As The Stomach Turns... Pediatric GI Gems
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As The Stomach Turns... Pediatric GI Gems As The Stomach Turns... Pediatric GI Gems Presentation Transcript

  • As the stomach turns…Pediatric GI Gems Barb Bancroft, RN, MSN, PNP
  • Group A beta hemolytic strep
    • “ I have a sore throat and I can’t swallow…”
    • “… and, my tummy hurts…”
    • Dehydration with drooling in young kids
    • How do you look at a toddler’s throat?
    • Digression: saliva
  • Enlarged tonsils
    • EBV infection of tonsils
    • Waldeyer’s ring (tonsils and adenoids)
    • Kids and sleep apnea; kids, lack of sleep and growth hormone
    • ?hypertension in kids?
    • Behavior disorders? ADHD? In kids?
    • Non-Hodgkin’s lymphoma
    View slide
  • Oral signs of an eating disorder
    • The frequent vomiting and nutritional deficiencies often associated with eating disorders can severely affect health
    • 89% of bulimic patients have signs of tooth erosion; over time, loss of tooth enamel can be considerable
    • Hypertrophy of the parotid gland in women with eating disorders (serum amylase will be elevated)
    • Dry and cracked lips
    • Chronic dry mouth
    View slide
  • The immunocompromised patient
    • Candida albicans (inhaled steroids in asthmatics)
    • Diabetics with hyperglycemia
    • Fungal infections and TNF- α antagonists (infliximab/Remicade; adalimumab/Humira; certolizumab/Cemzia etanercept/Enbrel)
    • HSV-1, HSV-2
  • Salivary glands—parotid, sublingual, submandibular
    • Parotid gland—MUMPS (kids and vaccines)
    • Acetylcholine innervates the salivary glands to produce saliva
  • OPEN Wide
    • Aphthous ulcers and celiac disease
    • Mouth clues to vitamin deficiencies
    • Vitamin C—gingivitis, dental erosion
    • Vitamin B2 (riboflavin)—stomatitis, cheilosis, geographic tongue
    • Vitamin B3 (niacin), B6 (pyridoxine), B12 (cobalamin), folic acid (B9)—glossitis
  • Say “ah”…
    • Soft palate and the uvula
    • Relationship of the pharyngeal musculature with CN IX (Glossopharyngeal) and X (Vagus)
    • Swallowing
    • What is the hardest thing to swallow?
  • Causes of nasal speech
    • Cleft palate (folic acid!!)
    • Glossopharyngeal nerve palsy—(viral)
    • Guillain-Barré syndrome with bulbar onset (cranial nerve onset vs. ascending paralysis beginning with the longest nerves first—ie. the feet)
    • #1 cause of Guillain-Barré?
  • Let’s go back to the tonsils, shall we?
    • Waldeyer’s ring—adenoids and tonsils
    • Lymphatic tissue
    • Growth hormone is produced at night
    • Adenoiditis/tonsilitis
    • Enlarged? Sleep apnea? Behavior disorders? ADHD?
  • Is it GER or is it GERD?
    • GER—Gastroesophageal reflux (regurgitation and vomiting are a normal part of infant life—physiologic reflux)
    • Passage of gastric contents into the esophagus—peak at 4-6 months (41%); decline after the first birthday with less than 5% aged 13-14 months)
    • 1.8% to 22% in children aged 3 to 18
  • What is GERD?
    • ACID is the bad guy
    • Physiologic sphincter (LES)—DA/ACH
    • With GERD--decreased pressure in the lower esophageal sphincter due to drugs*, nicotine, alcohol, fatty foods, obesity, increased pressure in stomach (late evening meal)
    • So, how about a pizza, cold beer and a cigarette before bedtime?
    • *What drugs? Beta agonists (bronchodilators in kids with asthma)
  • Digression
    • Biological rhythms—normal input to LES at night and to bronchioles
    • GERD and acid reflux—stimulates vagus nerve to release acetylcholine to tighten LES
    • Vagus also tightens bronchioles—cough, dyspnea, wheezing in patients with OPD (ROAD, COPD)
    • RX?
