GIT &

HEPATOBILIAR
Y
Group 7: Nandkumar, Ocampo, Omolon,
Pachagoundan, Panchal, Pangilinan, Parihar,
Pascual
 Case 1
A mother is concerned that her 4-day-old son’s face and chest are turning
yellow. Her son was delivered vaginally after an uncomplicated
term pregnancy. The family history is unremarkable. With the
exception of a large cephalhematoma, his physical examination is
normal. He is breastfeeding well and shows no signs of illness.
 Question 1
What is your most likely diagnosis? Basis?

Neonatal Hyperbilirubinemia

Basis: 4-day-old
Male
Cephalhematoma
 Question 2
What is the next step in the evaluation of this
baby?

Serum or Transcutaneous bilirubin level

 Question 3
If the jaundice persists for more than 2 weeks,
what could possibly be wrong with the baby?
 Question 4
How will you manage this 4 - day - old baby?
1. Maintain sufficient feeding
2. Diagnostic evaluation ex. Serum Bilirubin
3. Assign Bilirubin zone
4. Phototherapy if needed
 Case 2
A 12-year-old adolescent female has periumbilical pain that began 8
hours ago, since then she has vomited once and has had one small,
loose, bowel movement. Her last meal was 12 hours ago, and she is
not hungry. She denies dysuria, urinary frequency, and sexual activity;
her last menses 1 week ago was normal. On examination, she is
moderately uncomfortable and has a low-grade fever at 38.6”C; her other
vital signs are normal. Her abdominal examination reveals few bowel
sounds, rectus muscle rigidity, and tenderness to palpation, particularly
periumbilically. Breath sounds are clear; she has no rashes. Her pelvic
examination shows no vaginal discharge, but there is some abdominal
tenderness with gentle bimanual palpation. She has pain with digital rectal
examination.
 Appendicitis
(Pathophysiology and Clinical Features)

● Most common acute surgical condition in children

● Inflammation of the appendix that occurs after luminal obstruction
● Obstruction: increase intraluminal pressure, lymphatic and venous congestion
and edema, impared arterial perfusion, ischemia of the appendiceal wall,
bacterial proliferation
● Enteric infections:
○ Yersinia
○ Salmonella
○ Shigella spp.
○ Viruses (IM, mumps, coxsackievirus B, adenovirus)
● Cystic fibrosis have increased incidence
 Question 1
What is the most likely diagnosis? What is your basis?
● Appendicitis
● Clinical manifestations:
○ Periumbilical pain
○ Loss of appetite
○ Tenderness to palpation (periumbilically)
 Appendicitis
(Pathophysiology and Clinical Features)

● Signs and symptoms: depends on timing of presentation, patient age, the abdominal/pelvic
location of the appendix and dse process of each patient
● Most patients with appendicitis demonstrate an insidious onset of illness
● Perforation is common beyond 48 h of illness
 Appendicitis
(Pathophysiology and Clinical Features)

● Inflammatory process in the next 24 hours leads to involvement of the adjacent

parietal peritoneal surfaces, resulting in somatic pain localized to RLQ
● Retrocecal or pelvic position–slower progression of illness
● Abdominal pain is constant, emesis may become bile stained and persistent; clinical
course worsens
 Appendicitis
(Physical Examination)

