As the stomach turns…Pediatric GI Gems Barb Bancroft, RN, MSN, PNP
Group A beta hemolytic strep <ul><li>“ I have a sore throat and I can’t swallow…” </li></ul><ul><li>“… and, my tummy hurts...
Enlarged tonsils <ul><li>EBV infection of tonsils </li></ul><ul><li>Waldeyer’s ring (tonsils and adenoids) </li></ul><ul><...
Oral signs of an eating disorder <ul><li>The frequent vomiting and nutritional deficiencies often associated with eating d...
The immunocompromised patient <ul><li>Candida albicans (inhaled steroids in asthmatics) </li></ul><ul><li>Diabetics with h...
Salivary glands—parotid, sublingual, submandibular <ul><li>Parotid gland—MUMPS (kids and vaccines) </li></ul><ul><li>Acety...
OPEN Wide <ul><li>Aphthous ulcers and celiac disease </li></ul><ul><li>Mouth clues to vitamin deficiencies </li></ul><ul><...
Say “ah”… <ul><li>Soft palate and the uvula </li></ul><ul><li>Relationship of the pharyngeal musculature with CN IX (Gloss...
Causes of nasal speech <ul><li>Cleft palate (folic acid!!) </li></ul><ul><li>Glossopharyngeal nerve palsy—(viral) </li></u...
Let’s go back to the tonsils, shall we? <ul><li>Waldeyer’s ring—adenoids and tonsils </li></ul><ul><li>Lymphatic tissue </...
Is it GER or is it GERD? <ul><li>GER—Gastroesophageal reflux (regurgitation and vomiting are a normal part of infant life—...
What is GERD? <ul><li>ACID is the bad guy </li></ul><ul><li>Physiologic sphincter (LES)—DA/ACH </li></ul><ul><li>With GERD...
Digression <ul><li>Biological rhythms—normal input to LES at night and to bronchioles </li></ul><ul><li>GERD and acid refl...
What are non-drug ways to reduce GERD? <ul><li>Dietary changes? For infants with GERD—smaller, more frequent feeds; thicke...
Pharmacology of GERD for kids <ul><li>H 2  RA (receptor antagonists)—over-the-counter </li></ul><ul><li>Tagamet (cimetidin...
Has your patient been on the “prazoles” for longer than 5 years? <ul><li>The parietal cell that pumps acid also pumps out ...
Selected conditions <ul><li>Gastroenteritis—peri-umbilical pain </li></ul><ul><li>Acute diarrhea—watery—think viral? Blood...
Selected conditions <ul><li>Child abuse injuries </li></ul><ul><li>The second most common cause of death from child abuse ...
Child abuse and bruises <ul><li>“ The skin and the bones tell a story that the child is either too young or too frightened...
Age of bruise <ul><li>Is it red, purple, blue? </li></ul><ul><li>Green, yellow, brown? </li></ul><ul><li>Reddish/blue less...
Normal bruises in kids… <ul><li>Facial scratches in babies from long fingernails </li></ul><ul><li>Knee and shin bruises d...
The stomach <ul><li>“ Whoever said the way to a man’s heart is through his stomach flunked geography …” </li></ul><ul><li>...
Gastric acid <ul><li>At maximal secretory rates, the stomach intraluminal concentration of hydrogen ion is 3 million times...
Peptic ulcer disease <ul><li>Usually solitary lesions less than 4 cm in diameter </li></ul><ul><li>Duodenum, first portion...
Gastric ulcers (peptic ulcer disease) <ul><li>Helicobacter pylori—the  most common infection worldwide </li></ul><ul><li>E...
Gastric ulcer caused by NSAIDS <ul><li>2.74 RR of any GI complication </li></ul><ul><li>If over 50, RR is 5.57 </li></ul><...
The duodenum (12 fingerbreadths), —the organ of nausea <ul><li>5-HT 3  (serotonin) receptors) </li></ul><ul><li>Serotonin ...
Celiac disease and the duodenum  <ul><li>1 in 250 in U.S.; greater prevalence in 1 st  and 2 nd  degree relatives; ?durati...