  • What are non-drug ways to reduce GERD?
    • Dietary changes? For infants with GERD—smaller, more frequent feeds; thickened feeds with rice cereal or carob bean gum thickener
    • Don’t overfeed
    • Consider intolerance to cow’s milk for “GERD-like” symptoms
    • Upright feeding position; supine to sleep; small pillow or a folded blanket where infant sits in car seat to extend hips and decrease intraabdominal pressure
  • Pharmacology of GERD for kids
    • H 2 RA (receptor antagonists)—over-the-counter
    • Tagamet (cimetidine) (≥16 yo) , Zantac (ranitidine) (1 month to 16), Pepcid (famotidine )(1 year to 16), Axid (nizatidine) (≥12)(take at bedtime)
    • PPIs (Proton Pump Inhibitors) are more potent acid suppressors than H 2 RA—the “prazoles”; take 30 minutes before breakfast
    • Omeprazole (Prilosec )(2-16), lansoprazole (Prevacid )(1-17), and “the purple pill”—esomeprazole (Nexium )(12-17)**
  • Has your patient been on the “prazoles” for longer than 5 years?
    • The parietal cell that pumps acid also pumps out intrinsic factor (IF)
    • Intrinsic Factor is necessary for the absorption of B12 from food
    • If you stop pumping the acid into the stomach, you also stop pumping intrinsic factor for B12 absorption
    • May also be caused by an autoimmune disease with antibodies against IF (pernicious anemia); kids with type 1 diabetes may also have pernicious anemia
    • No acid, no calcium (kids and bones)
    • No acid, no iron (check for iron deficiency anemia)
  • Selected conditions
    • Gastroenteritis—peri-umbilical pain
    • Acute diarrhea—watery—think viral? Bloody—think more invasive, bacterial?
    • Acute appendicitis—no more than a 5-day disease; periumbilical pain followed by pain in the RLQ; increased WBC with left shift; fever; psoas sign; “the walk”
  • Selected conditions
    • Child abuse injuries
    • The second most common cause of death from child abuse is injury to abdominal organs
    • Small intestine, especially the duodenum, followed by mesenteric hemorrhage and liver lacerations
    • Accidental abdominal injury—spleen, kidney
  • Child abuse and bruises
    • “ The skin and the bones tell a story that the child is either too young or too frightened to tell.”
    • Normal bruises are facial scratches, one bruise on forehead (toddler), knee and chins
    • French proverb: “ The mother of a child who elects to re-wed, has taken the enemy into her bed.”
    • A child living with a stepparent is 100 times as likely to suffer fatal abuse.
  • Age of bruise
    • Is it red, purple, blue?
    • Green, yellow, brown?
