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NURG 604 Module 13 Exam Review (
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Gastroesophageal reflux (GER) •Very common in infants and typically resolves by 12 months •Causes include immature lower esophageal sphincter, supine positioning, small stomach capacity •Diagnosis can be made by H & P alone, upper GI, upper endoscopy, esophageal pH monitoring, or in older children, and a trial of acid suppression. •Red flags that warrant further studies include recurrent vomiting, bilious emesis, GI bleed, onset after 6 months of age, failure to thrive, fever, diarrhea, enlargement of liver and/or spleen, abdominal tenderness or distention, respiratory problems, irritability, or neurologic changes. •Treatment consists of feeding changes, medications, and surgery in severe cases. •DO NOT HESITATE to refer to a pediatric gastroenterologist. What is GERD? Symptoms? Treatment? GERD refers to the passage of gastric contents into the esophagus from the stomach through the LES. Symptoms may include recurrent regurgitation with/without vomiting, ruminative behavior, heartburn, chest pain, hematemesis, dysphagia, odonyphagia, respiratory disorders, halitosis. See table 40.4 for symptoms Treatment includes:
● Pharmacologic- H2 blockers, PPIs, and buffering agents ● Nutrition- Feeding techniques, volumes, and frequency of feeding should be normalized ● Lifestyle- Supine positioning during sleep, may be some benefit in older children to left-side positioning or elevation of HOB ● Surgical- fundoplication Reflux is not always treated, usually resolves by 18 months What position is best to sleep for reflux? Does that matter? Supine positioning. Positioning infants upright may worsen reflux. There may be some benefit in older children to left-side positioning or elevation of HOB Review possible surgical treatment of fundoplication for GERD Used for management of cases that have not responded to less invasive strategies, have life-threatening complications, or will have long-term dependence on medical therapy in which compliance or patient preference precludes ongoing use What is EoE? What is the management/treatment? Eosinophilic Esophagitis An emerging disease related to food ingestion. Characterized by an isolated inflammation of the esophagus by a specific WBC, the eosinophil. Recurrent vomiting and abdominal pain may occur in school-aged kids. Older children and adolescents often present with dysphagia, choking, and food impaction.
Hiatal Hernia •Sliding hiatal hernias are the most common
- If symptomatic, GERD is the main symptom •Congenital paraesophageal hernias are rare, but more serious
- Symptoms include pulmonary infections, vomiting, anemia, dysphagia, and failure to thrive •Diagnosis by upper GI or CT •Treat symptoms of GERD if present •Surgery in severe cases Pyloric Stenosis •Hypertrophy of the pylorus
•Progressive obstruction that presents between birth and 12 weeks of age, but more commonly seen at 2 - 4 weeks of age •Unknown etiology •Projectile postprandial vomiting, upper abdominal distention, prominent peristaltic waves, and a palpable olive-shaped mass in a small percentage of patients •Diagnosed by abdominal ultrasound and upper GI •Treatment is surgical and can typically be done laproscopically Gastric and Duodenal Ulcers •Affects males more commonly than females •Seen in patients with underlying illnesses, H. pylori infection, and excessive use of NSAIDS •Symptoms in younger children include vomiting and upper GI bleeding. Older children complain of epigastric pain •Diagnosed by endoscopy •Treatment includes medications for acid suppression (H2 receptor antagonists and PPIs are most commonly used in children), avoidance of food that increases symptoms. Aspirin, NSAIDS, caffeine, and alcohol should be avoided as well •Treatment for H. pylori include a combination of multiple meds
What type mass may be palpated with Intussusception Sausage like mass may be palpated Intussusception: symptoms? Physical exam? Management? Symptoms: intermittent colicky (crampy) abdominal pain, vomiting, and bloody mucous stools (currant jelly stools), screaming with drawing up of the legs with periods of calm, sleeping, or lethargy between episodes PE: Child appears glassy-eyed and groggy b/t episodes, sausage like mass may be felt in the RUQ of the abdomen with emptiness in the RLQ, abdominal distention and tender to palpation, grossly blood or guaiac-positive stools **Sausage like mass may be palpated Management:
- emergency management and consultation with a pediatric radiologist and a pediatric surgeon is recommended
- rehydration and stabilization of fluid status
- gastric decompression
- radiologic reduction using a therapeutic air contrast enema under fluoroscopy is the gold standard of treatment
- surgery necessary if perforation
- IV abxs are often administered to cover potential intestinal perforation, a period of observation following radiologic reduction is recommended (12-18 hours). Inguinal hernia
- A portion of the intestines protrude through a weakened area in the abdominal muscles
- Occurs more frequently in preterm infants and in males
- Often painless, inguinal or scrotal swelling seen on exam
- Should be reducible
- Diagnosis is made by exam and ultrasound if needed
- Manual or surgical reduction is required if incarcerated Umbilical Hernia
- Seen more commonly in full-term African American infants
- Typically resolve by 12-18 mos
- Diagnosis by physical exam
- Surgery not usually indicated until 3 years of age Acute appendicitis
- Most common reason for emergency abdominal surgery in children
- Peak age 15-30 years
- 40% incidence of perforation in children under 2
- Symptoms include epigastric or periumbilical pain that localizes to the RLQ, fever, N/V/D, constipation, and anorexia
- Chronic constipation (two or more of the following):
- Fewer than 3 bowel movements per week
- More than 1 episode of encopresis weekly
- Fecal impaction
- Retention and fecal withholding
- Pain with bowel movement
- Treatment
- Dietary changes
- Osmotic stool softeners
- Behavior modification Colstridium Difficile Infection (C. diff)
- Spore-forming gram positive bacteria
- Colonization is common in infants and children
- Hospitalized patients are at an increased risk. Other risk factors include prolonged use of antibiotics, intestinal injury, IBD, Hirschsprungs, and patients who are immunocompromised
- Symptoms include fever, abdominal pain, nausea.
