* 6yo boy complains of hard bowel movements every 5th day. Exam is normal for weight and height. Abdomen is soft and hard stool is palpable on rectal exam.
* Constipation is the infrequent passage of hard dry stools. Obstipation is the inability to pass any stools.
* Most common cause of constipation is voluntary withholding, functional constipation. This is outside of infancy as an infant cannot voluntarily withhold.
* Constipation can occur secondary to defects in filling or emptying of the rectal vault. Other causes include imperforate anus, Hirschsprung syndrome, infantile botulism (no honey in first year of life).
* Constipation causes hard stools, sometimes liquid stools (looks like diarrhea) then encopresis. * Think about Hirschsprung anytime a neonate presents with constipation.
* Diagnosis for Hirschsprung is by biopsy. Encopresis more commonly with functional constipation.
* Functional constipation can occur with toilet training too early, child will toilet train on its own when ready. * Physical exam shows abdominal distension and poor weight gain in Hirschsprung. Anal tone normal in Hirschsprung and functional constipation. Rectal exam likely no palpable stool in Hirschsprung. With functional constipation, you will palpate hard stool immediately in the rectal vault.
* Monometry can be done for functional constipation. Biopsy can be done too but shouldn’t need to get to that point. --- Gastrointestinal: Vomiting
* Celiac disease causes bloating due to malabsorption and diarrhea. Will have buttocks wasting due to FTT and chronic diarrhea.
* Just vomiting in neonate think obstruction (volvulus, malrotation).
* Infant differential for vomiting includes GE reflux, food allergies, milk protein intolerance, overfeeding, inborn errors of metabolism (galactosemia, phenylketonuria).
* Just vomiting in infants and up, think gastroenteritis. Then systemic infections, toxic ingestions, appendicitis, ulcers, pancreatitis.
* Newborn presents with bilious vomiting with every feed. Abdominal film reveals a double bubble. Suspect duodenal atresia. Associated with trisomy 21.
* Duodenal atresia presents early, usually first day of life, no abdominal distension. Treatment is surgical. * 4mo is admitted with episodes of apnea occurring 20-30mins after feeds. The mother states the baby has been spitting up since birth. She is at the 5th percentile for weight. This is GE reflux. Most babies will spit up a little bit, but the problem is when the baby is not gaining weight.
* With GE reflux, lower esophageal sphincter pressure is reduced or inappropriate relaxation of sphincter, or hiatal hernia, or delayed gastric emptying which can back things up.
* GE reflux occurs and then there is a reflexive laryngospasm, causing apnea. Can aspirate (coughing, wheezing). * Patients with developmental delay and cerebral palsy tend to have more reflux.
* Symptoms of GE reflux vary, can have spitting up, forceful vomiting “gushes out”, apnea as presenting sign, chronic cough and wheezing due to aspiration, poor weight gain is significant.
* Sandifer syndrome is GE reflux with opisthotonus positioning (spasmodic torsional dystonia). The back arching is a reflex mechanism to relieve the pain and prevent the reflux.
* Best way to diagnose GE reflux is a pH probe.
* Treatment is anti-reflux measures (sitting up when feeding/sleeping), thickening the feeds, medications (e.g. H2 blockers, prokinetics).
* pH probe is placed in distal 1/3 of the esophagus and measures pH overnight, if pH drops too low for too long then you have your diagnosis.
* Other studies for GE reflux include technetium “milk” scan or barium swallows. Best is pH probe though. * Anti-reflux measures include elevating the head of the bed, adding cereal to feeds to thicken, antacids, H2 receptor blockers, protein-pump inhibitors, pro-kintetics.
* If medical management fails, surgical measures including Nissen fundoplication where a cuff is made around the esophagus to help prevent reflux.
* Majority of patients will get better without treatment as they get older.
* 4week old boy has non-bilious projectile vomiting. Exam is remarkable for a small mass palpated in the abdomen. * Pyloric stenosis is a gastric outlet obstruction, more common in males, more common in first born child, tends to be genetic predisposition. If one child with pyloric stenosis, 5% chance of another. If mother had pyloric stenosis, 25% of her having a child with pyloric stenosis.
* Symptom is non-bilious projectile vomiting, usually around 3-4 weeks. Baby is hungry after vomiting. Vomiting is very forceful, gushes, shoots, like a hose, like exorcist.
* May palpate abdominal “olive” mass on exam. May see/feel peristaltic wave on exam. May be jaundiced, may have weight loss, may be dehydrated.
* Best test is abdominal ultrasound. Barium could be done but has to be sucked out.
* Other lab findings include hypokalemic hypochloremic metabolic alkalosis due to repeated vomiting. * Pylorus will be elongated with a small outlet, showing a “string sign” with “mushroom cap” or “umbrella” as barium is squirted out into duodenum.
* Ultrasound will show thickened wall, “donut sign”. Hole of donut is the opening, donut is muscular wall.
* Treatment is surgical. First, rehydrate, correct electrolytes. Do pyloromyotomy and patient is eating again 8h later. --- Gastrointestinal: Bleeding
* GI bleeding can be hematemesis (blood stained vomitus, upper GI), melena (soft black tarry stools, from any part of GI tract), hematochezia (bright red stool, lower GI, could be upper). Children have a quicker GI transit time and blood itself is a cathartic, so bright red blood in the stool could be from higher up, but generally is not.
* Upper GI < 1yo think gastritis, swallowed maternal blood, peptic ulcer (duodenal and gastric), malrotation, volvulus. Upper GI > 1yo, think peptic ulcer, varices, gastritis.
* For swallowed maternal blood, best test is Apt test. Apt test differentiates from fetal hemoglobin (belongs to newborn) versus adult hemoglobin (swallowed maternal blood). Swallowed blood could be from delivery or during nursing if mother has cracked/bleeding nipple.
* Lower GI < 1yo think anal fissure (most common). Anal fissure could be from irritation due to diarrhea or hard stool that tore the wall. Other causes include intussusception, necrotizing enterocolitis, malrotation, volvulus. * Lower GI > 1yo think peptic polyp, intussusception, Meckel diverticulum, diarrhea, IBD, hemorrhoid. * 13yo girl complains of chronic cramping abdominal pain and diarrhea. She has noticed occasional blood in her stools. She has had fever off and on for three months and has complained of persistent right wrist pain. CBC shows anemia and elevated sed rate (ESR).
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