2025 – PAGE 239 – GASTROENTEROLOGY

RUMINATION

Rumination is when a child chews something over and over again. This occurs in patients with intellectual disability and in some children who are emotionally disturbed.

BILIOUS EMESIS IN A NEWBORN

Bilious emesis is a surgical emergency in a newborn! Look for evidence of duodenal atresia or malrotation. In older children, bilious emesis can be less severe/emergent.

• Duodenal Atresia = bilious emesis on 1^stDOL, double bubble on KUB. The patient could have jaundice due to increased enterohepatic circulation. If there is “complete” atresia, there will be NO SECOND BUBBLE—NO AIR BEYOND ATRESIA. Remember, 1^st DOL, NOT at 2 months. (If a 2-month-old baby has bilious emesis, consider pyloric stenosis, although that’s typically NON-bilious!!!)

PEARL: For enterohepatic circulation, think of it as the following circuit: the LIVER processes “something” (bilirubin, medications, etc.) → that “something” gets excreted into BILE → the bile goes into the BOWEL → and then that “something” can potentially be absorbed AGAIN from the bowel! So, if stool isn’t moving along, reabsorption of that “something” will be increased.

DOUBLE BUBBLE

A “double bubble” refers to the radiologic sign noted when there is a small bowel obstruction. There will be a “large bubble” and a “small bubble.” These represent a dilated stomach and a dilated duodenum, respectively. Most commonly, the double bubble sign is seen in duodenal atresia, followed by intestinal malrotation. Other associated conditions include duodenal webs, annular pancreas and choledocal cyst. With duodenal atresia, NO DISTAL GAS WILL BE SEEN. With malrotation and perforated duodenal webs, DISTAL GAS WILL BE SEEN.

IMAGE: www.pbrlinks.com/DOUBLEBUBBLE1

VOMITING PEARLS

• One episode of vomiting in an otherwise healthy child probably warrants reassurance.
• Always keep in mind infections (pneumonia, urinary tract infections, gastroenteritis, rotavirus, etc.) as possible causes of emesis.
• Inborn errors of metabolism and Diabetic Ketoacidosis (DKA) are a couple of metabolic causes of emesis.

GI BLEEDING

GI BLEEDING PEARL

STEP 1 is to NG LAVAGE! This is done to evaluate for an upper GI bleed. A brisk upper GI bleed can result in what looks like lower GI bleed because the blood acts like a laxative.

LOWER GI BLEEDING (LGIB)

• DIFFERENTIAL FOR LOWER GI BLEEDING(LGIB) IN THE NEONATAL PERIOD:
  • Maternal Blood: Perform an Apt test on the blood, which will differentiate fetal hemoglobinfrom adult (maternal) hemoglobin.
  • Malrotationwith Volvulus
  • Necrotizing Enterocolitis (NEC): Particularly in premature neonates
• DIFFERENTIAL FOR LOWER GI BLEEDING(LGIB) AT 1–2 YEARS OF AGE
  • Anal Fissure: Usually secondary to constipation; commonly located anteriorly.
  • Intussusception
  • Juvenile Polyp: Painless bleeding. There may be a history of an intermittently seen mass protruding from the rectum.
  • PEARL: There is no increase in the risk of cancer with just one juvenile polyp, but there is an increased risk of gastric and colorectal cancer with > 5 juvenile polyps.
• DIFFERENTIAL FOR LOWER GI BLEEDING (LGIB) AT 2–5 YEARS OF AGE
  • Meckel’s Diverticulum: Painless, CAN be melenic, do Technetium-99m study.
  • Juvenile Polyp: Painless.
• DIFFERENTIAL FOR LOWER GI BLEEDING (LGIB) IN SCHOOL-AGED KIDS
  • Meckel’s Diverticulum: Painless, CAN be melenic, do Technetium-99m study
  • Juvenile Polyp: Painless.
  • Familial Adenomatous Polyposis: 100% chance of future malignancy.
  • Ulcerative Colitis
  • Crohn’s Disease