TAB M - GI DISORDERS
PEDIATRIC QUESTIONS AND ANSWERS
1. A 2-year-old previously well white male is happily at play when he suddenly cries out in pain, indicating to his parents that his “tummy hurts.” The pain lasts briefly, and the child resumes playing, only to have the pain recur a short time later, this time accompanied by vomiting. The second episode is also brief, and the child again appears well afterwards. Because his pattern repeats itself at frequent intervals over the course of an hour, the parents bring the child to your office. On abdominal examination, the child has a sausage-like mass in the right upper quadrant. You notice bloody mucus on your finger after completing the rectal examination. The physical examination is otherwise normal.
The most likely diagnosis is:
A) colicky abdominal pain of anaphylactoid purpura.
B) enterocolitis.
C) gastroenteritis.
D) Meckel’s diverticulum.
E) intussusception.
ANSWER: E
An intussusception occurs when a portion of the alimentary tract is telescoped into a segment just caudad to it. It is the most common form of intestinal obstruction from 2 months to 6 years of age. It is rare under 3 months and decreases in frequency after 3 years.
In typical cases there is a sudden onset of severe paroxysmal pain in a previously well child, which recurs at frequent intervals and is accompanied by straining efforts and loud outcries. Initially, the child may be comfortable and play normally between the paroxysms of pain, but if the intussusception is not reduced, the child becomes progressively weak and lethargic. Vomiting occurs in most cases, but is usually more frequent at the beginning. Fecal material of normal appearance may be evacuated during the first few hours of symptoms. After this time fecal excretions are small or more often do not occur, and little or no flatus is passed. Blood generally is passed in the first 12 hours, but at times not for 1 to 2 days, and in rare cases not at all; only 60% of patients will pass a stool containing red blood and mucus, the classic “currant jelly” stool. Thus, approximately 40% of intussusception patients do not pass a “currant jelly” stool. Palpation of the abdomen usually reveals a slightly tender sausage-shaped mass, sometimes ill defined, which may increase in size and firmness during a paroxysm of pain and is most often in the right upper portion of the abdomen. About 30% of patients do not have a palpable mass.
It may be particularly difficult to diagnose intussusception in a child who already has gastroenteritis; a change in the pattern of illness, character of pain, nature of vomiting, or the onset of rectal bleeding should alert the physician. Bloody bowel movements and abdominal cramps accompanying enterocolitis can usually be differentiated from intussusception because the pain is less severe and less regular and because the child is recognizably ill between pains from the time of onset. Bleeding from a Meckel’s diverticulum is usually painless. The intestinal hemorrhage of anaphylactoid purpura is usually, but not invariably, accompanied by joint symptoms or purpura elsewhere; the colicky pain may be similar to intussusception.
Ref: Oski FA (ed): Principles and Practice of Pediatrics. JB Lippincott Co, 1990, pp 1695-1696.
2. A 3-year-old child swallowed a thumbtack 1 hour ago. She is asymptomatic. The treatment of choice at this time is:
A) endoscopic removal.
B) induced catharsis.
C) induced emesis.
D) expectant observation.
E) surgical removal.
ANSWER: D
A great variety of objects that are capable of penetrating the gut wall are swallowed by young children. These include glass and metal fragments, pins, needles, toothpicks, fish bones, coins, whistles, toys, and broken razor blades.
Treatment is expectant, since the patient is asymptomatic and the vast majority pass without difficulty. Catharsis and inducing emesis is contraindicated.
Sharp, pointed objects such as sewing needles may penetrate the bowel wall. If abdominal pain, tenderness, fever, or leukocytosis occur, immediate surgical removal of the offending object is indicated. Post-perforation abscess or granuloma formation are the usual outcomes without surgical therapy.
In this question, the correct answer is expectant observation, since the patient is asymptomatic and the object is likely to pass. One distinct exception to this strategy is ingestion of a small watch or hearing aid battery. This should be removed from the esophagus as it can discharge electrons causing esophageal sclerosis and stricture.
Ref: Schwartz SI (ed): Principles of Surgery, ed 5. McGraw-Hill Book Co, 1989, p 1213.
3. In mid-winter an 11-month-old white male is brought to your suburban office after 2 days of vomiting, diarrhea, and fever to 40.5 C (104.9 F) rectally. You hospitalize him and treat him for significant dehydration. His WBC count is 5300/mm3, with a normal differential. His stools are negative for WBCs.
The most likely etiologic agent is:
A) toxigenic Escherichia coli.
B) Shigella.
C) Clostridium difficile.
D) Norwalk-like virus.
E) rotavirus.
