Correct Answer: B
EXPLANATION:
The typical patient with CVS presents with recurrent, stereotypic episodes of frequent emesis every 2 to 4 weeks that begin suddenly and last 24 to 48 hours. There is a return to periods of baseline health between episodes. The vomiting cannot be attributed to another disorder. A thorough history and physical examination is important, as specific conditions and symptoms suggest that the diagnosis is not consistent with CVS. These conditions are (1) presentation at less than 2 years of age; (2) bilious vomiting, abdominal tenderness, and/or severe abdominal pain; (3) attacks associated with intercurrent illness, fasting, and/or a high-protein meal; (4) abnormalities on neurologic examination; or (5) progressively worsening episodes or a conversion to a continuous or chronic pattern.
The patient in scenario A had nonbilious emesis that occurs after a period of fasting or a high-protein meal. These symptoms suggest a partial urea cycle enzyme deficiency, which can occur after such situations. The patient in scenario
C has bilious emesis and abdominal pain. Although CVS can present with similar symptoms, it is important to rule out a surgical condition, such as volvulus or malrotation, as well as pancreatitis. In addition, this child does not have a 3-week cycle with a return to baseline. The patient in scenario D has neurologic symptoms, which is concerning for increased intracranial pressure or a metabolic disorder. The patient in scenario E has symptoms consistent with pyloric stenosis.
MCQ#2
Correct Answer: B
EXPLANATION:
A child who presents with acute vomiting should first be evaluated for the degree of dehydration; if severe (5%-10%) dehydration is present, immediate intravenous access and fluids should be provided. However, this child is not severely dehydrated. In addition, there is a high suspicion for CVS. If CVS is suspected in a child without other “alarm” symptoms such as severe dehydration, shock, abnormal neurologic examination, or severe abdominal pain, it is appropriate to check labs prior to initiation of intravenous fluids. Serum electrolytes can help assess for the possibility of a metabolic, renal, or endocrine disorder. They can also demonstrate abnormalities such as hypoglycemia or elevated BUN/creatinine that would assist in deciding on appropriate fluid resuscitation.
Abdominal radiograph may be useful in patients with suspected intestinal obstruction; head CT may be useful in patients with focal neurologic findings on examination suggesting increased intracranial pressure as a cause for vomiting. Intravenous proton pump inhibitors are unlikely to be helpful in the immediate treatment of acute recurrent nonbloody, nonbilious vomiting.
MCQ#3
Correct Answer: A
EXPLANATION:
This patient has chronic recurrent vomiting, with at least 3 episodes of mild but frequent emesis over a 3-month period. Among the most frequent causes of vomiting in the schoolage child and adolescent are gastro-esophageal reflux disease, which may occur after meals and is not typically associated with weight loss. In a child with chronic vomiting without alarm symptoms or other concerning examination findings, the most likely diagnosis is an acid-peptic disorder such as gastroesophageal reflux disease or gastritis that should be initially treated with empiric 2- to 4-week trial of H 2 -receptor antagonist or proton pump inhibitor for acid suppression. If there is no symptomatic improvement after a time limited trial of these medications, it may then be appropriate to proceed with laboratory testing, imaging, or consultation with pediatric gastroenterology. Odansetron may be useful for symptomatic improvement in the setting of acute, rather than chronic, vomiting.
MCQ#4
Correct Answer: E
EXPLANATION:
This patient most likely has chronic nonspecific diarrhea of childhood, also called toddler’s diarrhea. She is well grown, has no other symptoms other than diarrhea, and has significant intake of apple juice daily, which has a high fructose-to-glucose ratio and is often implicated in toddler’s diarrhea. Toddler’s diarrhea is thought to be caused by mild carbohydrate malabsorption and hypermotility; a reasonable first step in treatment of suspected toddler’s diarrhea is elimination of juice from the diet with reevaluation.
Determination of stool electrolytes and osmolality can be helpful in distinguishing between osmotic and secretory diarrhea. Stool pH and reducing substances may help in screening for malabsorptive causes of diarrhea. Stool cultures may help identify infectious causes of chronic diarrhea such as protozoal or bacterial infection. However, in an otherwise healthy, well-grown child who has a history consistent with toddler’s diarrhea, empiric elimination of juice from the diet is a more reasonable first step in management rather than pursuing laboratory evaluation for less likely causes. Although lactose intolerance/lactase deficiency may be another cause of chronic diarrhea in childhood, excessive juice intake is more likely and should be pursued as a cause prior to trying a lactose-free diet.
MCQ#5
Correct Answer: D
EXPLANATION:
It is important to distinguish between the common problem of functional constipation and less common organic causes of constipation, including Hirschsprung disease. A diagnosis of Hirschsprung disease is suggested by small-caliber soft stool, episodes of explosive soft stool preceded by a lack of stool passage and abdominal distension, and history of delayed meconium passage in the first few days of life. If Hirschsprung disease is suspected, suction rectal biopsy should be considered as the next step in evaluation.
Children with functional constipation may have fecal incontinence (encopresis) with soiling of the undergarments due to seepage of liquid stool around impacted rectal fecal mass. Urinary tract infections may also occur due to partial
urethral obstruction by pressure from fecal mass in the colon or by ascending infection from soiled undergarments. Many children with functional constipation have a history of large caliber stools and stool retentive posturing in an attempt to avoid uncomfortable passage of large and/or hard stools.
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