2025 – PAGE 233 – GASTROENTEROLOGY
INFANTILE GASTROESOPHAGEAL REFLUX (GERD)
Infantile gastroesophageal reflux (GERD) may be noted in up to half of all children 4–6 months of age and usually resolves by 18 months of age. There is no need to treat if the child is healthy and doing well otherwise.
EOSINOPHILIC ESOPHAGITIS
Eosinophilic esophagitis (EoE) is a chronic, immune-mediated esophageal disease characterized by eosinophilic infiltration. Symptoms may include dysphagia, food impaction, refractory GERD-like symptoms, chest or abdominal pain, and feeding intolerance. Diagnosis involves an esophageal biopsy and ruling out other causes. Treatment options include elimination diets since EoE is often associated with food allergies, PPIs, and topical steroids (e.g., fluticasone or budesonide). Esophageal dilation may be needed to treat strictures.
(DOUBLE TAKE) IRRITABLE BOWEL SYNDROME (IBS)
Irritable bowel syndrome (IBS) is a crampy abdominal pain associated with diarrhea or constipation. Symptoms may alternate. This is a diagnosis of EXCLUSION. Treat with fiber.
PEARLS: There must be some type of poop issue! There’s often an emotional component as well. Do not choose this answer unless at least some type of workup has been done already. If no workup has been done, start with noninvasive tests such as a CBC, ESR, anti-TTG, and stool guaiac. Do not choose an invasive test unless other tests are negative and the patient failed a FIBER trial. Non-invasive testing -> Fiber trial -> EGD and/or Colonoscopy.
INFLAMMATORY BOWEL DISEASE (IBD) – CROHN’S AND ULCERATIVE COLITIS
Know the similarities and differences between the different inflammatory bowel diseases (Crohn’s Disease and Ulcerative Colitis). Both are associated with HLA B27 and toxic megacolon. Both also have similar treatments.
- ULCERATIVE COLITIS(UC) typically presents in a TEEN of an Ashkenazi (European) Jewish Look for a history of chronic, crampy lower abdominal pain that may or may not be associated with bloody stool. If there is severe colitis, fever may be present. Lab findings may include hypoalbuminemia and anemia. Diagnosis is by colonoscopy and biopsy. First-line treatment includes 5-ASA (AKA mesalazine or 5-aminosalicylic acid). Second-line therapy options include steroids, metronidazole, azathioprine, cyclosporine, methotrexate, and tacrolimus.
- PEARLS: An acute ulcerative colitis flare can make the colon very fragile and susceptible to PERFORATION. If “barium enema” is an option, cross it out. Also, remember that this disease refers to a COLITIS and is primarily a LARGE BOWEL disease.
- CROHN’S DISEASEmay present simply as short stature and weight loss prior to the onset of any of the usual GI symptom of diarrhea. GI findings may include transmural ulcers in a “skip lesion” pattern, noncaseating granulomas of the upper GI tract, and perianal fistulas. Other manifestations include hepatic disease, erythema nodosum, pyoderma gangrenosum, and uveitis. Supportive laboratory data may include elevated inflammatory markers (ESR or CRP) and anti-Saccharomyces antibodies. Treatment options include 5-ASA, steroids, metronidazole, and immunomodulators/immunosuppressives.
- PEARL: Unlike UC, Crohn’s lesions can occur anywhere from the mouth to the anus. Also, a future conversion to cancer is the RULE for ulcerative colitis patients, but that is not the case for Crohn’s patients.
- MNEMONIC: A positive “anti-saCROHNamyces” antibody can help make the diagnosis.
APPENDICITIS
Consider a diagnosis of appendicitis in any child > 2 years of age with abdominal pain. Look for a child who is not hungry and has periumbilical abdominal pain that migrates to the right side of the abdomen (RLQ at McBurney’s Point). This may be associated with diarrhea. A psoas sign might be noted on exam, and a “sentinel loop” of bowel with absence of air in the RLQ may be noted on an X-ray. Inflammation may be seen on a CT of the abdomen. An ultrasound can also be used, but all you truly need to make the diagnosis is a good history. Treatment is surgery (if the story fits, take the child to surgery). If the appendix has already ruptured, the patient may suddenly be PAIN-FREE. In that case, an acceptable choice may be to give IV antibiotics with plans for a delayed appendectomy (weeks later!).
PEARL: The psoas sign is the finding of abdominal pain elicited by passively extending the thigh of a patient lying on his side with knees extended, or asking the patient to actively flex his thigh at the hip.
IMAGE: (video) www.pbrlinks.com/APPENDICITIS1