Pediatric Gastrointestinal Disorders

A 4-day-old term female infant is brought to the emergency department by her parents due to multiple episodes of green-tinged vomiting that began 6 hours ago. She has been exclusively breastfed and previously had normal stooling and wet diapers. Her temperature is 37.1°C (98.8°F), heart rate is 148/min, respiratory rate is 42/min, and blood pressure is 76/42 mm Hg. Physical examination reveals a soft, non-distended, and non-tender abdomen with active bowel sounds. Capillary refill time is 2 seconds. Arrange the following steps in the most appropriate sequence for the evaluation and management of this patient, from the first step to the definitive final step.

Match each classic clinical presentation and associated diagnostic imaging finding with the most appropriate pediatric gastrointestinal diagnosis.

A 48-hour-old full-term male neonate is evaluated in the nursery because he has not yet passed meconium. The nurses report that the infant has had three episodes of bilious vomiting in the past 12 hours. On physical examination, the infant's abdomen is visibly distended and tympanitic. During a digital rectal examination, there is an explosive release of gas and foul-smelling stool, after which the abdomen becomes notably less distended. Which of the following is the most likely underlying pathophysiology of this patient's presentation?

A $7$-month-old boy is brought to the pediatric emergency department due to a $24$-hour history of high fever, lethargy, and foul-smelling, explosive diarrhea. According to his parents, the patient has had severe constipation since birth, often requiring glycerin suppositories to pass stool. His first meconium was passed approximately $36$ hours after birth. On presentation, his temperature is $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), pulse is $175/\text{min}$, respirations are $55/\text{min}$, and blood pressure is $72/45\text{ mmHg}$. Physical examination reveals a lethargic, ill-appearing infant with dry mucous membranes. The abdomen is markedly distended and tympanitic. Digital rectal examination is followed by a sudden expulsion of foul-smelling liquid stool and flatus. Laboratory studies show a leukocyte count of $22,000/\text{mm}^3$ with $15\%$ bands. An abdominal radiograph demonstrates significantly dilated loops of bowel with multiple air-fluid levels, but no free air under the diaphragm. Which of the following is the most appropriate next step in management?

A fundamental understanding of developmental biology and neonatal pathophysiology is essential when evaluating surgical and medical abdominal emergencies in the pediatric population. Match each specific embryologic defect or pathophysiologic mechanism with the corresponding pediatric gastrointestinal disorder.

A $3$-week-old female infant is rushed to the emergency department by her parents after she began forcefully vomiting green-tinged fluid earlier in the day. She has vomited several times and has become increasingly lethargic over the past few hours. Her parents note that she had a normal bowel movement yesterday. The pregnancy was uncomplicated, and she was born at full term.

Vital signs reveal a heart rate of $185$/min, respiratory rate of $60$/min, and blood pressure of $62/34$ mm Hg. Her temperature is $37.9^\circ$ C ($100.2^\circ$ F). On physical examination, the infant appears pale and poorly responsive. Capillary refill time is $5$ seconds. Abdominal evaluation shows marked distension, absent bowel sounds, and involuntary guarding with rigidity when palpated. Additionally, there are scattered erythematous macules with central tiny yellow pustules on her anterior trunk.

Laboratory results are as follows:

Arterial blood gas:
pH: $7.21$
pCO $_2$: $32$ mm Hg
HCO $_3^-$: $12$ mEq/L

Serum lactate: $6.8$ mmol/L (Normal: $0.5$ - $2.2$ mmol/L)

A plain radiograph of the abdomen displays a few dilated loops of small intestine without any gas in the distal bowel. There is no evidence of free intraperitoneal air.

Which of the following is the most appropriate next step in the management of this patient?

A 2-year-old girl is brought to the emergency department 30 minutes after accidentally ingesting a liquid drain cleaner containing sodium hydroxide. She is crying, drooling continuously, and refusing to swallow. Her temperature is 37.2°C (99.0°F), heart rate is 140/min, respiratory rate is 30/min, and oxygen saturation is 98% on room air. Physical examination reveals mild inspiratory stridor, swollen erythematous lips, and small ulcerations on the buccal mucosa. Arrange the following management steps in the most appropriate chronological sequence for this patient.

