Pediatrics 8
Celiac disease = gluten-sensitive enteropathy (GSE) = celiac sprue
Etiology: absorption problem with genetic predisposition, possibly immune abnormality Pathophysiology
inability to digest gliadin (byproduct of gluten); permanent intolerance of gluten. increasing levels of glutamine in the intestine, toxic to mucosal cells atrophy of villi and decreased absorptive surface ( illustration ) malabsorption of fats, carbohydrates, vitamins and electrolytes gluten is found in the grain of wheat, barley, rye, and oats
Findings (most often appears between ages of one and five years)
diarrhea (stools: pale and watery, offensive odor) abdominal distention failure to thrive vomiting muscle wasting steatorrhea anorexia abdominal pain
Diagnostics:
history (symptoms occur three to six months after infant begins eating grains) serum anti-gliadin antibody (AGA) jejunal biopsy
Management
diet: gluten-free with vitamin supplements crisis: IV fluids, steroids
Hirschsprung's disease
Definition / etiology: congenital aganglionic megacolon Pathophysiology
absence of autonomic (parasympathetic) ganglion cells, usually at rectum and part of large intestine intestine does not propel stool stool builds up; colon dilates, constipation results with risk of intestinal rupture
Findings
newborn: failure to pass stool or merconium in first 24 hours of life, reluctance to ingest fluids, bile-stained vomitus, distended abdomen, "ribbon-like" stools - flat, wide, and wavy later: failure to thrive, distended abdomen, constipation, signs of fecal impaction
Diagnostics: history and physical exam, radiographic barium enema, rectal biopsy, anorectal manometry Management
surgical correction: remove aganglionic portion temporary ostomy for three to six months, then reanastomose
Appendicitis ( illustration )
Etiology:
virus, impacted fecal material, parasites, foreign body most common in children school-age or older
Pathophysiology
trigger obstruction increased mucous accumulation distention, capillary occlusion and engorgement of capillary walls eventually, abscesses and fistula form possible perforation leading to peritonitis
Findings
colicky abdominal pain
generalized but usually localizes to lower right quadrant most intense pain at McBurney's point
nausea, vomiting possible fever and chills decreased bowel sounds guarding of abdomen rebound tenderness
Diagnostics: physical exam, laboratory tests (CBC with WBC), MRI Management
surgical removal IV fluids antibiotics analgesics
Concerns: perforation and peritonitis, fluids Caution: do not give enemas or cathartics or use heating pad if suspected appendicitis
Genitourinary System ( illustration ) Common findngs: renal and urinary tract (UT) disorders Urinary tract infection
Definition
bacteria in urine and inflammatory response may involve any structure in urinary system: kidney (pyelonephritis), ureters, bladder (cystitis) or urethra findings will point to location peak age: toddler to preschool age
Etiology
bacterial, structural defect, physiological extrinsic (example: foley catheter, medications) improper perineal hygiene
Pathophysiology
organism usually ascends through urethra to bladder. with a structural defect, urine flows back from ureters into kidney.
Findings often depend on age
under two years: often nonspecific resembling GI disturbance
failure to thrive, feeding problems, nausea/vomiting, dysuria, persistent diaper rash, abdominal distention
over two years:
enuresis, daytime incontinence in toilet-trained, foul smelling urine frequency and urgency, dysuria possible pyelonephritis: similar signs but with fever, back pain, and lethargy
Diagnostics: urine culture and serum testing, radiographic testing Management
antimicrobials antipyretics analgesics fluids (IV and oral) education
wipe front to back (in girls) do not delay urination
Concerns
hydration recurrence long term complications such as scarring, renal failure
Enuresis
Definition: inability to control bladder functions, often due to maturation; nocturnal, or "bed wetting" very common Etiology/findings
primary: never dry at night, and due to CNS or psychological reasons secondary: child has been toilet trained and becomes incontinent again
findings as above due to infection, medications, trauma
Diagnostics: history, urine tests, serum culture Management
primary
have the child participate in activities limit fluid at night, void before bedtime imagery, behavioral conditioning
tricyclic antidepressant; imipramine desmopressin (DDAVP)
secondary: treat underlying cause
