Transcript Gastrointestinal Case Studies from Infancy to Adulthood

Kristen Wallis, MD
Children’s Medical Group
Hamden, CT
April 8, 2016
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Common Presentations
Differential Diagnoses
Workup
Treatment
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One month old baby boy
◦ No significant PMH
◦ Full term NSVD
◦ Gaining weight well
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One week increasing spitting up
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?Questions for parents
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Fever
◦ Infectious
 Sepsis
 UTI
 Gastroenteritis
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Bilious
◦ Bowel obstruction
 Surgical emergency
 Volvulus/malrotation
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Projectile
◦ Pyloric stenosis
 First born male
 Not surgical emergency
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No fevers
Yellow seedy stools
Waking on own for feeds
Nonbilious, nonprojectile emesis
Up to 1 hr after feeds
Recent increase in volume of feeds
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Well appearing
Normal vital signs
Stable growth curves
Soft nondistended abdomen
Spit up formula
No arching or discomfort
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?Diagnosis
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Gastroesophageal reflux
◦ Effortless regurgitation of gastric contents
◦ Common physiologic process
◦ Usually outgrown by 9-12 months
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?Treatment
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Smaller more frequent feeds
Reflux precautions
Thickened feeds
?Dietary changes
Medications
◦ Discomfort and poor weight gain
◦ H2 blockers
◦ Proton Pump Inhibitors
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Four month old baby girl with diarrhea
◦ PHx Eczema
◦ Otherwise unremarkable history
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?Differential Diagnosis
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Infectious
◦ ?Daycare or older sibling
◦ Rotavirus
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Milk Protein Allergy
◦ Blood streaks in stools
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Celiac
◦ FTT
◦ 9-24 months when gluten introduced
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Gaining weight appropriately at WCCs
Breastfeeding well
◦ Recent formula supplementing with return to work
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Intermittent fussy and distended belly
◦ Tried simethicone and Gripe Water
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2 days with increasing mucous and now
blood streaks in stools (guaiac +)
Diagnosis?
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Cow’s Milk Protein Allergy
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Most common food allergy in young children
Affects ~2-7% kids <4yrs, most prevalent in infants
Immunologic response to cow’s milk proteins
Different than lactose intolerance
 Non-immune mediated
◦ Commonly outgrown by 1yr
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Removal of cow’s milk proteins from diet
◦ Breastfed
 Dietary elimination
 Milk and soy (25-30% cross-reactivity)
 Ca/D supplement
◦ Formula fed
 Not soy
 Extensively hydrolyzed formula with probiotic
 Amino acid based formulas
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Grossy bloody stools improve in few days
◦ Microscopic lasts 2-6wks, longer if still in diet
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3 ½ year boy with 4 days of vomiting
◦ Seen on day 2, vomiting decreasing, otherwise well
◦ Dx AGE (going through preschool)
◦ Returned on day 4 increasing vomiting, lethargy
 No fevers or diarrhea
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Physical exam
◦ Afebrile, tachycardic
◦ Pale, tired, dry cracked lips
◦ Soft abdomen, no masses, generalized tenderness
and guarding
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Differential Diagnosis?
