* Will post correctons
GI 2/17/03 8 a.m.
Dr. Gilfillan
Scribe: Daniel Richey
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Intro. To Clinical Pediatric Gastroenterology
I. Goals
- Be able to understand common or important basic concepts and clinical
problems.
- To initiate the process of attaining clinical competence in both the diagnosis and
management of GI problems.
- To emphasize history and physical examination.
- To prepare us for GI 2
- To prepare us for the COMLEX
II. Most common pediatric problems in gastroenterology
- Neonatal Jaundice
- Gastroesophageal Reflux ( very different from adult version)
- Vomiting
- Diarrhea
- Constipation
- Abdominal Pain
1) Neonatal Jaundice(50-70% of all newborns will have jaundice)
- Major cause is physiologic jaundice.
* A problem based on the immaturity of the liver, in particular a
problem with the conjugation of bilirubin. Conjugation involves
the modification of fat soluble bilirubin into water soluble
bilirubin.
- Breast feeding
* An infant with poor breast feeding can present with jaundice and
lack of energy.
- Hemolytic Disease
* Almost always manifests in the 1st 24 hours
- Breast Milk
* Jaundice doesn’t start until 4 or 5 days after birth in this case.
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Two types of jaundice are direct and indirect. Indirect is the
predominate finding and is fat-soluble, while direct is water soluble.
The indirect can cross the blood/brain barrier and deposits in certain
areas of the brain. This leads to a condition called Kernicterus, or
Bilirubin Encephalopathy. Anything above 20 should be treated
vigorously.
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2) Gastroesphageal Reflux (GER)
- Majority of reflux in infants is physiologic.
- Reflux is the movement of things that reach the stomach back up. If
they come back up and are seen then it’s reflux with regurgitation.
- Bradypnea, apnea, bradycardia due to reflux caused by stimulation of
vagal bundle
- Reasons for infant GER
* lack of neuromuscular control over swallowing
* pressure changes in peritoneal cavity
* lower esophageal sphincter has occasional relaxations
- GER ceases usually at about 8-14 months
* infant assumes a more upright position
* starts eating heavier foods
- Failure to Thrive
* Infant spitting up so much that they’re not getting enough
energy for growth. Most serious problem with GER.
- Wheezing, coughing, and aspiration are unusual and usually occur with
a child that is having some failure to thrive.
- Acute Life Threatening Event (ALTE)
* Apnea can occur
- Overall CNS function
* Children at 1 yr. of age that still exhibit symptoms should be
evaluated for some kind of CNS disorder.
Case: A baby spits up after every feeding, but exhibits normal weight gain.
Normal physical exam. Therefore, increase burping, and keep upright. If the
infant develops GERD then:
- get ultrasound of lower esophagus
- do a Barium swallow
- Medications
- pH probe measures pH of lower esophageal sphincter area
- Fundoplication major surgery, involves wrapping the stomach around the
lower part of the esophagus.
3) Vomiting
- Very common pediatric problem
- Differentiate between bilious and non-bilious.( i.e. Bile containing)
Caused by:
- GER can induce vomiting
- Formula intolerance
- Viral gastroenteritis most common infectious cause of vomiting
- Excessive mucous in stomach due to cold
- Overeating
- Antibiotics Erythromycin or other Macrolides
- Infections in other systems
* Classic example is Otitis Media
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Case: 6 month with a low grade fever that is vomiting but has no dehydration.
Physical Exam is normal.
- Place on Pedialyte or Gatorade
 Pedialyte is preferred due to a better salt balance.
**Tape cuts off here
4) Diarrhea
- Found either primary or secondary to infection
- Can be caused by antibiotics Amoxicillin
- Formula Intolerance
- Gastroenteritis
- Infection in other system
Case: 4 month old with diarrhea. Nine episodes over the past 12 hours but with
no vomiting or apparent colic. Urinary output is only slightly decreased.
- Most likely viral gastroenteritis with mild dehydration.
- Treat by discontinuing formula and giving pedialyte.
5) Constipation
- Most common cause of abdominal pain in children
Caused by:
- Improper diet
- Psychogenic Megacolon (functional constipation) develops after years
of chronic constipation
- Encopresis
- Hirschprungs Disease look for stool in the 1st 24 hours
- Imperforate Anus
6) Abdominal Pain
- Identified by palpation and observation, and taking a detailed history.
- Develop an extensive differential
- Rule out surgical abdomen
Caused by:
- Gastroenteritis
- Constipation
- Asthma
- Pneumonia
- Psychogenic
- Colic
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