    • Reddish/blue less than 1 day, immediate
    • Blue/purple 1-5 days
    • Green 5-7 days
    • Yellow 7-10 days
    • Brown 10-14 days
    • Resolution 2-4 weeks
  • Normal bruises in kids…
    • Facial scratches in babies from long fingernails
    • Knee and shin bruises due to usual wear and tear of playing rough and tumble
    • Single bruise on the forehead of a toddler
    • Bruises on bony prominences such as the knees and elbows
  • The stomach
    • “ Whoever said the way to a man’s heart is through his stomach flunked geography …”
    • --anonymous
    • The stomach is a saccular organ with a volume of 1200 to 1500 ml but a capacity of greater than 3000 ml
  • Gastric acid
    • At maximal secretory rates, the stomach intraluminal concentration of hydrogen ion is 3 million times greater than that of the blood and tissues
    • The mucosal barrier protects the gastric mucosa from autodigestion and is created by:
    • mucus secretion;
    • bicarbonate secretion
    • epithelial barrier and,
    • mucosal blood flow
    • Truly a physiological marvel, or gastric walls would suffer the same fate as a T-bone
  • Peptic ulcer disease
    • Usually solitary lesions less than 4 cm in diameter
    • Duodenum, first portion
    • Stomach, antrum
    • GE junction, in the setting of GERD
    • 4 million people have peptic ulcers; 350,000 new cases per year, 100,000 hospitalized, 3000 die
    • Male/female for duodenal = 3:1; male/female for gastric = 1.5 to 2:1
    • Imbalance between the gastroduodenal mucosal defense mechanisms and the damaging forces—gastric acid and pepsin
    • Hyperacidity is NOT a prerequisite
    • H. pylori is present in 100% of duodenal ulcers and about 70% of patients with gastric ulcers
  • Gastric ulcers (peptic ulcer disease)
    • Helicobacter pylori—the most common infection worldwide
    • Elaborates urease and produces ammonia which buffers gastric acid in the immediate vicinity
    • Gastric ulcers
    • Chronic inflammation (gastritis) and regeneration of the antrum
    • The only bacteria known to be “oncogenic”
    • Is it normal flora?
    • How do you “catch” it?
    • How do you treat it?
    • Is H. pylori a good thing?
  • Gastric ulcer caused by NSAIDS
    • 2.74 RR of any GI complication
    • If over 50, RR is 5.57
    • RR 12.7 with NSAIDS and warfarin; 4.76 with NSAIDS and steroids
    • PPIs decrease ulcer/ bleed by 4-fold
  • The duodenum (12 fingerbreadths), —the organ of nausea
    • 5-HT 3 (serotonin) receptors)
    • Serotonin release causes nausea--Makes ya’ sick to your duodenum
    • 5-HT 3 blockers--The “setrons”—ondansetron (Zofran), granisetron (Kytril), doasetron (Anzemet), palonosetron
    • Adding ondansetron to oral rehydration in kids reduces nausea and vomiting and decreases the need for IV fluids by greater than 50%
    • Bariatric surgery, Type 2 DM, and kids
  • Celiac disease and the duodenum
    • 1 in 250 in U.S.; greater prevalence in 1 st and 2 nd degree relatives; ?duration of breast feeding; age at which a person ingests gluten; cigarette smoking
    • Autoimmune disease—HLA-DQ2; HLA-DQ8
    • Ingested gluten crosslinks with tissue transglutaminase released in the lamina propria and epithelium of the small intestine
    • Immune system helper T cells (CD4 cells) release cytokines IF- γ and IL-4 which damage villi; flattened villi and malabsorption
    • Anti-transglutaminase antibodies
  • Celiac disease
    • Absorption problems result in anemias—iron deficiency (growth problems in kids); folate deficiency; calcium absorption problems (osteopenia)
    • Always check for osteopenia and osteoporosis in your long-term patients with celiac disease!
