hypothyroidism
-lead poisoning |
|
|
Term
| What is the clinical presentation of infant dyschezia? |
|
Definition
| -at least 10 min of straining and crying before passing a soft stool |
|
|
Term
| What is the etiology of infant dyschezia? |
|
Definition
| -inability to coordinate increased intra-abdominal pressure with relaxation of pelvic floor |
|
|
Term
| What is management of infant dyschezia? |
|
Definition
| -avoid rectal stimulation |
|
|
Term
| What is the clinical presentation of constipation in adolescents? |
|
Definition
|
|
Term
| What is the clinical presentation of encopresis? |
|
Definition
-involuntary fecal soiling or leaking of liquid feces around retained stool mass
-after 1-5 years of chronic constipation
-more often later in day or when tired
-associated urinary incontinence or UTI |
|
|
Term
| What are the key points of the history for functional constipation? |
|
Definition
-passage of meconium within 1st 24 hours
-age of toilet training, stool withholding behaviors
-size and frequency of stools
-painful defecation, bleeding
-soiling |
|
|
Term
| What are key points for the PE in functional constipation? |
|
Definition
-stool mass
-perianal exam: + anal wink, + cremasteric reflex
-rectal exam
-back lesions
-DTRs
-growth parameters |
|
|
Term
| What diagnostic tests are used in constipation? |
|
Definition
-CBC
-ESR
-CMP
-thyroid function tests
-celiac screen
-sweat test
-lead level
-UA
-abdominal Xray
-unprepped barium enema
-Xray of spine
-spinal MRI |
|
|
Term
| What is the management of constipation? |
|
Definition
-aggressive, early
-oral daily laxative x months (polyethylene glycol 3350 0.8 g/kg/day)
-possibly stimulant laxative (biscodyl or senna)
-regular toileting after meals
-positive reinforcement
-psychologist |
|
|
Term
| What is the etiology of Hirshsprung dz? |
|
Definition
-aganglionosis of the colon: absence of enteric nerve cells
-always begins at anus |
|
|
Term
| What is the incidence of Hirshsprung dz? |
|
Definition
-1:5,000 live births
-5x more common in boys
-associated with other congenital abnormalities, like Down syndrome |
|
|
Term
| What is the clinical presentation of Hirshsprung dz in infants? |
|
Definition
-failure to pass meconium within 24 hrs
-infrequent, explosive BM
-abdominal distension
-vomiting
-failure to thrive, poor growth
-enterocolitis: diarrhea, fever, sepsis |
|
|
Term
| What is the clinical presentation of Hirshsprung's dz in older children? |
|
Definition
-absence of soiling/encopresis
-ribbon-like stools
-chronic progressive constipation
-failure to thrive
-fecal impaction
-abdominal distention |
|
|
Term
| What diagnostic tests are used in Hirshsprung's disease? |
|
Definition
-unprepped barium enema
-anorectal manometry
-rectal suction biopsy (if positive, full thickness biopsy) |
|
|
Term
| What is the management for Hirshsprung's dz? |
|
Definition
| -surgery (usually in 2 parts) diverting colostomy then "pull-through" |
|
|
Term
| What is the etiology of enterocolitis? |
|
Definition
-inflammation of colonic mucosa, erosion of lining
-pre- and post-surgery for Hirshsprung's dz |
|
|
Term
| What is the clinical presentation of enterocolitis? |
|
Definition
-abdominal distension
-foul-smelling, water stools
-lethargy
-emesis
-fever
-hematochezia: bright red bloody stools
-shock
-death |
|
|
Term
| What is the management of enterocolitis? |
|
Definition
|
|