ANSWER: E
In this patient, the absence of WBCs in the stool, along with a normal WBC count, suggests a viral etiology. In the first 2 years of life, rotavirus infection is the most common cause of infection in developed nations. It is most common in the winter in temperate climates, with epidemics generally spreading eastward from the western United States during the course of the winter. Toxigenic E. coli is rare in developed nations, but is seen in the Third World. The presentation of this case makes shigellosis unlikely. C. difficile commonly occurs in association with prior antibiotics use. Norwalk-like viruses causes sporadic outbreaks of gastroenteritis in common-source (food- and water-borne) infections in all ages, but more often in young adults.
Ref: Behrman RE, Kliegman RM (eds): Nelson Textbook of Pediatrics, ed 14. WB Saunders Co, 1992,pp 664-665, 831-832. 2) Kapikian AZ: Viral gastroenteritis. JAMA 1993;269(5):627-630.
4. Over the last 6 months a developmentally normal 12-year-old white female has experienced intermittent abdominal pain, which has made her quite irritable. She describes joint pain and general malaise. She has lost 5 kg (11 lb) and has developed an anal fissure.
Which one of the following is the most likely cause of these symptoms?
A) Celiac disease (gluten enteropathy)
B) Irritable bowel syndrome
C) Hepatitis A (infectious hepatitis)
D) Crohn’s disease
E) Giardiasis
ANSWER: D
Twenty-five percent of all patients with inflammatory bowel disease in the United States are children, with Crohn’s disease having approximately a 2:1 predominance over ulcerative colitis. Abdominal pain, growth retardation, and perianal disease are especially common manifestations of Crohn’s disease.
Celiac disease, while also responsible for failure to thrive, is usually detectable during infancy, with steatorrhea being a nearly universal finding.
Irritable colon and other functional bowel disorders may mimic symptoms of Crohn’s disease, but objective findings of weight loss and anal lesions are extremely uncommon. This is also true for viral hepatitis and giardiasis. In addition, the historical and epidemiologic findings in this case are not consistent with either of these infections.
Ref: Behrman RE, Kliegman RM (eds): Nelson Textbook of Pediatrics, ed 14. WB Saunders Co, 1992, pp 969-970.
5. An infant begins to vomit shortly after birth and his abdomen becomes distended. A roentgenogram of the abdomen shows a “double-bubble” gas shadow.
The infant’s problem most likely is:
A) tracheoesophageal fistula.
B) esophageal atresia.
C) duodenal atresia.
D) malrotation.
E) congenital megacolon.
ANSWER: C
Vomiting is the most common presentation of congenital duodenal obstruction in the newborn. Abdominal distension ensues, and a flat plate radiograph of the abdomen shows a classic “double-bubble” gas shadow with an absence of gas in the distal bowel. While a tracheoesophageal atresia and malrotation also cause vomiting, they are not associated with the “double-bubble” radiograph.
Ref: Behrman RE, Kliegman RM (eds): Nelson Textbook of Pediatrics, ed 14. WB Saunders Co, 1992, pp 950-951.
6. A 5-month-old infant has had several episodes of wheezing, not clearly related to colds. The pregnancy and delivery were normal; the infant received phototherapy for 1 day for hyperbilirubinemia. He had an episode of otitis media 1 month ago. There is no chronic runny nose or strong family history of asthma. He spits up small amounts of formula several times a day, but otherwise appears well; his growth curve is normal. An examination of unremarkable except for mild scattered wheezing.
Which one of the following is the most likely diagnosis?
A) Benign reactive airway disease of infancy
B) Cystic fibrosis
C) Unresolved respiratory syncytial virus (RSV) infection
D) Early asthma
E) Gastroesophageal reflux (GER)
ANSWER: E
Gastroesophageal reflux (GER) is a common cause of wheezing in infants. At 5 months of age, most infants are not continuing to spit up several times a day, and this is a major clue that the wheezing may be from the reflux. Also, there is no family history of asthma and the wheezing is not related to infections. Cystic fibrosis is more likely to present with recurrent infections and failure to thrive than with intermittent wheezing.
Ref: Hart JJ: Pediatric gastroesophageal reflux. Am Fam Physician 1996:54(8):2463-2471.
7. A 4-month-old infant has an umbilical hernia which is 5 cm in diameter. It protrudes when the infant cries and strains, but is easily reduced.
Which one of the following is the most appropriate management?
A) Ultrasonography
B) Transcutaneous nerve stimulation of the rectus abdominis
C) Surgical repair
D) Strapping
E) Observation only
ANSWER: E
Most umbilical hernias that appear before the age of 6 months disappear spontaneously by 1 year of age. Even larger hernias (5 to 6 cm) have been known to close by 5 to 6 years of age. Strapping is ineffective. Surgery is reserved for strangulation (which is quite rare) or hernias that persist to 3 to 4 years of age, enlarge after 1 to 2 years of age, or cause symptoms.
