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PEDIATRIC GI EMERGENCIES Kevin Levere Jan 16, 2003

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Objectives To acknowledge contrasts from grown-ups in GI drains Pancreatitis Liver illness To audit basic pediatric stomach crises IBD, lethal megacolon, metabolic malady, clogging, colic, and jaundice are not talked about

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Pediatric GI Bleeds Many etiologies like grown-up Frequency varies essentially Some interestingly pediatric causes Mortality lower than grown-up partners Fewer comorbidities Relatively more prominent physiological adaptability Division amongst upper and lower Ligament of Treitz

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Case 4wo ex35wker young lady, bosom sustaining. Spat up a shot-glass worth of red blood. Aside from oral thrush, her exam is typical. Hx: Got Vit K. No meds. Developing. No BRBPR. FHx: No draining diatheses. Mother not on meds, but rather has mastitis. Adept test turns yellow-cocoa

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Case 2yo kid passing a few genuinely expansive maroon hued BMs, x12hrs. Effortless. Typical BM Hx until then. 37, 140, 90/70, 24, pale yet perky. OB+. Hgb 60, rest of CBC ordinary. Which is best game-plan? A) cross-coordinate, radionuclide examine, IV bolus, surgery B) cross-coordinate, IV bolus, filter, surgery C) cross-coordinate, IV bolus, surgery, check D) IV bolus, 0-transfusion, surgery, overlook the sweep

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Pediatric GI Bleeds Hemorrhagic ailment of the infant Early (<1wk) Vitamin K insufficiency Rare now organization of vitamin K soon after birth has gotten to be standard Maternal anticoagulant and intrapartum antiepileptic sedate utilize Late onset (2-6mos) Fat malabsorption

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Pediatric GI Bleeds Ingestion of maternal blood Apt Downey test 1:1 stool with faucet water, turn 5:1 supernatant with 1% NaOH After 2 mins Pink = fetal Hgb Yellow = maternal Hgb

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Pediatric UGI Bleeds Upper GI Bleeds No great epidemiologic information outside PICU 6-25%, contingent upon prophylactic treatment 0.4% considered critical Commonest endoscopic discoveries Gastritis Esophagitis Varices Ulcers Mallory-Weiss tears

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Pediatric UGI Bleeds Ulcers and Gastritis Gastric corrosive generation starts not long after birth Ulcers generally uncommon Most are connected with NSAIDs and stress H. pylori disease Diffuse nodular gastritis commonest presentation Infection increments with age <5yo uncommon ~20-half by 10yo (SES subordinate) 40-80% grown-ups (SES subordinate)

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Pediatric UGI Bleeds Esophagitis Severe GERD FB or concoction damage Infection Vascular peculiarities Hemangiomas Hereditary telangiectasia Aortoenteric fistulas Congenital mutations Duplications, impediments Predisposed to mechanical harm

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Pediatric UGI Bleeds Management Similar to grown-ups ABC's, history and physical NG Same situation as in grown-ups, yet no pediatric information No longer utilize super cold lavages Diagnostics CBC, PTT/INR, LFT's, cross-coordinate Limited parts for imaging – CXR, U/S, angiography Medications Acid-suppressive +/ - instinctive vasoconstrictive Limited yet steady information; dosing is the key contrast

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Pediatric UGI Bleeds Management Endoscopy Indications less institutionalized than in grown-ups For serious or industrious/intermittent draining Diagnostic No information on danger of rebleeding in light of discoveries Interventional as in grown-ups Size the constraining component for methods Safety like grown-up information Complication rate 0.3% in review investigation of 2026

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Pediatric UGI Bleeds Management Surgery as move down Failed endoscopic treatment Surgical sore, e.g. Dieulafoy's injury Take home point Non-GI sources as normal as GI sources in "pediatric UGI drains"

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Pediatric LGI Bleeds Lower GI Bleeds 0.3% of ED visits half <1yo Allergic colitis, gaps commonest >1yo Infectious GE, gap, polyps commonest Ann Emerg Med, 1994

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Pediatric LGI Bleeds Diagnosis Nature of draining restricts inception N.B. hematochezia inconsistent in babies, with their speedier GI travel times History and physical If question dying, or suspect false-pos guaiac Immunodiffusion of fecal Hgb Sensitivity and specificity ~70% each, as with guaiac Fecal alpha-1-AT estimation Sensitivity 88%, specificity 90% Also raised in protein-losing enteropathy???

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Pediatric LGI Bleeds Numerous research facility and imaging choices Blood Stool Urine Plain movies, atomic sweeps, endoscopy Commonly utilized as a part of effortless draining Non-barium differentiate thinks about, U/S, CT, MRI, angiography Dependent on presumed etiology

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Pediatric LGI Bleeds Management Similar to grown-ups ABC's, history and physical NG Aspirate can recognize if blood from UGI source Diagnostics CBC, PTT/INR, LFT's, cross-coordinate, and so on Medications Visceral vasoconstrictive Supportive information for part in LGI drains Treat hidden cause

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Pediatric LGI Bleeds Neonatal NEC Risk variables Prematurity (87% of cases) Hypoxia Sepsis Acidosis Early enteral sustains Umbilical vascular catheter PDA Epidemics bolster irresistible segment

