Case study...Peds...GI

[hopefornursing]

Hey all,

Been assigned a case study for Peds....

Would appreciate any insight, but I will tell you what I have thought of thus far and am trying to narrow it to top two choices.....We were to try to come up with possible Dx and tests we might anticipate ordered, etc...

Number one dx would be Hiatal Hernia although not too frequent in kids

Numer two dx GERD But i wonder if it's not something more since it's unresponsive to on H2 and two PPI's...

Tests I would anticipate would be another barium swallow, a gastric motility, perhaps a 24 hour pH, maybe an H. Pylori breath test...

Here are the details that were given to us, I want to see if I am missing anything, Thanks!!

7 year old male, 59 pounds, normal neuro signs. C/O daily regugitation post meals, up to 20 times per day, quantity usually a mouthful...Sometimes vomitus in nature and sometimes undigested from meals 4 hours prior.

Unresponsive to Zantac, Prevacid and Prilosec. Prior dx of reflux at age of two with a barium swallow. Hx of occasional bouts of wheezing Tx with albuterol..

I am trying to give this my best shot, but it seem too vague??? Any thoughts would be greatly appreciated!!!

Thanks!

[hopefornursing]

You are one smart cookie. Your critical thinking skills are excellent. The medications he is on treat the SYMPTOMS of GERD but don't address the problem. A weak LES is common in children although it is more common in children less than 12 months of age. I also agree there is some motility issue as well. Do they say anything about frequent URI's?

Thanks!Boy, that's something you don't hear too often in nursing school....

It mentions he'd had two Bronchitis in a course of two months just prior to the time period Also in his history, there is quite a significant hx of rsv, pneumonias and bronchitis as well as bronchilitis, all as an infant. However, it said that he'd not had a resp. issue from before the recent bronchitis for a period of 3 years....

[FlyingScot, RN]

Well, he's clearly aspirating. If he was underweight I'd be thinking of CF too but I think it's unlikely given his nutritional status. It might be worth investigating if everything else comes up normal. So, with all the information you have why don't you list for us the differential diagnoses and the tests you think would be appropriate.

[leslie :-D]

resp symptoms are very common w/gerd, and often overlap.

since he seems unresponsive to the traditional meds, he will likely need (gawd, let me spell this right) esophagogastroduodenoscopy, which can dx or r/o pud, h pylori, stricture, inflammation.

or, an upper gi?

how are his lungs?

any cough, hoorificeness, sore throat?

how is his dentition? (acid can erode enamel)...

leslie

[hopefornursing]

Well, he's clearly aspirating. If he was underweight I'd be thinking of CF too but I think it's unlikely given his nutritional status. It might be worth investigating if everything else comes up normal. So, with all the information you have why don't you list for us the differential diagnoses and the tests you think would be appropriate.

I'll give it whirl, thanks so much for your help.....

A. Slow gastic motility......tests include a gastric emptying study

B. Hiatal Hernia.....a barium swallow study , perhaps a EGD

C. Eosiniphic Gastritis....Scope with biopsy looking for elevated eosinophils,RAST or food allergy test

D. GERD .....Scope for abnormal cells biopsy,Rast for food allergies, H. pylori breath test for possible ulcer, hemoccult stool and vomitus. Barium swallow study. 24 hour pH study to see if episodes of reflux coincide with wheezing.

[hopefornursing]

resp symptoms are very common w/gerd, and often overlap.

since he seems unresponsive to the traditional meds, he will likely need (gawd, let me spell this right) esophagogastroduodenoscopy, which can dx or r/o pud, h pylori, stricture, inflammation.

or, an upper gi?

how are his lungs?

any cough, hoorificeness, sore throat?

how is his dentition? (acid can erode enamel)...

leslie

Hey, good job with the spelling, I always use the initials,,

Lungs presently clear, no cough presently, occasional hoorificeness, occasional sore throat but no C/O pain....Dentition showing no etching/erosion....

[FlyingScot, RN]

Great job. I think a plain old chest film would be in order as well to rule out (or in) chronic aspiration.

What medication is commonly used to treat reflux due to a weak LES? Hint...it's been around for a long time.

Are there any other treatments for chronic reflux?

[hopefornursing]

Ah, yes the chest film!! What about a plain abdominal xray to check for a megacolon or fecal block???Others meds that might be tried include,,,,

Reglan, which speeds motility, erythromycin, to speed,,,

BUT I am confounded by which other med would be used to treat due to weak LES...(Help!).....

Other treatments for chronic reflux include dietary changes, like no caffeine, no chocolate, acidic foods, tomatoe products, spicy foods,fatty foods.....

Surgical treatment for chronic reflux can rarely include a Nissan fundipulation (sp) which is not without it's own risks......a feeding tube could be used in very severe cases..... Am I missing anything??

[FlyingScot, RN]

Terrific!! Reglan does increase motility but it is thought to also tighten the LES. An abdominal film would be a good idea too. The Nissen procedure is not all that rare in children. It is, however, rare in adults. I've taken care of many, many children who have had the procedure. When you say feeding tube are you speaking of NG or GT? Personally it sounds like this child has been medically ignored given that he has suffered what sounds like severe reflux for 5 years.

[roser13, ASN, RN]

7 years old? Vomiting 20 times a day?

Anyone looked at the psych/social situation? What are the family dynamics?

[hopefornursing]

Terrific!! Reglan does increase motility but it is thought to also tighten the LES. An abdominal film would be a good idea too. The Nissen procedure is not all that rare in children. It is, however, rare in adults. I've taken care of many, many children who have had the procedure. When you say feeding tube are you speaking of NG or GT? Personally it sounds like this child has been medically ignored given that he has suffered what sounds like severe reflux for 5 years.

Sorry, I guess I left out some info I didn't think would be important, apparently his reflux when treated at two either went away or was so slight that it seemed to have gone away until recently??? As far as tubes, I'm not sure but I thought I had read something about that poss. somewhere? Maybe with infants?

[hopefornursing]

7 years old? Vomiting 20 times a day?

Anyone looked at the psych/social situation? What are the family dynamics?

Curious how family dynamics might cause painless regurgitation so frequently? In any event, the paper stated he lives at home with both his parents, two older brothers and a puppy. Both parents accompianed child to appt. and appeared concerned, both are professional and there were no s/sx of abuse and when questioned no hx of accidental ingestion/injury/intubation preceeding the beginning in Sept....

[PostOpPrincess, BSN, RN]

Achalasia.