Ref: Behrman RE, Kliegman RM, Arvin Am (eds): Nelson Textbook of Pediatrics, ed 15. WB Saunders Co, 1996, p 507. (ABFP, 2000, 67).
8. A 4-year-old white female is brought to your office by her parents because she swallowed a penny 1 hour ago. Examination of the pharynx is normal. A roentgenogram reveals a coin in the area of the gastric antrum.
Which one of the following would be most appropriate?
A) Immediate consultation with an otolaryngologist
B) Immediate consultation with a gastroenterologist
C) An abdominal roentgenogram in 12 hours
D) An abdominal roentgenogram in 24 hours
E) Advising the parent to monitor stools for passage of the coin and to report any abdominal symptoms
ANSWER: E
Many children are exposed to unnecessary radiation and surgery after swallowing coins. It is recommended that all affected children have a single initial film of the chest and neck. A swallowed coin may lodge in either the esophagus or trachea. Because the esophagus is floppy and accommodates expansion, the coin is usually visualized in the transverse (flat) position. In the trachea, owing to the fact that the tracheal cartilage does not extend circumfrentially posteriorly, coins are lodged sideways. Unless they have symptoms, patients with coins below the cardia should require no follow-up other than reassurance.
Ref: Stringer MD, Capps SNJ: Managing swallowed coins in children. BMJ 1991;302:1321-1322. 2) Behrman RE, Kliegman RM, Arvin AM (eds): Nelson Textbook of Pediatrics, ed 15. WB Saunders Co, 1996, pp 1074-1075.
9. You see a 3-year-old white female in the emergency department for blunt trauma to the abdomen. Your working diagnosis of intramural hematoma of the duodenum is confirmed by an upper GI series which shows a coil-spring appearance of the second and third portion of the duodenum. Slight elevation of serum amylase provides additional evidence for the diagnosis.
The most appropriate treatment at this time includes which one of the following?
A) Exploratory laparotomy with evacuation of the hematoma
B) Gastroenterostomy
C) Duodenal resection
D) Non-surgical treatment with bowel rest
ANSWER: D
An intramural hematoma of the duodenum can be associated with blunt abdominal trauma, including child abuse. The hematoma forms a dark, sausage-shaped mass in the submucosal layer of the duodenum, resulting in partial or complete duodenal obstruction. The patient often manifests signs of high bowel obstruction, although the obstruction is usually only partial. The classic diagnosis is based on dilation of the duodenal lumen, with a coil-spring appearance of the second and third portion of the duodenum due to crowding of the valvulae conniventes by the hematoma. Serum amylase is often elevated.
For many years, the traditional treatment of intramural duodenal hematoma was surgical. Typically, these operations included simple evacuation of the hematoma, gastroenterostomy, and duodenal resection. However, over the past 15 years, increasing evidence has suggested that this condition can be treated by conservative non-surgical means with cessation of oral intake, nasogastric suction, and intravenous replacement of fluid and electrolytes.
Ref: Schwartz SI (ed): Principles of Surgery, ed e. McGraw-Hill Inc, 1994, p 201. 2) Sabiston DC Jr: Textbook of Surgery, ed 15. WB Saunders Co, 1997, p 315.
10. A 6-year-old Hispanic female develops watery diarrhea, with at least twelve episodes over a 48 hour period. She is taking fluids orally without nausea and vomiting, is afebrile, and has an unremarkable physical examination except for hyperactive bowel sounds. There are no signs of dehydration.
According to current practice guidelines, which one of the following is the most appropriate recommendation?
A) Clear liquid diet (juices, soft drinks) and loperamide (Lomotil) orally
B) Clear liquid diet alone
C) Age-appropriate diet
D) Age-appropriate diet without milk products
ANSWER: C
The American Academy of Pediatrics Practice Parameter on the Management of Acute Gastroenteritis in Young Children states that children who have diarrhea and are not dehydrated should continue to be fed age-appropriate diets. Conventional practice has been to delay giving food to children who have diarrhea. When feeding has been resumed, only a restricted spectrum of foods has been recommended, and dairy products have been avoided. However, regular diet does not worsen the course or symptoms of mild diarrhea, and may reduce the duration somewhat. A good rule is to avoid foods high in simple sugars, such as juices and sugar containing soft drinks. Most children who have diarrhea will tolerate full-strength milk or formula well. Because of the unacceptable risk of side effects, loperamide is not recommended to treat acute diarrhea in children.