Pediatric Gastrointestinal Disorders

A $16$-day-old male infant, born at $27$ weeks gestation, is being evaluated in the neonatal intensive care unit for sudden clinical deterioration. For the past $24$ hours, he has been managed for necrotizing enterocolitis with bowel rest, nasogastric decompression, intravenous fluids, and broad-spectrum antibiotics. Over the last $2$ hours, the infant has developed recurrent apnea and profound bradycardia. His temperature is $35.1^\circ\text{C}$ ($95.2^\circ\text{F}$), heart rate is $190$/min, respiratory rate is $70$/min, and blood pressure is $40/20 \text{ mm Hg}$. Physical examination reveals a grossly distended, shiny, and erythematous abdomen with absent bowel sounds. Capillary refill time is $5$ seconds. A stat bedside cross-table lateral abdominal radiograph reveals massive pneumoperitoneum. Which of the following is the most appropriate next step in the management of this patient?

A female infant born at 26 weeks gestation is evaluated in the neonatal intensive care unit on day 16 of life. The nursing staff notes that she has become increasingly lethargic over the last 6 hours and has had multiple episodes of apnea and bradycardia. She has been tolerating small volumes of expressed breast milk via an orogastric tube. Vital signs show a temperature of 35.1°C (95.2°F), heart rate of 178/min, and blood pressure of 42/22 mm Hg. Physical examination reveals a tense, shiny, and grossly distended abdomen with absent bowel sounds. Capillary refill time is 4 seconds. Laboratory studies demonstrate a leukocyte count of 3,200/mm³ and a serum bicarbonate of 11 mEq/L. A supine anteroposterior abdominal radiograph displays air in the bowel wall and a distinct area of radiolucency outlining the falciform ligament. Which of the following is the most appropriate next step in management?

Match each of the following definitive histopathologic or mucosal biopsy findings to the corresponding pediatric gastrointestinal disorder it most accurately diagnoses.

A 14-month-old infant is brought to the emergency department with a 3-day history of severe watery diarrhea and non-bilious vomiting. On examination, the infant is lethargic, has sunken eyes, dry mucous membranes, and a delayed capillary refill of 4 seconds. Vital signs show a heart rate of 170/min, respiratory rate of 40/min, and blood pressure of 70/40 mmHg. Arrange the following management steps in the correct sequential order from immediate priority to subsequent care.

A 2-day-old full-term male neonate is evaluated in the neonatal intensive care unit for progressive abdominal distension and bilious emesis. The infant has not passed meconium since birth. Vital signs are within normal limits. Physical examination reveals a markedly distended, tympanic abdomen. Digital rectal examination produces a forceful expulsion of foul-smelling gas and stool, which temporarily relieves the distension. Arrange the following steps in the most appropriate sequential order for the diagnostic evaluation and management of this patient's most likely condition.

A 4-year-old boy is brought to the pediatric emergency department by his parents due to recurrent episodes of severe abdominal pain that started 12 hours ago. During the episodes, he cries inconsolably and pulls his knees to his chest; between episodes, he appears exhausted and lethargic. He has had two episodes of bilious emesis. His last bowel movement consisted of dark red, gelatinous stool. Temperature is 37.2°C (99.0°F), heart rate is 125/min, blood pressure is 95/60 mm Hg, and respiratory rate is 24/min. Physical examination reveals a palpable, sausage-shaped mass in the right middle quadrant. An abdominal ultrasound demonstrates a "target sign." An ultrasound-guided hydrostatic enema is performed, successfully reducing the obstruction. A detailed post-reduction ultrasound identifies a 3.5-cm blind-ending tubular structure protruding from the antimesenteric border of the distal ileum. The patient is now pain-free and resting comfortably. Which of the following is the most appropriate next step in management?

A 2-year-old boy is brought to the emergency department by his parents after they found a large amount of maroon-colored stool in his diaper. The parents report that the child has had no episodes of emesis, diarrhea, or apparent abdominal pain. He has been active and playing normally at home today. His medical history is unremarkable, and his immunizations are up to date. His temperature is 36.9°C (98.4°F), heart rate is 112/min, respiratory rate is 22/min, and blood pressure is 92/58 mm Hg. On physical examination, the child appears comfortable and in no acute distress. The abdomen is soft, non-tender, and non-distended, with no palpable masses. Bowel sounds are active. Inspection of the perianal area shows no fissures. Laboratory studies reveal a hemoglobin of 10.2 g/dL and a mean corpuscular volume of 78 fL. Which of the following is the most appropriate next step in evaluating this patient's condition?

Match each pediatric patient's clinical presentation with the most likely corresponding imaging finding.

Match the following classic radiologic findings with the most appropriate pediatric gastrointestinal pathology.

An 8-week-old male infant is brought to the emergency department by his parents due to a 24-hour history of severe abdominal distension, lethargy, and multiple episodes of explosive, foul-smelling diarrhea. His mother notes he has been feeding poorly and had two episodes of nonbilious emesis this morning. The patient's past medical history is notable for delayed passage of meconium, which required glycerin suppositories during his first week of life, and he has suffered from chronic constipation since discharge. His temperature is $38.9^\circ C$ ($102^\circ F$), blood pressure is $65/35\text{ mm Hg}$, pulse is $188/\text{min}$, and respirations are $62/\text{min}$. On physical examination, the infant appears mottled and lethargic. The abdomen is markedly distended and tense, with sluggish bowel sounds. Digital rectal examination produces a sudden, high-pressure expulsion of liquid stool and gas. A plain abdominal radiograph demonstrates markedly dilated loops of bowel with multiple air-fluid levels, but no free air is visible under the diaphragm. Which of the following is the most appropriate next step in management?