    • aphthous ulcers are strongly associated w/ celiac disease ( This Week in Medicine, MDConsult, 1/31/07 )
  • Celiac disease
    • Classic symptomatic presentation characterized by diarrhea, abdominal pain, weight loss, flatulence, and nutritional deficiencies
    • Atypical presentation characterized by gait ataxia, seizures, peripheral neuropathy, aphthous stomatitis, arthritis, migraine headaches
    • Associated with other autoimmune diseases—Type 1 diabetes, autoimmune myocarditis, primary biliary cirrhosis
    • Gluten-free diets and the improvement of symptoms
  • Gastroenteritis…
    • Umbilicus (belly button)—embryologic origins with colon (Homer and Dr. Colón)
    • Word o’ the day…
    • Omphaloskepsis (om-fuh-lo-SKEP-sis); noun
    • Definition: Contemplation of one’s navel. (From Geek omphalos (navel) + skepsis (act of looking, examination)
    • Peri-umbilical pain
    • Causes of gastroenteritis—food poisoning, viral infections, bacterial infections
  • Gastroenteritis
    • Infectious gastroenteritis—causes more than 12,000 deaths per day from dehydration among children in developing countries and constituting one half of all deaths worldwide before age 5
    • Attack rates of one to two illnesses per person per year in U.S.—results in an estimated 99 million acute cases of either vomiting or diarrhea per year—approximately 40% of the population
  • Viral gastroenteritis
    • Rotavirus—140 million cases and 1 million deaths worldwide per year; 6 to 24 months of age; shed 1,000,000,000,000 (10¹² particles)/ml of stool (the minimum infective inoculum is only 10 particles, hence the rampant outbreaks in daycare and pediatric populations in hospitals)
    • Norwalk virus (norovirus)—rare in young kids
  • Noroviruses
    • Responsible for majority of nonbacterial food-borne epidemic gastroenteritis in older children and adults;
    • Salad bars (cold foods, raw shellfish), person-to-person,water on cruise ships
    • Has also been found in the community and in nursing homes
    • Vicious cycle of vomiting and diarrhea for an average of 23 hours—known as “shuking”
    • start shedding virus before symptoms occur and shed virus for 4 days after symptoms subside (hence, the rapid spread of infection); can shed virus up to 4 to 8 weeks after illness
  • Bacterial entercolitis
    • Ingestion of preformed toxin in food—Staphylococcus aureus , Vibrio species, Clostridium perfringens
    • Infection by toxigenic organisms, which proliferate in the gut lumen and elaborate an enterotoxin (Cholera toxin is the prototype secretagogue)
    • Infection by enteroinvasive organisms, which proliferate, invade, and destroy mucosal epithelial cells ( Salmonella, Yersinia enterocolitica)
  • Acute appendicitis
    • Acute appendicitis presents initially with peri-umbilical pain and subsequently localizes to the right lower quadrant (RLQ)
    • High risk occupation for acute appendicitis?
    • Pig farmers
  • Food-borne illness and gastroenteritis
  • Salmonella in raw or undercooked eggs and chicken
    • Pasteurized eggs for “seizure” salad (Caesar salad), eggnog, and guacamole
    • Salmonella in chicken
    • No more sunny-side up, especially for high-risk patients (unless the eggs are pasteurized)
  • Digression:
    • Salmonella in reptiles—snakes, turtles, iguanas
  • Campylobacter jejuni
    • Undercooked chicken
    • Cuddly puppies
    • 180º whole chicken
    • 170º white meat
    • 180º dark meat
  • E. Coli 0157:H7— the “burger” bug
    • 3 rd most deadly toxin in the world
    • 10-100 pathogens to make you ill or kill you
    • Very young, very old, very immunocompromised
    • Acute Renal Failure in Kids—hemolytic uremic syndrome
    • Swimming pools, petting zoos
    • Mickey D’s—30 outbreaks per year
    • Supportive Treatment
    • Prevent—cook burgers to 160º F
  • Spinach
    • Produce is the biggest offender for E.Coli O157:H7
    • Parasites and salmon sushi; raw fish
  • Crohn’s disease—inflammatory bowel disease
    • Primarily small bowel, but can include anywhere from the esophagus to the rectum
    • Skip lesions; fistulas; strictures
    • Cause? Bacteria? Mycobacterium paratuberculosis?