- More severe symptoms include bloody diarrhea and abdominal tenderness
- Labs: Stool cultures or antigen testing
- Treatment: Stop the triggering antibiotics and begin Flagyl or Vancomycin. •Prevention: Good hand washing and avoiding overuse of antibiotics Acute Gastroenteritis (AGE)
- General term used to describe inflammation of stomach & intestine
- Signs and symptoms include:
- N/V/D, anorexia, and abdominal pain
- Usually viral, but can also be bacterial •Usually transmitted fecal-oral route from either infected person or contaminated water/food
- If viral, management is supportive, but watch diarrhea that is prolonged, for fever, presence of blood in the stool, and signs of dehydration.
- Antibiotics should only be used when etiology is bacterial. What is the most common cause of acute gastroenteritis (AGE) Viruses are the most common cause •Rotovirus: Severe vomiting, fever, and watery diarrhea •Norovirus: Severe N/V/D, fever, headache, body aches •Both are highly contagious
- GI symptoms include chronic diarrhea, abdominal distention, irritability, N/V, and poor weight gain. Stools are often pale, greasy, and foul-smelling.
- Onset is typically between 6 - 24 months of age (after first gluten intake)
- Non-GI symptoms include in undiagnosed patients include delayed puberty, short stature, delayed menarche, IDA, decreased bone density, elevated liver enzymes, arthritis, and epilepsy
- Labs: Antibody testing and intestinal biopsy for confirmation
- Treatment: Gluten-free diet for life Inflammatory Bowel Disease Crohns and ulcerative colitis Crohn Disease
- Chronic, relapsing inflammatory disorder of the bowel that can affect any part of the GI tract from the mouth to the anus
- Characterized by skip lesions involving entire thickness of the intestinal wall
- Symptoms depend on location of the lesions, but typically begin with irritable bowel symptoms, then progress to abdominal pain, diarrhea, and passage of blood and mucous.
- Usually diagnosed between 10-30 years of age
Crohns: Symptoms fever, weight loss, delayed growth velocity, short stature, delayed bone age, arthralgias and/or arthritis in large joints, obstructive symptoms associated with meals, bloating, early satiety, pain in the umbilical region and RLQ, anorexia, malabsorption and lactose intolerance, diarrhea (with or without blood or mucus) and pain with stooling, jaundice, oral aphthous, especially during exacerbations of illness Crohns: Diagnostic studies Diagnostic Studies: ● Inflammatory markers such as ESR, CRP, Nutritional ● Nutritional Labs: Albumin, total protein (consider iron panel, calcium, zinc, alkaline phosphatase, folate, B12) ● Other blood tests: CBC with diff, AST, ALT, total bilirubin, GGT, amylase, lipase ● Stool- routine culture, C.Difficile, blood, WBCs, and fecal alpha 1-antitrypsin, fecal calprotectin ● Radiologic studies- bone age, bone density, abdominal plain films, upper Gi series with small bowel follow-through, abdominal CT w/contrast ● Ileocolonoscopic is a 1st step to assess Crohn's. Other endoscopic studies include small bowel capsule endoscopy, push enteroscopy, single or double balloon enteroscopy, intraoperative enteroscopy or spiral enteroscopy. Esophageal endoscopy is recommended in children diagnosed with Crohn disease who have perianal disease ● Screen for TB if the child is at risk. Biologic agents used in Crohn disease therapy can activate latent TB. Crohns disease: Management Management:
- Involves the mucosal layer of the colon and rectum with no skip lesions.