Celiac disease <ul><li>Absorption problems result in anemias—iron deficiency (growth problems in kids); folate deficiency;...
Celiac disease <ul><li>Classic symptomatic presentation characterized by diarrhea, abdominal pain, weight loss, flatulence...
Gastroenteritis… <ul><li>Umbilicus (belly button)—embryologic origins with colon (Homer and Dr. Colón) </li></ul><ul><li>W...
Gastroenteritis <ul><li>Infectious gastroenteritis—causes more than 12,000 deaths per day from dehydration among children ...
Viral gastroenteritis <ul><li>Rotavirus—140 million cases and 1 million deaths worldwide per year; 6 to 24 months of age; ...
Noroviruses <ul><li>Responsible for majority of nonbacterial food-borne epidemic gastroenteritis in older children and adu...
Bacterial entercolitis <ul><li>Ingestion of preformed toxin in  food—Staphylococcus aureus ,  Vibrio  species,  Clostridiu...
Acute appendicitis <ul><li>Acute appendicitis presents initially with peri-umbilical pain and subsequently localizes to th...
Food-borne illness and gastroenteritis
Salmonella in raw or undercooked eggs and chicken <ul><li>Pasteurized eggs for “seizure” salad (Caesar salad), eggnog, and...
Digression: <ul><li>Salmonella in reptiles—snakes, turtles, iguanas </li></ul>
Campylobacter  jejuni <ul><li>Undercooked chicken </li></ul><ul><li>Cuddly puppies </li></ul><ul><li>180º whole chicken </...
E. Coli 0157:H7— the “burger” bug <ul><li>3 rd  most deadly toxin in the world </li></ul><ul><li>10-100 pathogens to make ...
Spinach <ul><li>Produce is the biggest offender for  E.Coli O157:H7 </li></ul><ul><li>Parasites and salmon sushi; raw fish...
Crohn’s disease—inflammatory bowel disease <ul><li>Primarily small bowel, but can include anywhere from the esophagus to t...
Signs and symptoms <ul><li>Usually begins with intermittent attacks of relatively mild diarrhea, fever, and abdominal pain...
Treatment <ul><li>Methotrexate to reduce the immune response </li></ul><ul><li>Inflammation via TNF-alpha </li></ul><ul><l...
Ulcerative colitis—inflammatory bowel disease <ul><li>Limited to the colon and affects only the mucosa and submucosa; exte...
Antibiotic-associated diarrhea <ul><li>“ the usual, run-of-the-mill diarrhea” vs. </li></ul><ul><li>Clostridium difficile ...
Clostridium difficile <ul><li>Clostridium difficile  (difficult to culture, hence,  difficile)  and soap and water kill sp...
A few more notes on  C. diff <ul><li>Has the child had dental work with prescribed antibiotics?  </li></ul><ul><li>Treatme...
The sheep <ul><li>You wanna do WHAT with my intestines? </li></ul><ul><li>Clinical uses of a sheep’s cecum </li></ul>
Chronic constipation—4% of preschoolers; 2% of school-age kids <ul><li>Normal number of bowel movements? </li></ul><ul><li...
Constipation <ul><li>Advise parents to try fruit juices with sorbitol like prune, pear and apple </li></ul><ul><li>Miralax...
Kiddie constipation <ul><li>Give Miralax before using other osmotic laxatives </li></ul><ul><li>0.7 to 1.5 g/kg/day for ki...
Examination of the belly <ul><li>Ticklish? How to relax the abdomen… </li></ul><ul><li>Inspection…scars, bruises, distenti...
Abdominal distention—the 6 F’s <ul><li>Fluid </li></ul><ul><li>Fat </li></ul><ul><li>Flatus </li></ul><ul><li>Feces </li><...
The end. <ul><li>Barb Bancroft, RN, MSN, PNP </li></ul><ul><li>www.barbbancroft.com </li></ul><ul><li>[email_address] </li...
Bibliography <ul><li>Hay WW et al. Current Diagnosis and Treatment—Pediatrics. 19 th  ed. McGraw Hill-Lange; 2009 </li></ul>
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As The Stomach Turns... Pediatric GI Gems

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

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