Berkowitz’s – Section IX: Gastrointestinal Disorders

Vomiting

George Gershman, MD
CASE STUDY
A 6-week-old boy who has been vomiting after each meal for 3 days is brought to the office. He is breastfed, afebrile, and otherwise well. The history of the pregnancy and birth are normal. His birth weight was 3,500 g, and his current weight is 4,500 g. The physical examination is unremarkable. The mother nurses the infant in the office. Although he feeds hungrily and well, he vomits about 5 minutes after the feeding. The vomiting is projectile, and the vomitus shoots across the room. The vomitus contains curdled milk. On reexamination of the abdomen, a small mass is felt in the right upper quadrant.
Questions
1. What is the mechanism of vomiting, and how does it differ from regurgitation and rumination?
2. What are the common causes of vomiting in infants?
3. What are the common causes of vomiting in older children?
4. What is the significance of bilious vomiting?
5. What are the unique features of vomiting related to increased intracranial pressure?
6. What are some strategies for the management of vomiting in older children?

Gastroesophageal Reflux

George Gershman, MD
CASE STUDY
A 15-month-old boy presents with a history of vomiting small amounts of food 3 to 4 times per week. The emesis occurs most often after meals. There does not seem to be any pain or discomfort with the vomiting. He has been otherwise healthy, with an uneventful course as an infant, good weight gain, and no hospitalizations. There is no history of pneumonia or abdominal pain. Physical examination is normal, with no anemia or urinary tract disease noted on laboratory assessment.
Questions
1. What are the characteristics of gastroesophageal reflux?
2. What is the difference between gastroesophageal reflux and gastroesophageal reflux disease (GERD)?
3. What groups of children are at risk for GERD?
4. What is the appropriate workup for an infant with suspected GERD?
5. What is the appropriate management of infants and children with gastroesophageal reflux and GERD?
6. What is the natural history of gastroesophageal reflux in children?

Gastrointestinal Bleeding

George Gershman, MD
CASE STUDY
A 4-year-old boy is evaluated for intermittent passing of bright red blood from the rectum for 2 weeks. Blood coats the stool or appears as a spot after a bowel movement. The mother reports no vomiting, diarrhea, loss of appetite, weight loss, fever, or abdominal pain. The boy has no history of constipation, straining, or pain with defecation and is taking no medications. The family has no pets and has not traveled recently. On physical examination, the boy is a well-appearing, energetic, interactive youngster. Weight and height are at the 75th percentile for age. The abdomen is soft, flat, and non-tender, and bowel sounds are normally active. No organomegaly or masses are evident. No rashes, bruising, or hemangiomas are present. No tags, fissures, or fistulas are seen on close visual inspection of the perianal area. Digital rectal examination reveals normal sphincter tone, and a small, mobile, pealike mass is palpable in the rectal vault. A film of bright red blood is present on the glove after the examination. A complete blood cell count with platelet count and a prothrombin and partial thromboplastin time determination yield normal results.
Questions
1. What is a proper way to assess the children with gastrointestinal (GI) bleeding?
2. What are the specific characteristics of upper and lower GI tract bleeding?
3. What age-related conditions account for upper and lower GI tract bleeding in children?
4. What is the appropriate approach to the child with GI bleeding?
5. How does the physician decide what type of management is appropriate for a given patient?

Diarrhea

George Gershman, MD
CASE STUDY
A 10-year-old boy is evaluated for a 10-lb weight loss, fatigue, poor appetite, abdominal and joint pain, and bloody diarrhea for the last 5 months. He reports 5 to 7 bowel movements per day and frequent awaking at night due to the urge to defecate. He describes the stool as liquid and mushy with streaks of blood and mucus. Bowel movements are associated with tenesmus and the feeling of incomplete defecation. There are no ill contacts or history of recent travel. Vital signs are normal. The patient appears pale and malnourished. The mucous membranes are moist without ulcers. The abdomen is soft with mild tenderness in the left hypogastric area. Bowel sounds are active. The rectal examination is unremarkable except for the presence of gross blood.
Questions
1. What are the major categories of diarrhea?
2. What are the common infectious agents that cause diarrhea in infants and children?
3. What are the manifestations of acute and chronic diarrhea?
4. What conditions lead to prolonged diarrhea in infants and children?
5. How is diarrhea managed in infants and children?