    • Autoimmune response
  • Signs and symptoms
    • Usually begins with intermittent attacks of relatively mild diarrhea, fever, and abdominal pain, spaced by asymptomatic periods lasting for weeks to many months
    • 1/5 th of patients with abrupt onset, with acute RLQ pain, fever, and diarrhea
    • Diff dx suggesting acute appendicitis or acute bowel perforation
    • Chronic disease with fibrosing strictures, marked loss of albumin, generalized malabsorption, B12 malabsorption, or malabsorption of bile salts leading to steatorrhea
  • Treatment
    • Methotrexate to reduce the immune response
    • Inflammation via TNF-alpha
    • Drugs that block TNF-alpha include infliximab (Remicade), adalimumab (Humira), etanercept (Enbrel)
    • Certolizumab pegol (Cemzia)
  • Ulcerative colitis—inflammatory bowel disease
    • Limited to the colon and affects only the mucosa and submucosa; extends in a continuous fashion proximally from the rectum
    • Peak onset between 20 and 25 years of age
    • Risk for colon cancer—risk is highest in patients with pancolitis of 10 or more years duration; 30% @ 35 years after dx
    • Dysplasia (distortion of the normal orientation and architecture of cells)—low-grade dysplasia vs. high-grade dysplasia and ulcerative colitis
  • Antibiotic-associated diarrhea
    • “ the usual, run-of-the-mill diarrhea” vs.
    • Clostridium difficile diarrhea (new strain)—the “floxacins” and Clindamycin are the biggest offenders for C. difficile
  • Clostridium difficile
    • Clostridium difficile (difficult to culture, hence, difficile) and soap and water kill spores better than alcohol-based gels
    • New strain (2003) produces more toxin and causes more severe outbreaks—produces 16x more toxin A and 23 times more toxin B; characterized by the deletion of a gene that downregulates the production of both toxins
    • Major risk factor? Use of the fluoroquinolones; Other antibiotics? Amox/Ampicillin, 2 nd /3 rd generation cephalosporins
  • A few more notes on C. diff
    • Has the child had dental work with prescribed antibiotics?
    • Treatment—vancomycin, metronidazole
    • Stool transplants in chronic C. diff
    • High risk of recurrence in patients over 65, patients with severe underlying disease, and additional antibiotic use after discontinuing therapy for C. diff .
    • Surawicz CM. Reining in recurrent Clostridium difficile infection—Who’s at risk? Gastroenterology 2009 Apr;136:1152.
  • The sheep
    • You wanna do WHAT with my intestines?
    • Clinical uses of a sheep’s cecum
  • Chronic constipation—4% of preschoolers; 2% of school-age kids
    • Normal number of bowel movements?
    • 3 per day to 3 per week or fewer than seven bowel movements over a 2-week period with no medication usage as a precipitating cause
    • Pain—avoid passing stools; resist the urge by squeezing buttocks and standing straight
    • Causes—drugs (anti-cholinergic agents, opiates including codeine, morphine, meperidine; laxative abuse over the years; too much cow’s milk; not enough fluids; not enough fiber)
  • Constipation
    • Advise parents to try fruit juices with sorbitol like prune, pear and apple
    • Miralax is only approved for 17 and over, but more and more pediatricians are using it for young kids after trying dietary changes and the above juices
  • Kiddie constipation
    • Give Miralax before using other osmotic laxatives
    • 0.7 to 1.5 g/kg/day for kids over 2; but no more than the adult dose of 17g/day
    • Takes 1 to 3 days to work; use glycerin suppositories if help is needed fast
    • Docusate for hard, dry stools; nasty taste and takes a few days to kick in
    • Use stimulants (senna, bisacodyl) for “rescue therapy” when other treatments fail; stimulants can cause abdominal pain and cramping
    • (Prescriber’s Letter, April 2009)
  • Examination of the belly
    • Ticklish? How to relax the abdomen…
    • Inspection…scars, bruises, distention
    • Auscultation—are the bowel sounds present or absent; does it matter where you place the stethoscope?
    • Palpation—rebound tenderness for localized peritonitis
    • The 6 F’s (fat, flatus, feces, fibroid [tumor], fluid, fetus)
  • Abdominal distention—the 6 F’s
    • Fluid
    • Fat
    • Flatus
    • Feces
    • Fibroids (or other tumors)
    • Fetus (or other tumors--)
  • The end.
    • Barb Bancroft, RN, MSN, PNP
    • [email_address]
  • Bibliography
    • Hay WW et al. Current Diagnosis and Treatment—Pediatrics. 19 th ed. McGraw Hill-Lange; 2009