A 3-year-old boy is brought to the emergency department by his parents after vomiting a large amount of bright red blood. He has a past medical history of biliary atresia, for which he underwent a Kasai hepatoportoenterostomy during infancy, and subsequent portal hypertension. On presentation, the child appears lethargic and pale. His temperature is 37.1°C (98.8°F), heart rate is 165/min, blood pressure is 70/40 mm Hg, and respiratory rate is 28/min. He has another episode of voluminous hematemesis while in the resuscitation bay. Arrange the following management steps in the most appropriate chronological order for this patient.

A $2$-day-old full-term male neonate is evaluated in the neonatal intensive care unit for abdominal distension and vomiting. The emesis is dark green. The infant was born via uncomplicated vaginal delivery to a $28$-year-old primigravid woman. The prenatal course was unremarkable. The infant has not passed meconium since birth. His temperature is $37.1^\circ$ C ($98.8^\circ$ F), heart rate is $145$/min, respiratory rate is $42$/min, and blood pressure is $65/40$ mmHg. Physical examination reveals a markedly distended and firm abdomen. Bowel sounds are absent, and there is no erythema of the abdominal wall. An anteroposterior abdominal radiograph demonstrates multiple dilated loops of small bowel with a distinct lack of air-fluid levels. A bubbly, granular appearance is noted in the right lower quadrant. There is no free air under the diaphragm.

Which of the following is the most appropriate next step in management?

Match each classic pediatric gastrointestinal clinical presentation with its most appropriate definitive procedural or surgical management.

An infant boy born at $27$ weeks of gestation is currently $14$ days old and recovering in the neonatal intensive care unit. Over the past $8$ hours, the nursing staff has reported increased episodes of apnea, bradycardia, and a drop in body temperature. The patient had previously been tolerating slowly advancing orogastric feeds, but a large bilious residual was aspirated prior to his last scheduled feed. On evaluation, his temperature is $36.0^\circ\text{C}$ ($96.8^\circ\text{F}$), blood pressure is $45/28\text{ mm Hg}$, pulse is $182/\text{min}$, and respirations are $62/\text{min}$. Physical examination reveals a lethargic and mottled neonate. His abdomen is markedly distended, firm, and diffusely tender, with prominent erythema spreading across the abdominal wall. Laboratory analysis demonstrates a leukocyte count of $3,200/\text{mm}^3$ with $25\%$ band forms, a platelet count of $55,000/\text{mm}^3$, and a serum lactate level of $4.8\text{ mmol/L}$. A supine abdominal radiograph shows diffusely dilated loops of bowel, branching linear lucencies overlying the right upper quadrant, and a prominent radiolucent outline of the falciform ligament. Intravenous fluid resuscitation, broad-spectrum antimicrobial therapy, and bowel rest (NPO) are promptly initiated. Which of the following is the most appropriate next step in the management of this patient?

A $7$-month-old male infant is brought to the emergency department due to intermittent episodes of inconsolable crying over the past $6$ hours. During these episodes, the infant intensely draws his knees to his chest and appears visibly distressed. Between episodes, he becomes uncharacteristically lethargic. His parents report one instance of non-bilious emesis and note that his last diaper contained dark red, mucoid stool. Vital signs reveal a heart rate of $165$/min, respiratory rate of $40$/min, temperature of $37.8$°C ($100$°F), and blood pressure of $85/50$ mm Hg. Physical examination is notable for dry mucous membranes and a palpable, slightly tender, sausage-shaped mass in the right upper quadrant. The abdomen is otherwise soft without involuntary guarding.

Arrange the following steps in the most appropriate chronological sequence for the management of this patient.

Match each pediatric gastrointestinal clinical presentation (left) with its most characteristic imaging or histopathologic diagnostic finding (right).

A $7$-year-old girl is evaluated in the pediatric emergency department for severe abdominal pain and vomiting. She underwent a laparoscopic appendectomy for perforated appendicitis $6$ days ago and was discharged home on postoperative day $3$. Over the past $12$ hours, she has developed intense, colicky abdominal pain and repeated episodes of bilious emesis. Her parents note she has not passed stool or flatus since yesterday. On presentation, the child appears toxic, pale, and lethargic. Vital signs reveal a temperature of $39.0^\circ\text{C}$ ($102.2^\circ\text{F}$), heart rate of $145\text{/min}$, respiratory rate of $30\text{/min}$, and blood pressure of $85/50\text{ mm Hg}$. Physical examination demonstrates a markedly distended, rigid abdomen with diffuse rebound tenderness and involuntary guarding. Bowel sounds are absent. Laboratory studies show a leukocyte count of $22,000/\text{mm}^3$ with a left shift and a serum lactate of $4.6\text{ mmol/L}$. An upright plain radiograph of the abdomen reveals multiple dilated loops of small intestine with prominent air-fluid levels and a paucity of colonic gas. Following the initiation of aggressive intravenous fluid resuscitation, which of the following is the most appropriate next step in the management of this patient?

