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Pediatrics 7

Upper GI Disorders

    1. Tracheoesophageal fistula (TEF) and esophageal atresia (EA)
      1. Definition: failure of esophagus to develop as a continuous passage and a failure of the trachea and esophagus to separate into distinct structures
      2. Etiology: congenital, idiopathic, VATER syndrome (combination of vertebral, anorectal, and renal abnormalities in addition to TEF)
      3. Findings
        1. coughing
        2. cyanosis with feeds
        3. increased oral secretions
        4. depend on type of defect
      4. Diagnostics: history, abdominal x-rays
      5. Management
        1. pre-op: airway patency, NPO, IV therapy, positioning
        2. prevention of aspiration pneumonia
        3. surgery
    2. Gastroesophageal reflux disease: GERD (illustration)
      1. Etiology: physiological, functional, pathologic. Very common. If GERD occurs often and findings persist, treat it.
      2. Pathophysiology: defect in neural control of lower esophageal sphincter; stomach contents flow back into esophagus
      3. Findings
        1. vomiting or spitting up with meals
        2. recurrent aspiration pneumonia
        3. failure to thrive
        4. anemia
        5. for older child, heartburn
        6. heme-positive emesis or stools
        7. irritable
        8. pallor/cyanosis
      4. Diagnostics: history, barium swallow, upper GI series, esophageal pH, manometry studies, endoscopy
      5. Management
        1. depends on the severity of findings
        2. none if child is thriving without findings
        3. diet: thicken feeds; decrease caffeine, acid foods and solutions; give small, more frequent feeds with frequent burping
        4. position: prone with head of bed elevated, or flat prone following feeding and at night
        5. medications: H2-receptor antagonists, prokinetic agents
        6. surgery: fundoplication
      6. Concerns: airway, fluid and electrolyte balance, apnea
    3. Pyloric stenosis
      1. Etiology
        1. unknown cause
        2. hypertrophy, hyperplasia of circular muscles of pylorus
      2. Pathophysiology
        1. trigger irritates mucoid lining of pylorus; edema
        2. narrowed pylorus resists passing of fluid; chyme
        3. pylorus then enlarges and contracts with more force to attempt gastric emptying
        4. slowly pylorus constricts, and resistance persists until next cycle
      3. Findings
        1. usually begins at two to four weeks of age
        2. progressive, projectile, nonbilious vomiting after eating
        3. metabolic alkalosis
        4. movable, palpable, firm, olive-shaped mass in right upper abdominal quadrant
        5. irritability, crying, hunger
      4. Diagnostics: history, abdominal x-ray, upper GI, ultrasound
      5. Management
        1. pre-op: IV fluids, NPO, surgery (pyloromyotomy)
        2. post-op: small, frequent feedings initially, gradually increasing
      6. Concerns: fluid and electrolyte balance, airway, nutrition

Lower GI Disorders

    1. Constipation
      1. Definition: infrequent passage of firm or hard stools
      2. Etiology
        1. triggered by diet, medication, dehydration, emotions, or neurogenic
        2. structural disorders (Hirschsprung's disease) (illustration)
        3. systemic disorders (hypothyroid)
      3. Findings
        1. abdominal pain and cramping
        2. palpable, movable fecal mass
        3. malaise, anorexia, nausea
      4. Diagnostics: abdominal x-rays, rectal exam, palpation & percussion
      5. Management
        1. prevention (higher fiber diet, fluids, exercise, regular toileting habits)
        2. medications (stool softeners, enemas, laxatives)
    2. Diarrhea
      1. Etiologies: intestinal infections (bacterial, viral, parasitic); food intolerance; overfeeding; medications; stress; malabsorption; colon disease
      2. Pathophysiology:
        1. causative factor - irritates mucosal lining
        2. damages microvilli, increases secretion and decreases absorption
        3. abnormal intestinal water and electrolyte transport
        4. increased intestinal water permeability and dehydration in younger children.
        5. possible metabolic acidosis
        6. can be acute or chronic
      3. Findings
        1. dehydration (mild, moderate, severe)
        2. increased stooling
        3. increased heart & respiratory rate
        4. dry hot skin
        5. dry mucous membranes
        6. decreased urine, decreased tearing in infants
      4. Management
        1. goals: restore fluid and electrolyte balance and return bowel to normal functioning
        2. fluids: oral rehydration or parenteral rehydration
        3. medications: antibiotics, antidiarrheals
    3. Celiac disease = gluten-sensitive enteropathy (GSE) = celiac sprue
      1. Etiology: absorption problem with genetic predisposition, possibly immune abnormality
      2. Pathophysiology
        1. inability to digest gliadin (byproduct of gluten); permanent intolerance of gluten.
        2. increasing levels of glutamine in the intestine, toxic to mucosal cells
        3. atrophy of villi and decreased absorptive surface (illustration)
        4. malabsorption of fats, carbohydrates, vitamins and electrolytes
        5. gluten is found in the grain of wheat, barley, rye, and oats
      3. Findings (most often appears between ages of one and five years)
        1. diarrhea (stools: pale and watery, offensive odor)
        2. abdominal distention
        3. failure to thrive
        4. vomiting
        5. muscle wasting
        6. steatorrhea
        7. anorexia
        8. abdominal pain
      4. Diagnostics:
        1. history (symptoms occur three to six months after infant begins eating grains)
        2. serum anti-gliadin antibody (AGA)
        3. jejunal biopsy
      5. Management
        1. diet: gluten-free with vitamin supplements
        2. crisis: IV fluids, steroids