CDP: THE SICK VISIT FINAL EXAM
Umbilical hernia risk factors
Premature and/or low weight infants
Family history
Down Syndrome
Asymptomatic umbilical hernia
Presence of fullness or mass of intestinal loops at the hernia site
Enlarges with increased intra-abdominal pressure
Is reducible- can push back into the abdomen
Incarcerated umbilical hernia
Painful, swollen mass of intestinal loops at the hernia site
Is NOT reducible- unable to push back into the abdomen
Symptoms of small bowel obstruction
Strangulated umbilical hernia
Painful, swollen mass of intestinal loops at the hernia site
Is NOT reducible- unable to push back into the abdomen
Might be dark or pale in color due to compromised blood supply
Symptoms of small bowel obstruction
Umbilical hernia diagnostic imaging
US first choice, but can also use CT or MRI
Visualize bowel loop protruding through surrounding structures
Differentiate between strangulated and incarcerated by US Doppler view of blood
vessels
umbilical hernia asymptomatic management
Small- observation (> 80% close
spontaneously by age 5)
Large- elective surgical repair
incarcerated hernia management
NPO (bowel rest)
IV Fluids
Bowel decompression via Nasogastric or Proctosigmoidoscopy
Urgent surgical repair
strangulated hernia management
NPO (bowel rest)
IV Fluids
Bowel decompression via Nasogastric or Proctosigmoidoscopy
Emergent surgical repair
Most common cause of intestinal obstruction in the first 3 months of life
Pyloric stenosis
Pyloric stenosis risk factors
,Males (4:1 ratio)
Erythromycin use within the first 2 weeks of life
Pyloric stenosis clinical presentation
Projectile vomiting
Usually occurs at 2-4 weeks of age, but can be up to 12 weeks
Vomitus can be blood streaked
Typically non-bilious
Distended abdomen
After eating
Hungry babies
Their body tells them they are hungry, but then they cant keep it down
Pyloric stenosis PE
palpable olive shaped mass in the epigastrium possible
Pyloric stenosis diagnosis
Ultrasound: Test of choice; thickened and elongated Pylorus
Barium Swallow: Shows a reduction or absence of barium going through Pyloric region
Pyloric stenosis management
Send to pediatric ER for further management
Pyloromyotomy
The most common cause of bowel obstruction in children ages 6 months- 4 years
Intussusception
Intussusception etiology
Telescoping (invagination) of an intestinal segment
Leading to bowel obstruction
Intussusception risk factors
Age 6-18 months
Recent viral infection
Intussusception classic triad
1- Vomiting
2- Colicky abdominal pain
Screaming and drawing knees up
3- Passage of blood per rectum
Stool comprised of blood and mucous
Aka “Currant jelly stools”
Intussusception PE
Sausage-shaped mass felt in the mid to right upper abdomen
Intussusception diagnosis
Ultrasound - Best initial test
Air or contrast enema - Both diagnostic and therapeutic
Intussusception management
Refer to ER
Intussusception Reduction
, - Air or contrast enema
After reducing, then admit for observation x 24 hours
10% chance of recurrence within 24 hours of treatment
Surgical Resection
- For recurrent or refractory cases
most common cause of viral gastroenteritis worldwide
Norovirus
most commonly seen in unimmunized children ages 6 months- 2 years old
Rotavirus
Gastroenteritis risk factors
Contact with infected person
Ingestion of contaminated food or water
Gastroenteritis clinical presentation
Asymptomatic incubation period
Malaise, N/V, abdominal cramping/pain, voluminous diarrhea without blood or mucous
Gastroenteritis PE
Soft abdomen with mild, vague tenderness to palpation
Possible signs of dehydration - dry mucous membranes, decreased cap refill
Gastroenteritis diagnosis
Often clinically diagnosed
Labs not required if strong clinical suspicion for viral cause of diarrhea
Gastroenteritis management
Supportive care
Fluids, electrolyte replacement, BRAT diet, Antimotility agents, Antiemetics, Antipyretics
Gastroenteritis prevention
Contact precautions
Rotavirus vaccine
2 or 3 dose oral vaccine (depending on brand)
Typically given at age 2-6 months
Rare potential adverse effect of Intussusception
80% of fecal incontinence associated with retentive constipation
Encopresis
Encopresis etiology
Dietary changes
Psychosocial causes
Encopresis risk factors
Autism Spectrum Disorder
ADHD
