Case study...Peds...GI - page 2

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... Read More

  1. by   FlyingScot
    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.
  2. by   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, hoarseness, sore throat?
    how is his dentition? (acid can erode enamel)...

    leslie
  3. by   hopefornursing
    Quote from FlyingScot
    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.
  4. by   hopefornursing
    Quote from 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, hoarseness, 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 hoarseness, occasional sore throat but no C/O pain....Dentition showing no etching/erosion....
  5. by   FlyingScot
    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?
  6. by   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??
  7. by   FlyingScot
    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.
  8. by   roser13
    7 years old? Vomiting 20 times a day?

    Anyone looked at the psych/social situation? What are the family dynamics?
  9. by   hopefornursing
    Quote from FlyingScot
    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?
  10. by   hopefornursing
    Quote from roser13
    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....
  11. by   PostOpPrincess
    Achalasia.
  12. by   hopefornursing
    Well, I turned it in, thanks to everyone who helped me think it thru...I put as my first probable dx slow gastic motility and that tests that could be anticipated would include a gastic motility study, and a 24 hour pH study as well as endoscopic eval of the esophagus.....
    And the correct answer,,,as per the instructor.....Drum roll please,,,,






    something I really hadn't considered much, and none of us got it right,:angryfire


    constipation.
    Which is curious, as there was really no indication of a problem in the info we were given that would have led us to that......Good thing it wasn't graded....

    HOW could constipation possibly cause repeated regurgitation over a period of months.
    I am really curious about that and the instructor didn't have time to discuss....
    I guess they want us to think outside the box.....
    Thanks :redpinkhe
  13. by   FlyingScot
    Well now that's just ridiculous. The first sign of constipation is lack of bowel movements which wasn't mentioned. In addition if the kid is so backed up that he's vomiting there would be other significant signs like a distended abdomen and abdominal/rectal pain. Anybody here who's been backed up for even a few days can attest to that. While I don't recommend it I'd want to let that instructor know that a bunch of peds nurses with YEARS of experience think that diagnosis is a bunch of hooey!!!!! Although, in the end, you did learn a bunch...I hope!

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