Exam 4 Study Guide NOV 2021
Nurs 629 Family and Pediatrics
Week 11
Chapter 40 Gastrointestinal disorders
Jaundice physiological vs breast fed vs biliary atresia – OTHER STUDY GUIDE
Vomitting / Emesis- forceful emptying of gastric contents coordinated by the medullary vomiting
center and or chemoreceptor trigger zone of brain. Can be caused by GI or extraintestinal disorders that
are acute or chronic. Can be projectile (CNS) or nonprojectile, bilious (usually due to obstructive lesion),
bloody (upper GI bleeding- gastritis, peptic ulcer disease), nonbilious (usually caused by infection,
inflammation, and metabolic, neurologic or psychological problems), or nonbloody.
Newborns with emesis: infectious process, congenital GI anomaly, CNS abnormality, inborn errors of
metabolism.
Infants and young children: gastroenteritis, GERD, milk/soy protein allergies, pyloric stenosis or
obstructive lesion, inborn errors of metabolism, intussusception, child abuse, intracranial mass.
Older children: gastroenteritis, systemic illness, CNS, abdominal migraine, meningitis, brain tumor,
intussusception, rumination, superior mesenteric artery syndrome, pregnancy.
History: symptoms with onset of vomiting; duration of vomiting, quality and quantity, presence of blood,
bile, odor, precipitating event, pain, relationship of vomiting with meals, activities, or time of day. (early
morning vomiting could be increased intracranial pressure). Exposure to illness or injury, stress, travel,
swimming activities, poisoning or contaminated foods. Medication history, presence of associated
symptoms, past illness history, surgery, hospitalizations, family hx of GI issues or fetal/nonfetal death.
****assess for dehydration: mental status, thirst, decreased tearing, urination, depressed fontanels in
infants.
PE: growth, vital signs, neurological exam, abdominal exam- distension, scars from surgery, visible
peristaltic waves, bowel sounds, palpate abdomen, check for organ enlargement, rebound tenderness,
rectal exam if needed. Respiratory exam, assess for dehydration.
Risk factors: see above
Dx: CBC, blood culture, CMP, BUN, creatinine, glucose, liver function, CRP and ESR, UA and urine culture,
toxicology screen, stool for culture and occult blood, rapid strep, throat culture, pregnancy test. Imaging:
abdomen x ray, chest radiograph, ultrasound, barium swallow or enema, CT or MRI, endoscopy,
esophageal pH probe analysis, EEG.
Management: identify and alleviate the cause, determine degree of dehydration and hydrate. Zofran is
effective with oral rehydration therapy. Supportive care, treat fever. Consider referral to GI or ER if
repeating issue.
Education: oral rehydration therapy, signs of worsening dehydration that would warrant ER visit
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,Diarrhea- SEE OTHER STUDY GUIDE
GERD vs pyloric stenosis
GERD Gastroesophageal reflux disease- passage of gastric contents into esophagus from the
stomach through the LES. Inappropriate relaxation of LES. LES is influenced by intraabdominal pressure,
hormones, neurologic control, and age. In infants 4 months old up to 67% regurgitate more than once
per day. Regurgitation peaks at 4 months with tapering beginning at 6 months then declining
infrequency until 12-15 months. Alterations in swallowing, pharyngeal coordination, esophageal motility
and delayed gastric emptying r/t GERD. Increased muscle tone, chronic supine positioning and altered GI
motility exacerbate GERD.
Risk factors: prematurity, neurological impairment, obesity, cystic fibrosis, hiatal hernia, family hx of
GERD.
History: amount/freq of feedings (overfeeding?), preparation of formula, changes in feeding, position
during and after feeding, behavior during feeding, burping technique and frequency, presence of
choking, gagging, coughing, arching, discomfort, refusal, growth and development, recurrent illnesses,
hospitalizations, medications, hoarseness, fussiness, hiccups, apnea.
S/s: may c/o chest pain, recurrent regurgitation with or without vomiting, weight loss, poor weight gain,
ruminative behavior, hematemesis, dysphagia, respiratory disorders (wheezing, stridor, cough, apnea,
hoarseness, recurrent pneumonia).
PE: height, weight, head circ, growth pattern, signs of failure to thrive, torticollis (neck arching),
hoarseness, anemia, tooth erosion, facial rash, recurrent diarrhea, persistent vomiting, early morning
vomiting.