A $5$-week-old male infant is brought to the pediatric evaluation center by his mother due to a $5$-day history of progressively forceful vomiting. The mother reports that the infant vomits large amounts of milk immediately after feeding but remains eager to eat again shortly afterward. The vomitus does not contain bile or blood. The infant has had fewer wet diapers over the last $2$ days. Vital signs are temperature $37.0^{\circ}\text{C}$ ($98.6^{\circ}\text{F}$), heart rate $178/\text{min}$, respiratory rate $42/\text{min}$, and blood pressure $70/40\text{ mm Hg}$. On physical examination, the infant appears lethargic with a sunken anterior fontanelle, dry mucous membranes, and delayed capillary refill. Palpation of the abdomen reveals a $2$-cm, firm, mobile mass in the right upper quadrant. Laboratory studies demonstrate:

Sodium: $131\text{ mEq/L}$
Potassium: $2.7\text{ mEq/L}$
Chloride: $85\text{ mEq/L}$
Bicarbonate: $36\text{ mEq/L}$
Blood urea nitrogen: $32\text{ mg/dL}$
Creatinine: $0.9\text{ mg/dL}$

Based on the patient's presentation and laboratory findings, which of the following is the most appropriate initial step in management?

An otherwise healthy neonate, delivered at term 4 days ago, presents to the emergency room after developing green-colored emesis. The parents report three episodes of vomiting since this morning. On triage, the patient appears lethargic but maintains normal perfusion, blood pressure, and heart rate for his age. Abdominal examination demonstrates a non-distended, soft abdomen with no signs of peritonitis. Arrange the following steps in the most appropriate sequential order for the evaluation and management of this patient.

A 2-day-old full-term male newborn is evaluated in the nursery for failure to pass meconium since birth. He has developed abdominal distension and is refusing to feed. Physical examination reveals a markedly distended, tympanitic abdomen and a tight anal sphincter. A digital rectal examination results in an explosive expulsion of gas and stool.

Arrange the following steps in the most appropriate chronological order for the diagnosis and definitive management of this patient's condition.

Match each classic clinical presentation and associated radiographic or sonographic finding with the most appropriate pediatric gastrointestinal diagnosis.

An emergency medical team evaluates a $22$-day-old male neonate who was rushed to the hospital after developing forceful, green-tinged emesis. His parents note that he became suddenly lethargic and irritable this morning. Previously, the infant had been breastfeeding adequately and gaining weight appropriately. Vital signs reveal significant tachycardia at $190$/min, tachypnea at $58$/min, and profound hypotension ($58/34$ mm Hg). The patient appears pale, mottled, and diaphoretic. Palpation of the abdomen elicits diffuse rigidity and involuntary guarding, with visually apparent distension. Digital rectal examination yields normal-appearing stool with no gross blood. Venous blood analysis demonstrates a pH of $7.21$, bicarbonate of $12$ mEq/L, and a lactate level of $7.1$ mmol/L. A plain radiograph of the abdomen demonstrates a gasless abdomen with a single prominent gastric bubble. Which of the following is the most appropriate next step in the management of this patient?

A 9-month-old boy is brought to the emergency department by his parents due to sudden-onset, intermittent episodes of severe crying. During these episodes, he draws his knees up to his chest and appears inconsolable. Between episodes, the parents note that he appears uncharacteristically lethargic. He has vomited twice since the morning, and a recent diaper change revealed dark red, mucus-like stool. On physical examination, temperature is 37.2°C (99.0°F), heart rate is 170/min, and blood pressure is 85/50 mm Hg. Capillary refill time is 4 seconds. Abdominal examination reveals a palpable, sausage-shaped mass in the right upper quadrant, with no rebound tenderness, guarding, or rigidity.

Arrange the following management steps in the most appropriate chronological order for this patient.