● Physical examination: Inspection and appearance of the abdomen

● Early appendicitis (18-36h)
○ Appear mildly ill and move tentatively, hunched forward and with a slight
limp favoring the right side
○ Supine position: lie in their right side with their knees pulled up to relax the
abdominal muscles
○ Abdomen is flat (early appendicitis)
○ Auscultation: Normal or hyperactive bowel sound
● Disease progression:
○ Abdominal distention (perforation/small bowel obstruction)
○ Auscultation: Hypoactive bowel sound
● Localized abdominal tenderness is the single most reliable finding in the diagnosis
of acute appendicitis
 Appendicitis
Classic signs:
○ McBurney’s point
○ Psoas sign
○ Obturator sign
○ Rovsing’s sign
○ Dunphy sign
 Appendicitis
Classic signs:
○ McBurney’s point
○ Psoas sign
○ Obturator sign
○ Rovsing’s sign
○ Dunphy sign
 Appendicitis
Classic signs:
○ McBurney’s point
○ Psoas sign
○ Obturator sign
○ Rovsing’s sign
○ Dunphy sign
 Appendicitis
Classic signs:
○ McBurney’s point
○ Psoas sign
○ Obturator sign
○ Rovsing’s sign
○ Dunphy sign
Appendicitis
(Risk Scoring Systems)
 Appendicitis
Laboratory Findings:
● CBC with differential
● Urinalysis
● Electrolytes and liver chemistries
● Amylase
● CRP
Imaging Studies:
● Ultrasound: first-choice tool
● Computed Tomography: gold standard
● MRI and WBC scans
Antibiotics:
● Initiated promptly once the diagnosis of appendicitis is made or highly
suspected
● Regimen directed against
○ Anaerobes: Bacteroides, Clostridia, Peptostreptococcus spp.
○ Gram (-) aerobic bacteria: Escherichia coli, Pseudomonas
aeruginosa, Enterobacter and Klebsiella spp.
 Question 2
What is the next step in the evaluation and
management of the patient?
● Consult a surgeon once diagnosis of appendicitis is suspected
● Request for:
○ Ultrasound
○ CT scan
○ Urinalysis
○ CBC
○ Pregnancy test
 Case 3
A 3-month-old baby was brought to the out-patient clinic because of frequent
crying. The mother disclosed that she does not get enough sleep because her child has
interrupted sleeps. The baby prefers being carried to be able to sleep. She is tempted to
give a pacifier by she is not so sure if this will work. She is exclusively breastfeeding, and
she has normal stooling. She does not have fever, cough, and colds. At the clinic, she has
normal physical findings.
 Question 1
What is the most likely diagnosis
Infant Colic
It is a normal developmental process associated with fussiness,
irritability, and difficulty consoling the infant.
 Question 1
What is the most likely diagnosis
Infant Colic
It is characterized by the “rule of 3”
● 2nd or 3rd week of life
● Lasts about 3 hr/day
● Occurs 3 days/wk
● Lasts for more than 3 wks
● Resolves by 3 or 4 months of age
 Question 1
What is the most likely diagnosis
 Question 2
What is the next step in the management of this
patient?
● Parental support - Take a break
● Dietary and feeding technique changes
● Pharmacological management
● Change in the environment
Infantile Colic: Recognition and Treatment - America
n Family Physician (aafp.org)
 Question 3
How will you educate the mother regarding the
condition of her baby?
● Parents must be counseled
○ Series of calm, systematic steps to sooth the infant
○ Plan for stress relief
○ Colic is self-limited
● Parents are reminded that it is better to allow the baby to cry than engage in
shaking that leads to head trauma
● Precry cues
● Reassurance
 Case 4
A 2 1/2 -year-old child complains of an on and off abdominal pain which is quite
tolerable. He does not have vomiting, fever, or diarrhea. In fact, his last bowel
movement was 5 days ago. On further history taking, the mother said that that is his
normal pattern of stooling for the past 2 months. He has difficulty passing out stool
because it is hard most of the time. You then proceeded to ask for his diet history and
found out that he is not fond of eating fruits and vegetables. He likes friend food and
consumes artificial fruit juices.
 Question 1
What is the most likely diagnosis? Basis?
Functional Constipation
● Occur at the time of diet changes in
infants and at the initiation of toilet
training for toddlers.
● The diagnosis is based on medical history
and physical examination, including digital
rectal examination.
● Rome IV criteria – Diagnostic criteria for
Functional Constipation

Reference: Kilegman, et.al. (2020)., Nelson's Textbook of Pediatrics, 21st Edition

Chapter 368: Functional Gastrointestinal Disorders
Constipation
● Defined as a delay or difficulty in defecation present for >1 month and significant enough to cause
distress to the patient.

Functional Constipation also known as Idiopathic Constipation or Fecal Withholding

● Usually, there is an intentional or subconscious withholding of stool.
● Daytime encopresis is common. Encopresis is defined as voluntary or involuntary passage of feces
into inappropriate places at least once a mo for 3 consecutive months once a chronologic or
developmental age of 4 yr has been reached.