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Pediatric LGI Bleeds Neonatal NEC Onset Typically <4wks of age; can be late as 3mos Manifestation Abdominal expansion, gastric maintenance Poor encouraging, V/D, laziness, apnea Gross blood in stools in just 25% Severe cases prompt to SIRS

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Pediatric LGI Bleeds Pneumatosis intestinalis in 50-75% at analysis Portal venous gas in serious ailment

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Pediatric LGI Bleeds Neonatal NEC Complications Mortality up to 5% Strictures in 10% Treatment Supportive Antibiotics, gut rest Surgical move down

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Pediatric LGI Bleeds Neonatal Hirschsprung illness Congenital aganglionic megacolon Delayed (>48hr) section of meconiom History of (frequently dynamic) obstruction 25% have blood in stool Diagnosis Contrast douche – proximal enlargement = ordinary entrail Rectal manometry Biopsy with truant ganglion cells Treatment is surgical resection

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Pediatric LGI Bleeds Infants "Hypersensitive" colitis Intolerance to dairy animals' drain protein 0.2-7.5% predominance Soy protein narrow mindedness in 14-25% of these Typically not IgE interceded Resolves in most by 2yo Treatment is dietary confinement Volvulus Intussusception

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Pediatric LGI Bleeds Children Infectious enterocolitis HUS, HSP, pseudomembranous colitis IBD Vascular abnormalities Hemangiomas, telangiectias, varices, hemorrhoids Polyps Other tumors, e.g. colon growth, are uncommon Trauma FB, NAT

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Pediatric LGI Bleeds Meckel's diverticulum Vitellointestinal pipe remainder half have gastric mucosa Most imperative wellspring of little gut draining Gastric mucosal ulceration versus intussusception Rule of 2's 2% of populace 2:1 male:female 2 feet from IC valve Under 2yo commonest Diagnosed by radionuclide filter Treatment is surgical resection

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Pediatric LGI Bleeds Take home point Think of NEC and Meckel's Both moderately regular Both possibly genuine

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Case 13yo young lady with 3days fever, notwithstanding Tylenol utilized round the clock. Likewise c/o N/V, anorexia, direct epigastric torment. Today somewhat embittered. Denies EtOH or other medication utilize. Her sweetheart has Mono. 38.7, 100, 120/85, 22. Abdo delicate, a bit stretched, else exam typical.

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Pancreatitis Differential Gastroenteritis Ulcer Hepatitis Pneumonia Biliary tract obstacle

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Pancreatitis Much less basic than in grown-ups Pathogenesis Cell damage (poison or something else) sets off pancreatic autodigestion and provocative reaction

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Pancreatitis Acute Interstitial edema Usually determines inside 2-7 days – mortality 5% Complications – uncommon Pseudocyst – ease back to develop and resolve (weeks) Phlegmon, putrefaction +/ - discharge SIRS – 50-80%+ mortality Chronic/repeating Endocrine and exocrine inadequacies Calcification

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Pancreatitis Etiology – the key contrast in pediatrics Trauma Blunt harm – commonest cause; consider NAT Infection Viral (not simply mumps), et al Multisystem sickness CF, collagen vascular ailment, vasculitits, metabolic Obstructive Congenital inconsistencies, biliary microlithiasis Drugs and Toxins EtOH, acetaminophen Hereditary – autosomal predominant Idiopathic (25%)

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Pancreatitis Clinical Picture Abdominal agony Steady, epigastric, with delicacy, extension Persistent regurgitating Proportional to stomach torment Fever Associations in muddled picture Mass, e.g. in half of cases with pseudocyst Asictes, pleural radiations, hypocalcemia, hyperglycemia, jaundice Gray Turner (flank) and Cullen (periumbilical) signs MSOF and stun

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Pancreatitis Diagnosis Serum lipase affectability 86% to 99%; specificity of half to 99% Elevated 1-2 weeks longer than amylase Serum amylase affectability 75% to 92%; specificity 20% to 60% General lab assessment Urinary trypsin enactment peptide (TAP) Investigational prognosticator Ranson and APACHE-II criteria Not solid in pediatrics

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Pancreatitis Diagnosis Diagnostic imaging – 20% typical at first Plain movies Pleural emissions, "sentinel circle", "cut-off sign" U/S Biliary tract assessment, or follow-up of growths/abcesses CT Usually just if poor U/S representation ERCP/MRCP Considered if intermittent/undiscovered issues For suspected stones

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Acute pancreatitis Pseudocyst 5 months after intense scene Pancreatitis

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Pancreatitis Management "Pancreatic rest" NPO +/ - NG Pain control Meperidine – opioid bringing on slightest enterobiliary weight by withdrawal of Sphincter of Oddi Fluid and electrolyte homeostasis Surgical and anti-infection intercessions uncommon Abcess, contaminated pseudocyst, corruption, drain Address basic cause if capable

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Pancreatitis Take home point Trauma, including non-inadvertent, is the commonest cause

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Liver Failure Fulminant hepatic disappointment Acutely weakened hepatocyte work with Encephalopathy inside 8 weeks of beginning side effects, with a formerly sound liver, or Encephalopathy inside 2 weeks of jaundice, regardless of the possibility that beforehand basic liver brokenness

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Liver Failure Cirrhosis