A 9-month-old male infant is brought to the pediatric clinic by his parents due to severe, chronic constipation and poor weight gain. The parents report that he has a bowel movement only once every 5 to 6 days, often requiring significant straining, and his abdomen frequently appears noticeably swollen. He was born at 39 weeks gestation and passed his first meconium at 50 hours of life. His diet consists of breast milk and age-appropriate pureed solids. His weight has fallen from the 45th percentile at birth to the 10th percentile currently. Vital signs are within normal limits for age. Physical examination reveals a distended, tympanitic abdomen. Upon digital rectal examination, there is increased anal sphincter tone and an empty rectal vault; withdrawal of the examining finger is immediately followed by an explosive expulsion of foul-smelling liquid stool and gas. Which of the following is the most accurate test to confirm the diagnosis in this patient?

A 48-hour-old full-term neonate is evaluated in the neonatal intensive care unit for failure to pass meconium since birth. Over the past six hours, the infant has developed progressive abdominal distension and just had an episode of dark green vomiting. Vital signs show a heart rate of 158/min, respiratory rate of 48/min, temperature of 37.1°C (98.8°F), and blood pressure of 65/42 mmHg. Physical examination reveals a tensely distended, tympanitic abdomen with hypoactive bowel sounds, but no abdominal wall erythema or rigidity. Digital rectal examination reveals normal anal tone and an empty rectal vault with no stool expulsion upon withdrawal of the finger. Arrange the following steps in the most appropriate sequence for the evaluation and management of this patient.

A 4-week-old male infant is brought to the pediatric clinic by his parents for persistent jaundice. He was born at 39 weeks gestation via an uncomplicated vaginal delivery and has been exclusively breastfed. His parents note that over the past two weeks, his stools have become pale and clay-colored, and his urine stains the diaper dark yellow. He is feeding well and gaining weight appropriately. Vital signs are within normal limits for age. Physical examination reveals scleral icterus, jaundice, and a soft, non-distended abdomen with a liver edge palpable 3 cm below the right costal margin. Arrange the following diagnostic and therapeutic steps in the most appropriate sequential order for the evaluation and management of this patient's most likely condition.

Match each underlying pathophysiological or embryological mechanism with the corresponding pediatric gastrointestinal disorder.

Paramedics bring a $1.5$-year-old boy to the emergency department after his parents found him lethargic in his crib. According to the parents, the child developed sudden, intense abdominal pain $12$ hours ago, which was followed by multiple episodes of dark green vomiting. He has not passed stool or gas since the symptoms began. On examination, the child is obtunded. Temperature is $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), heart rate is $175/\text{min}$, respiratory rate is $50/\text{min}$, and blood pressure is $68/38\text{ mm Hg}$. Auscultation of the lungs reveals bilateral crackles and scattered wheezes, which the paramedics report began after he choked on his vomit during transport. The abdomen is markedly distended, rigid, and diffusely tender with involuntary guarding. Bowel sounds are absent. An upright abdominal radiograph displays prominent, dilated small bowel loops with multiple air-fluid levels and an absence of distal gas. Following initiation of intravenous fluid resuscitation, which of the following is the most appropriate next step in management?

Please pair the following pediatric gastrointestinal conditions with their most characteristic radiological finding on diagnostic imaging.

A 3-week-old full-term male is evaluated in the emergency department for sudden onset of bilious (green) vomiting. He has had two episodes in the past four hours. His prenatal course and birth history were unremarkable. On physical examination, the infant is awake and alert. Vital signs are within normal limits for age, and he is hemodynamically stable. The abdomen is soft, non-distended, and non-tender, with normal bowel sounds. Arrange the following steps in the most appropriate chronological order for the evaluation and management of this patient.

A 14-day-old male infant is evaluated in the neonatal intensive care unit for new-onset feeding intolerance, abdominal distension, and lethargy. The infant was born prematurely at 28 weeks gestation and has been receiving advanced enteral formula feeds. Current vital signs reveal a temperature of $35.2^\circ\text{C}$ ($95.4^\circ\text{F}$), pulse of $175/\text{min}$, respirations of $65/\text{min}$, and blood pressure of $45/25\text{ mm Hg}$. Physical examination demonstrates a markedly distended, tense, and visibly erythematous abdomen with absent bowel sounds. Capillary refill time is 4 seconds. Arterial blood gas analysis on room air shows a pH of 7.15, $p\text{CO}_2$ of $35\text{ mm Hg}$, and $\text{HCO}_3^-$ of $12\text{ mEq/L}$. An anteroposterior abdominal radiograph demonstrates extensive pneumatosis intestinalis and a distinct radiolucency over the liver shadow, indicating free intraperitoneal air. Which of the following is the most appropriate next step in the management of this patient?

Match each brief clinical presentation of a pediatric gastrointestinal disorder with its most appropriate initial or definitive management step.

A $24$-month-old boy is brought to the emergency department by his parents after they noticed a large amount of maroon-colored stool in his diaper. The parents state the child has not had any fever, vomiting, diarrhea, or crying episodes suggesting abdominal pain. He has been eating well and his activity level is at baseline. He was born at $39$ weeks gestation and has met all developmental milestones. His vital signs are temperature $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), heart rate $110/\text{min}$, respiratory rate $22/\text{min}$, and blood pressure $90/60\text{ mm Hg}$. Physical examination reveals an alert, playful child with pale conjunctivae. The abdomen is soft, non-distended, and non-tender without palpable masses. Bowel sounds are normal. Examination of the perianal area shows no fissures or skin tags. Hemoglobin level is $9.2\text{ g/dL}$. Which of the following is the most appropriate next step in management?