- Usually diagnosed between 10-40 years of age
- Treatment:
- Anti-inflammatories, corticosteroids, antibiotics, antidiarrheal agents, and immunomodulators.
- Surgery may also be indicated.
- However, if you suspect that your patient has IBD, refer to a pediatric gastroenterologist. Ulcerative Colitis: diagnostic studies Diagnostic Studies: ● CBC with differential, iron-binding capacity, total protein, albumin, ESR, CRP ● Stool for WBCs, blood, and culture (bloody diarrhea with negative stool culture characteristics of UC). ● Bone age (usually delayed by 2 years) ● Colonoscopy (diffuse mucosal inflammation) ● Perinuclear neutrophil cytoplasmic antigen (+ in 60%-70%) ● Fecal calprotectin assay What are the symptoms of Ulcerative colitis? Symptoms: fever, weight loss, delayed growth and sexual maturation, arthritis and/or arthralgias of the large joints, anorexia, diarrhea, lower abdominal cramping, left lower quadrant pain, pain increased before stooling and passing gas, stool with bright red blood and mucus, nocturnal stooling, oral aphthous ulcers, skin lesions (erythema nodosum, pyoderma gangrenosum, and diffuse papulonecrotic eruptions). Management of Ulcerative Colitis
Management ● Goals of therapy include control the disease, prevent relapses and achieve normal nutrition, growth, and lifestyle ● Refer for colonoscopy, biopsy, definitive diagnosis, consultation, and close-follow up ● Medications ○ Topical mesalamine, oral 5-aminosalicylates, or topical steroids with topical mesalamine ○ Systemic steroids for moderate to severe UC ○ Thiopurines ○ Biologic agents ○ Hydrocortisone rectal preparation for tenesmus ○ Cyclosporine monotherapy ○ Probiotics ○ Curcumin ○ Iron supplementation to correct anemia ● Nutrition ○ Diet: high in protein and carbs, normal amount of fat, and decreased roughage. Omega-3 fatty acids have an anti-inflammatory effect on the bowel ○ Lactose is poorly tolerated ○ Parenteral or enteral nutritional supplements ○ refer for nutritional therapy to prevent or correct malnutrition and maintain and promote growth ● Monitor growth ● Surgery may be indicated (complete proctocolectomy with permanent ileostomy is curative). ● Refer for ophthalmologic exam to rule out ophthalmologic manifestations
● May occur as a result of a structural defect (esophageal narrowing-stricture, web, tumor, or extrinsic obstruction (vascular ring), neurologic (CP or muscular dystrophy), allergic, motor disorders, or mucosal injury (GERD, EoE, gastritis, or can also be due to caustic ingestion or medication). With vomiting it is important to consider the ___________ when formulating an appropriate diagnosis. age of the child A child comes in to clinic with mom saying her child has bloody vomit. What do you suspect? Bloody vomit accompanies active bleeding in the upper GI tract (gastritis, peptic ulcer disease) Dehydration is a concern with children- always important to remember. See Table 40.1 "Stages of Dehydration." page 770 What does bilious vomit indicate? An obstructive lesion generally causes bilious vomiting If a child comes to clinic with a chief complaint of vomiting, what should the NP do as part of the physical exam?
● Growth parameters and vital signs ● Neuro exam: nuchal rigidity decreased LOC, behavioral changes including irritability or lethargy. ● Abdominal exam: inspect for distention, abdominal scars from previous surgery (may be associated with obstruction and/or adhesion) or visible peristaltic waves. Auscultate bowel sounds (increased with gastroenteritis, decreased with obstruction, absent with ileus or peritonitis). Palpate for pain and/or rebound tenderness. Assess abdominal organs (liver and spleen size, masses). ● Respiratory exam: Tachypnea, decreased O2 sat, stridor ● Assessment of dehydration: assess cap refill (normal is <2), skin turgor, and tachypnea. 4 parameters used for assessment of dehydration are general appearance, eyes (sunken or not), moistness of mucous membranes, and presence of tears. Give an example of an antiemetic that can be used in children. Zofran (Ondansetron) Read about cyclic vomiting syndrome so you are familiar with this condition. ● An uncommon, idiopathic disorder that, in its most classical form, is characterized by recurrent, sudden-onset attacks of repeated retching and vomiting that are separated by symptom-free intervals of weeks to months. ● Etiology is unclear but often associated with conditions like migraine headaches and abdominal migraines ● Accompanying symptoms include pallor, listlessness, appetite loss, nausea, diarrhea, abdominal pain, fever, dizziness, headache, and photophobia.