A. Retentive Encopresis – with constipation and overflow incontinence

B. Non-retentive Encopresis – without constipation and

overflow incontinence
 ○ Imperforate anus, anal or colonic
stenosis, anteriorly
Question 2 displaced anus
● Spinal Cord Abnormalities
What are your differential diagnoses?
○ The presence of a hair tuft over the
spine or spinal dimple, or failure to elicit
a cremasteric reflex or anal wink
suggests spinal pathology.
● Metabolic Conditions: Hypothyroidism, Hypocalcemia, Lead toxicity, Celiac disease, and
disorders of neuromuscular gastrointestinal pathology.
● Irritable Bowel Syndrome

○ If pain does not resolve following

 Functional Constipation vs. Hirschsprung Disease

Reference: Kilegman, et.al. (2020).,

Nelson's Textbook of Pediatrics, 21st
Edition, Chapter 368: Functional
Gastrointestinal Disorders
 Question 3
How will you manage this patient in an out-patient set up?

● Management includes disimpaction followed by dietary and lifestyle approaches, osmotic

laxatives to soften stools, and behavioral approaches.

Reference: Kilegman, et.al. (2020)., Nelson's Textbook of Pediatrics, 21st Edition

Chapter 368: Functional Gastrointestinal Disorders
Reference: Kilegman, et.al. (2020).,
Nelson's Textbook of Pediatrics,
21st Edition, Chapter 368:
Functional Gastrointestinal Disorders
 Involvement of a psychologist or behavioral management.
● Stress reduction and learning effective coping strategies.
● Relaxation training, stress inoculation, assertiveness training, and/or general
stress management procedures.
● Neurostimulation (transcutaneous or sacral implantation) and pelvic
physiotherapy.

The goal of maintenance therapy is to avoid reaccumulation of stool by maintaining

soft bowel movements, preferably occurring once a day. It is generally continued
until a regular bowel pattern has been established and the association of pain with
the passage of stool is abolished.

Reference: Kilegman, et.al. (2020)., Nelson's Textbook of Pediatrics, 21st Edition

Chapter 358: Motility Disorders and Hirschsprung Disease
S. Nurko, et.al., (2014). Evaluation and
Treatment of Constipation in Children and
Adolescents, AFP Journal
 Question 4
How will you educate the mother regarding the condition of her child?

● Caregivers must understand that soiling associated with overflow incontinence is

associated with loss of normal sensation and not a willful act.
● There needs to be a focus on adherence with regular postprandial toilet sitting and
adoption of a balanced diet.
● Caregivers should be instructed not to respond to soiling with retaliatory or punitive
measures, because children are likely to become angry, ashamed, and resistant to
intervention.
● Parents should be actively encouraged to reward the child for adherence to a healthy
bowel regimen and to avoid power struggles.

Reference: Kilegman, et.al. (2020)., Nelson's Textbook of Pediatrics, 21st Edition

Chapter 358: Motility Disorders and Hirschsprung Disease
 Education and Behavior Modification
● Behavior modification with regular toileting (for five to 10 minutes) after meals
combined with a reward system is often helpful.
● Position — footstool to ensure knees are higher than hips.
● Chart or diary
● Review toilet access
● Delay toilet training attempts until child is painlessly passing soft stool.

Reference: The Royal Children’s Hospital Melbourne , Clinical Practice Guidelines on Constipation (March 2020)
S. Nurko, et.al., (2014). Evaluation and Treatment of Constipation in Children and Adolescents, AFP Journal
 Dietary Changes
● Increased intake of fluids and absorbable and nonabsorbable
carbohydrates can help soften stools.
● An increased intake of dietary fiber may improve the likelihood that a
child will be able to discontinue laxative therapies.
● Addition of Probiotics

Reference: The Royal Children’s Hospital Melbourne , Clinical Practice Guidelines on Constipation (March 2020)
S. Nurko, et.al., (2014). Evaluation and Treatment of Constipation in Children and Adolescents, AFP Journal
Thank you!
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