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AGE
Appendicitis
Obstruction
UTI
Ingestion
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IVF and bloodwork sent
Head CT negative
Urine tox negative
Urinalysis negative, culture pending
Sodium 122 to admit to PICU
◦ Hydrating 4 days with water only
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Abdominal ultrasound negative for
appendicitis but +soft tissue mass
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?Diagnosis
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Intussusception
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Invagination of a part of the intestine into itself
Most common abdominal emergency in early
childhood
◦ Particularly <2yrs
◦ Majority idiopathic
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Unusual in adults
◦ Usually pathologic
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Treatment
◦ Enema
 Air vs barium
◦ Surgery
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Air enema
◦ Only partial reduction
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Emergency surgery
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Small bowel into small bowel
15cm necrotic bowel resected
End to end anastomosis
IV antibiotics then home on oral
Doing well at follow up
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10yr old female seen for WCC
◦ Growth curve as shown
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Has always been small
◦ Assumed familial
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Regular diet plus daily Boost/Carnation
Occasional abdominal cramps
Intermittent constipation
School SW for anxiety and facial movements
thought to be behavioral
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?Differential Diagnosis
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?Workup
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Bone Age
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Chronological age 10 yrs 0 months
Standard deviation 11.7 months
Skeletal age 7 yrs 10 months
>2 SD
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Bloodwork
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Normal
Normal
Normal
Normal
Normal
Normal
CBC and ESR
electrolytes
liver enzymes
thyroid functions
LH and FSH
insulin like growth factor
◦ Transglutaminase IgA very high 2,900 (0-19.9)
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?Diagnosis
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Celiac Disease
◦ Lifetime sensitivity to the wheat protein gluten and
related alcohol-soluble proteins in rye and barley
◦ Presents any age from 6mo-85yrs
 Peaks in infancy up to 2 and young adulthood
◦ Classic presentation
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Diarrhea (explosive and foul-smelling)
Fat malabsorption
Abdominal bloating
Failure to thrive
Short stature and delayed puberty
Behavior problems and/or anxiety
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Gluten free diet for life
◦ Wheat, rye, barley, oats
◦ Normalization of symptoms and enteropathy
 Can take up to 6 months
◦ 70% see symptomatic improvement within 2 weeks
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Complications if not diet compliant
◦ Intestinal lymphoma or other GI malignancies
◦ Strictures
◦ Skeletal disorders
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2 month GI follow up
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Completely gluten free
Gained 2 lbs
Resolution of abdominal pain
Resolution of anxiety
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14 year old with increasing abdominal
cramps and blood streaked stool
◦ Recent URI now resolved
◦ History constipation when young
◦ Poor diet (frequent fast food, limited fruits and
veggies), little water
◦ Hard painful stools past few wks, now with blood
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Diagnosis?
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Complications?
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Chronic Constipation
◦ Hemorrhoids
◦ Anal fissures
 Perianal skin tags on exam
◦ Rectal prolapse
◦ Encopresis
 Progressive rectal dilation and decreased rectal
sensation
 Fecal impaction
 Secondary soiling
◦ Rare intestinal obstruction
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Cleanout
◦ Miralax
◦ Milk of magnesium
◦ Impaction
 Glycerine suppository
 Enemas
 If hospitalized NG meds
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Maintenance
◦ Miralax
 Titrate to 1-2 soft daily stools, decreased straining
◦ Water
◦ Fiber
 Diet, supplements
◦ Toilet sits
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22 year old male previously well now with
bloody diarrhea
?Differential diagnosis
◦ 2 primary categories
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Infectious
◦ Bacterial
 Salmonella, Shigella, Campylobacter, EColi0157,Yersinia
◦ Viral (usually nonbloody)
 Rotavirus, Norovirus
◦ Parasitic
◦ Staphylococcal food poisoning
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Inflammatory
◦ Crohn’s Disease
◦ Ulcerative Colitis
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External bleeding
◦ Hemorrhoid
◦ Fissure
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3 days prior started with nausea and multiple
episodes vomiting
Periumbilical pain
Low grade fevers
Following day developed diarrhea with increasing
amounts blood mixed throughout
No recent travel or camping
◦ Stream water with protozoa (Giardia, Crypto)
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No hx undercooked meat or eggs
Recently cleaned his brother’s
turtle tank
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?Labs
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If >1wk or bloody
Stool studies
◦ Culture
 Salmonella, Shigella, Campylobacter, EColi
◦ Ova and Parasites
 x3
◦ C Difficile
 Recent hospitalization with antibiotics
◦ Guaiac
 Red drinks
 Formula and antibiotics
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?Diagnosis
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Salmonella gastroenteritis
◦ Supportive care
 Hydration
 Electrolyte balance
◦ No anti-diarrheal meds
 Prolong GI transit time
◦ Consider antibiotics only in high risk patients
 Children <3mo
 Immunocompromised
 Chronic GI tract disease
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UpToDate.com, (2016) Wolters Kluwer Health
Cabana, M. (2015) The 5-Minute Pediatric
Consult, 7th edition, Lippincott, Williams and
Wilkins
Kliegman, R., Stanton, B., Geme, J., Schor, N.
(2015) Nelson Textbook of Pediatrics, 20th
edition, Elsevier Health Sciences