Dx: can be made clinical, try 4 week trial of PPI (not always recommended in infants), CBC w diff (rule out
anemia and infection), UA c urine culture, stool for occult blood, H. pylori. Referral to pediatric
gastroenterologist who may perform: esophageal pH monitoring***** gold standard of diagnosis… but
presence of reflux may not correlate with the severity of illness, some gastric contents may not be acidic,
PPIs and H2 blockers usually d/c 1-2 weeks prior to testing.
Management: Pharmacologic- H2Ras, PPIs. Nutrition- feeding techniques, volumes, frequencies,
hydrolyzed protein formula trial, thickened feedings (partially effective). Lifestyle- left sided positioning,
elevate HOB, book says positioning infants upright may worsen reflux…Surgical- anti-reflux surgery
strategies, fundoplication.
Education: complications are chronic cough, irritability, and malnutrition, asthma, respiratory issues. Red
flags: hematemesis and bilious vomiting. Regurgitation is usually self limited and symptoms improve as
child grows, reassurance parents wit h infants who have uncomplicated regurgitation, remind parents
that GERD may temporarily worsen during illnesses, review medication information and dosing and side
effects.
Pyloric Stenosis – characterized by hypertrophied pyloric muscle, causing a narrowing of the pyloric
sphincter. Occurs in 3/1000 births.
Risk factors: Caucasian, first born males, males 4x more likely to have, premature birth, family history
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, S/s: regurgitation and nonprojectile vomiting during the first few weeks of life, projectile vomiting
beginning at 2-3 weeks old, insatiable appetite with weight loss, dehydration, and constipation,
---*****administration of erythromycin and azithromycin within first 2 weeks of life*****
PE findings: weight loss, nonbilious vomiting that can contain blood and occur immediately after
feeding, distinct “olive” mass may be palpated in the epigastrium to the right of midline. Reverse
peristalsis visualized across abdomen.
Dx: ultrasound, with measurement of pyloric muscle thickness. Upper gastrointestinal UGI series may
demonstrate a “STRING SIGN” indicating a fine, elongated pyloric canal; may be required if ultrasound is
unavailable or inconclusive.
Management: surgical intervention (pyloromyotomy) after correction of fluid and electrolyte imbalance,
vomiting may continue a few days after surgery great prognosis.
Appendicitis (part of abdominal exam, signs of appendicitis)
Positive Rovsing sign- palpate for rebound tenderness (palpation in the left iliac fossa produces pain in
the right iliac fossa.
Obturator sign: a supine patient flexes the right thigh at the hip with the knee bent and internally rotates
the hip. The sign is positive when it induces abdominal pain.
Psoas sign: patient lies on the left side and extends and then flexes the right leg at the hip, a positive sign
induces abdominal pain. 36-72 hour maximum window of from the onset of pain to the rupture of
gangrenous appendix resulting in peritonitis. Average age 6-10, male:female 2: 1, rare in infancy. 4 cases
per 100,000 children. Perforation most common < 5 years.
History: Pain, starts as poorly defined periumbilical pain, shifts to RLQ after a few hours, becoming more
intense, continuous, and localized.
S/s: nausea and vomiting typically occurs after pain, anorexia, stool is low volume with mucus; diarrhea
can occur after perforation, fever is neither sensitive or specific. High fever could mean perforation. RLQ
tenderness with light palpation. Leukocytosis, left shift. Most comfortable position on side with legs
flexed. PE: involuntary guarding, RLQ rebound tenderness, maximal pain over McBurney’s point (1.5-2in
in from the right anterior superior iliac crest on a line toward the umbilicus, most reliable finding). Heel-
drop jarring test (toes for 15 sec then drop to flat feet elicits pain, positive), inability to stand or climb
stairs, winces when getting on/off exam table, riding in car over bumps hurts. Rovsing sign positive.
Positive Psoas sign or obturator sign or both.
Dx: CBC WBC increase with increase neutrophil count (present in 70-90% of cases) if early may not be
seen though. Amylase, lipase and liver enzymes to rule out other disorders. UA may show leukocytes,
blood. Abdominal xray may show fecalith if rupture occurred. US may show enlarged appendix or
rupture. CT with contrast has the highest accuracy, esp in adolescents. An appendiceal diameter greater
than 6mm = considered diagnostic. HCG level to rule out ectopic pregnancy.
Management: surgical consultation for appendectomy, opioid pain meds for pain, if suspected perf IV
antibiotics. Follow up in 2-4 weeks after surgery, if appetite and bowel function is normal; no pain or
fever present; findings on PE is normal and wound is healed child can return to normal activity.
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