Pediatric Examination and Board Review (83 page)

(D) male-to-female ratio is 8:1

(E) female-to-male ratio is 8:1

16.
In an infant with Hirschsprung disease, the findings on physical examination include

(A) empty rectum

(B) rectal impaction

(C) abdominal distention

(D) A and C

(E) B and C

17.
The findings with Hirschsprung disease on barium enema would be

(A) a transition zone between the dilated aganglionic section and the normal colon

(B) a transition zone between the contracted aganglionic section and the dilated colon

(C) a transition zone between the rectum and the dilated colon

(D) a transition zone between the descending and transverse colon

(E) there are no consistent findings on barium enema and rectal biopsy is the diagnostic test of choice

18.
The true statement about children with Hirschsprung disease is

(A) more than 90% do not pass meconium in the first 24 hours of life

(B) 75% do not pass meconium in the first 24 hours of life

(C) 50% do not pass meconium in the first 24 hours of life

(D) 25% do not pass meconium in the first 24 hours of life

(E) the history of when they pass meconium is unimportant

ANSWERS

1.
(B)
A rectal examination is the part of the physical examination that gives you the best information in this case. A patient with functional constipation and encopresis described in this vignette is going to have loose rectal tone and stool within the vault.

2.
(A)
Children with Hirschsprung disease have aganglionosis in certain sections of the colon. A 6-yearold presenting with Hirschsprung disease would have an ultrashort segment of Hirschsprung involvement. The rectal tone is increased in Hirschsprung disease. The vault is likely to be empty.

3.
(D)
Spina bifida, meningomyelocele, sacral agenesis, and spinal cord tumors can be associated with fecal incontinence. Other neurologic symptoms and signs such as urinary incontinence and loss of reflexes can be associated.

4.
(D)
Evaluation of the spine by an MRI is the most appropriate diagnostic test.

5.
(E)
Functional constipation is a clinical diagnosis. The vignette and the rectal examination findings are consistent with functional constipation.

6.
(E)
The aim of therapy is to alleviate the impaction, prevent recurrence, and retrain the child to appreciate normal bowel signals. Any and all of the therapies listed are appropriate.

7.
(D)
Once a child has developed encopresis and is successfully treated by the plan outlined above, the laxatives must be weaned slowly. This will frequently take more than 6 months. Parents should be counseled about the length of time it takes to treat.

8.
(B)
The chance of successfully weaning children off all laxatives and having normal bowel habits is 30-50% at 1 year but only 78% at 5 years.

9.
(C)
Rectal prolapse is frequently associated with severe constipation. In developing countries, it is associated with malnutrition. There is also an association with cystic fibrosis (CF), but these patients usually have loose oily stools. In a child who has constipation and no other problems, it is unnecessary to look for CF simply because of rectal prolapse (see
Figure 51-1
).

FIGURE 51-1.
Prolapsed Rectum. Recurrent rectal prolapse due to chronic constipation. (Reproduced, with permission, from Knoop KJ, Stack LB, Storrow AS, et al. Atlas of Emergency Medicine, 3rd ed. New York: McGraw-Hill; 2010:228. Photo contributor: Lawrence B. Stack, MD.)

10.
(A)
In a child who has other symptoms possibly attributed to CF the sweat test is not necessary. In this instance, the small stature “tips the scale” to doing the sweat test.

11.
(D)
Because constipation and urinary symptoms frequently occur together, it is important to treat both ailments. It is important to remember also to look closely for constipation when a child presents with urinary incontinence. The treatment with anticholinergic drugs can lead to constipation. Drugs associated with constipation include analgesics, antacids, anticholinergic, bismuth, iron, cholestyramine, and antipsychotics.

12.
(A)
Painless bright red blood is likely to be a polyp in a child in this age group. Although hemorrhoids are associated with constipation in adults, they are very unusual in children. Fissures lead to painful bleeding. A Meckel diverticulum can cause a significant bleed, but usually the blood is not bright red.

13.
(A)
It is not the frequency of stool that defines constipation. In breast-fed babies there can be stools ranging from several times a day to once every several days. As long as the stool is of normal consistency and easily passed, several days between stools is normal.

14.
(C)
A 6-week-old in good disposition, but with poor feeding and constipation is concerning. Poor feeding secondary to abdominal pain or reflux is usually associated with an irritable baby. Here you must be concerned with hypothyroidism. The signs can be subtle.

15.
(A)

16.
(D)
The physical findings consistent with Hirschsprung include increased rectal tone, lack of stool in the vault, and abdominal distention. The treatment involves resection of the poorly innervated colon. The most dangerous complications are enterocolitis and toxic megacolon. With this latter diagnosis, the baby presents with explosive diarrhea, fever, and shock.

17.
(B)
The aganglionotic area is contracted, hence the increased tone on rectal examination. The proximal colon will be dilated. The barium enema is diagnostic in more than 75% of patients with Hirschsprung.

18.
(A)

S
UGGESTED
R
EADING

DiLorenzo C, Benniga MA. Pathophysiology of pediatric fecal incontinence.
Gastroenterology.
2004;126(1 suppl 1):S33-S40.

Loening-Baucke V. Encopresis.
Curr Opin Pediatr.
2002; 14(5):570-575.

CASE 52: A 15-MONTH-OLD WITH DIARRHEA

A 15-month-old boy presents with a complaint of diarrhea. He is having 3-5 large “explosive” stools per day for 8 weeks. They are not malodorous, there is no blood or mucus, and they are not bulky or oily. Mom frequently sees food particles such as corn, carrots, and raisins in the stool.

On physical examination his vitals signs are HR 102, RR 28, and blood pressure (BP) 88/50. He is in no apparent distress. His breath sounds are equal and clear. His abdomen is nondistended with positive bowel sounds. There are no masses and no hepatosplenomegaly. There are no perianal lesions and the stool is heme negative. His growth curve is shown in Figure
Figure 52-1
.

SELECT THE ONE BEST ANSWER

1.
The first studies you would order include

(A) stool for fat, reducing substances, and pH

(B) a stool culture and assay for fecal leukocytes

(C) stool examination for ova and parasites

(D) all of the above

(E) none of the above

2.
The likely diagnosis for this child is

(A) nonspecific diarrhea of childhood (toddler’s diarrhea)

(B) carbohydrate malabsorption

(C) postinfectious malabsorption

(D) bacterial infection

(E) you cannot distinguish among these entities

3.
Chronic diarrhea of childhood can be secondary to

(A) excess intake of fruit juice

(B) excess intake of carbohydrate

(C) too little fat in the child’s diet

(D) all of the above

(E) none of the above

4.
The treatment for chronic nonspecific diarrhea includes

(A) reassurance and limiting dietary excess

(B) clear liquids when the number of stools is more than 5 per day

(C) diphenoxylate/atropine when the number of stools is more than 5 per day