Constipation

Doron D. Kahana, MD, and Khalid M. Khan, MD
CASE STUDY
A 9-year-old girl is brought to the office by her mother complaining of bloody stool. The mother reports that the blood is bright red and seen on the toilet paper and dripping into the bowl—there is no blood mixed into the stool. The child complains of perianal pain that is burning during defecation and says that the bleeding is noted toward the end of the bowel movement. On further history, the child has been complaining of intermittent, colicky abdominal pain, mostly in the afternoon and evening, which are relieved with bowel movements, which are reported to be infrequent, with multiple skipped days in between. The mom recalls that the toilet has been plugged a few times after the patient used it. There has been no weight loss and the child eats an ageappropriate diet that is high in pasta, cheese, processed meat, breads, and candy. The child at times is gassy and looks bloated, but otherwise she is healthy, growing and developing normally. On examination, vital signs are normal; patient is at the 65th percentile in height and 80th percentile in weight. Abdomen is soft and non-tender but mildly full in the left lower quadrant. Perianal examination reveals a deep anal fissure, and rectal examination reveals a firm fecal mass. The rest of the examination is normal.
Questions
1. What is the definition of constipation?
2. How is the stooling pattern related to diet?
3. What conditions are associated with constipation?
4. How do familial factors influence stooling patterns?
5. What is the management of chronic constipation?

Abdominal Pain

George Gershman, MD
CASE STUDY
A 16-month-old previously healthy boy was brought to the emergency department by his parents, who reported sudden onset of recurrent loud crying episodes lasting 10 to 15 minutes and a single episode of non-bloody, non-bilious vomiting over the last 12 hours. During each episode, the child was inconsolable, then fell asleep, only to awake crying again and moving his legs toward the abdomen as though he had abdominal pain. He refused to eat and looked exhausted. He also passed 2 bloody, mucus-like bowel movements. Three days prior to the current illness, the child had acute viral gastroenteritis. In the emergency department, the temperature and vital signs were normal except for mild tachycardia. Weight and height were at the 50th percentile. The physical examination revealed a slightly distended and tender abdomen. Bowel sounds were normal. There was no evidence of hepatosplenomegaly or ascites. The rectal examination showed an empty rectal vault and a small amount of gross blood.
Questions
1. What types of abdominal pain occur in children?
2. What characteristics distinguish functional from organic abdominal pain?
3. What are the common organic causes of recurrent abdominal pain in children?
4. What functional gastrointestinal disorders manifest with recurrent abdominal pain in children?

Jaundice

Doron D. Kahana, MD, and Khalid M. Khan, MD
CASE STUDY
A 4-week-old boy is brought to the office for a routine weight check because he is breastfeeding. He was the product of a full-term, normal, spontaneous vaginal delivery, with a birth weight of 3,600 g. He has been feeding well, exclusively at the breast, with loose stools following each feeding. On physical examination, the infant weighs 4,900 g. The examination is normal except that the boy appears jaundiced. On further questioning, the mother states that her son was jaundiced shortly after birth, but she was told that the bilirubin level was all right. She thinks the jaundice may be more noticeable now. His stool is yellow and pasty, though sometimes it seems lighter in color.
Questions
1. What are the common causes of unconjugated hyperbilirubinemia in young infants?
2. What are the common causes of conjugated hyperbilirubinemia in young infants?
3. What are the usual causes of jaundice in older children and adolescents?
4. What is the appropriate management of hyperbilirubinemia in breastfed infants?
5. What are the diagnostic studies that are done to determine the etiology of jaundice?

Viral Hepatitis

ChrisAnna M. Mink, MD
CASE STUDY
A 15-year-old boy is brought to the office with a 1-week history of intermittent fever, vomiting, diarrhea, and diffuse abdominal pain. His mother reports the appearance of “yellow eyes and skin” on the day before the visit. Her son was previously in good health, and he has not seen a hysician in several years. He is taking no medications and has no known ill contacts. He has no history of recent travel outside the United States and denies any unusual food ingestions. Mom reports that he frequently eats at a local fast-food restaurant with his soccer team, but his family does not eat there. He has one ear piercing and denies sexual activity, drug use, or tattoos. The physical examination is significant for a temperature of 101.4°F (38.6°C), pulse of 100 beats/min, and blood pressure of 110/63 mm Hg. The teen is a welldeveloped, well-nourished male with yellow skin and sclera. The abdomen is soft, with mild diffuse tenderness, most notably over the right upper quadrant, and normal bowel sounds. The liver edge is palpated 5 cm below the right costal margin, and no splenomegaly is present. The rectal examination is normal, with guaiac-negative stool.
Questions
1. What are the most common causes of viral hepatitis in children and adolescents?
2. What is the appropriate evaluation for children and adolescents with suspected hepatitis?
3. What complications are associated with viral hepatitis?
4. What treatments are currently available for viral hepatitis, and how does treatment differ depending on the specific etiology?