Anxiety
Depression
Umbilical hernia risk factors
Premature and/or low weight infants
Family history
Down Syndrome
Asymptomatic umbilical hernia
Presence of fullness or mass of intestinal loops at the hernia site
Enlarges with increased intra-abdominal pressure
Is reducible- can push back into the abdomen
Incarcerated umbilical hernia
Painful, swollen mass of intestinal loops at the hernia site
Is NOT reducible- unable to push back into the abdomen
Symptoms of small bowel obstruction
Strangulated umbilical hernia
Painful, swollen mass of intestinal loops at the hernia site
Is NOT reducible- unable to push back into the abdomen
Might be dark or pale in color due to compromised blood supply
Symptoms of small bowel obstruction
Umbilical hernia diagnostic imaging
US first choice, but can also use CT or MRI
Visualize bowel loop protruding through surrounding structures
Differentiate between strangulated and incarcerated by US Doppler view of blood
vessels
umbilical hernia asymptomatic management
Small- observation (> 80% close
spontaneously by age 5)
Large- elective surgical repair
incarcerated hernia management
NPO (bowel rest)
IV Fluids
Bowel decompression via Nasogastric or Proctosigmoidoscopy
Urgent surgical repair
strangulated hernia management
NPO (bowel rest)
IV Fluids
Bowel decompression via Nasogastric or Proctosigmoidoscopy
Emergent surgical repair
Most common cause of intestinal obstruction in the first 3 months of life
Pyloric stenosis
Pyloric stenosis risk factors
,Males (4:1 ratio)
Erythromycin use within the first 2 weeks of life
Pyloric stenosis clinical presentation
Projectile vomiting
Usually occurs at 2-4 weeks of age, but can be up to 12 weeks
Vomitus can be blood streaked
Typically non-bilious
Distended abdomen
After eating
Hungry babies
Their body tells them they are hungry, but then they cant keep it down
Pyloric stenosis PE
palpable olive shaped mass in the epigastrium possible
Pyloric stenosis diagnosis
Ultrasound: Test of choice; thickened and elongated Pylorus
Barium Swallow: Shows a reduction or absence of barium going through Pyloric region
Pyloric stenosis management
Send to pediatric ER for further management
Pyloromyotomy
The most common cause of bowel obstruction in children ages 6 months- 4 years
Intussusception
Intussusception etiology
Telescoping (invagination) of an intestinal segment
Leading to bowel obstruction
Intussusception risk factors
Age 6-18 months
Recent viral infection
Intussusception classic triad
1- Vomiting
2- Colicky abdominal pain
Screaming and drawing knees up
3- Passage of blood per rectum
Stool comprised of blood and mucous
Aka “Currant jelly stools”
Intussusception PE
Sausage-shaped mass felt in the mid to right upper abdomen
Intussusception diagnosis
Ultrasound - Best initial test
Air or contrast enema - Both diagnostic and therapeutic
Intussusception management
Refer to ER
Intussusception Reduction
, - Air or contrast enema
After reducing, then admit for observation x 24 hours
10% chance of recurrence within 24 hours of treatment
Surgical Resection
- For recurrent or refractory cases
most common cause of viral gastroenteritis worldwide
Norovirus
most commonly seen in unimmunized children ages 6 months- 2 years old
Rotavirus
Gastroenteritis risk factors
Contact with infected person
Ingestion of contaminated food or water
Gastroenteritis clinical presentation
Asymptomatic incubation period
Malaise, N/V, abdominal cramping/pain, voluminous diarrhea without blood or mucous
Gastroenteritis PE
Soft abdomen with mild, vague tenderness to palpation
Possible signs of dehydration - dry mucous membranes, decreased cap refill
Gastroenteritis diagnosis
Often clinically diagnosed
Labs not required if strong clinical suspicion for viral cause of diarrhea
Gastroenteritis management
Supportive care
Fluids, electrolyte replacement, BRAT diet, Antimotility agents, Antiemetics, Antipyretics
Gastroenteritis prevention
Contact precautions
Rotavirus vaccine
2 or 3 dose oral vaccine (depending on brand)
Typically given at age 2-6 months
Rare potential adverse effect of Intussusception
80% of fecal incontinence associated with retentive constipation
Encopresis
Encopresis etiology
Dietary changes
Psychosocial causes
Encopresis risk factors
Autism Spectrum Disorder
ADHD
Anxiety
Depression
