Pedi GI Handbook
Endoscopy
BRAVO CAPSULE PLACEMENT:
Confirm with RN that device is calibrated
Patient in left lateral decub position
Connect vacuum tubing to delivery device
Perform vacuum pump check to verify gauge reaches 700 mmHg.
Perform EGD. Identify the GE junction. Remove the endoscope by 6 cm and note distances from incisors. Capsule will be placed 6 cm proximal to the GEJ.
With either direct endoscopic guidance or blind, deploy the capsule
Insert capsule through the mouth to 6 cm proximal to GEJ
Apply suction to the catheter until 700 mmHg is reached for 60 seconds.
Depress plunger to advance pin.
Release capsule by rotating the plunger clockwise.
If done blind, repeat scope to confirm placement.
Begin pH recording.
See: https://youtu.be/AA-qzQAfLDs
Ref: Sofi et al Clin Exp Gastroenterol. 2010;3:147-51. PMID: 21694859
General Principles
-Do not treat: clean base with or without small flat spots
-Do not treat: an overlying adherent clot unless you have appropriate back-up and/or feel confident in your ability to treat underlying lesion
-Do treat: active bleeding or a non-bleeding visible vessel
-For treatment: Inject with Epi and then clip or gold probe, depending on size, location, accessibility
Inject Epi:
– How to inject epi (skip to 5:40)
– Diluted with saline to 1:10,000 is injected in 1 mL aliquots in four quadrants within 3 mm of the bleeding site
Clip
– How to clip (skip to 7:15)
Gold probe (thermal coagulation)
– What to gold probe? An active bleeding and nonbleeding visible vessel
Gastric ulcer: Moderate to firm pressure, 15 to 20 watts, 10 seconds per pulse (prior to probe retraction), three to five pulses total
Duodenal ulcer: Light to moderate pressure, 10 to 15 watts, 10 seconds per pulse (prior to probe retraction), three to five pulses total
Irrigation via the probe is used to wash the ulcer base, to release the probe to prevent sticking after cautery, and to facilitate repositioning of the probe for further treatment if bleeding continues. Targeted irrigation and suctioning of excess blood or fluid are extremely important to identify the specific bleeding site and focus the treatment.
To prevent the probe from sticking to the area that has been treated, water irrigation via the probe can be applied after each application of cautery to gently separate the probe from the underlying area before retracting the devic
band ligator set up (skip to 2:00)
Clinic
Among the unique qualities of our program is strong outpatient experience. Fellows see patients two-half days per week, where they are assigned new patients who they follow throughout their training. Though there is always appropriate supervision, the fellow is the primary provider for their patients, not the attending. Fellows are expected to take full ownership of their patients, follow up test results, manage disease exacerbation and questions or concerns from families. There is true continuity in our continuity clinic. Building rapport and long-term relationships with patients and their families is cited by our fellows as among the most gratifying components of their fellowship experience.
- Each fellow attends two, half-day continuity clinics per week
- Fellows precept with an attending for all patients
On call
-N.p.o.
-CBC, LFTs, BMP (BUN), PT/INR, type and screen
-IV PPI 2 mg/kg bolus then 2 mg/kg divided twice daily
or
-IV PPI drip (2 mg/kg bolus max 80 mg, followed by 0.2 mg/kg/h max 8 mg/h)
-Fluid resuscitation (gentle)
-Transfuse 15 mL/kg up to 2 units
-Consider vitamin K, FFP
-Consider octreotide drip: 1-2 mics per kilo bolus then start 1-2 mics per kilo per hour (max 50-100 mic/hr)
-Consider IV erythromycin to empty stomach
-Recent line infections? Check prior sensitivities
-Labs: CBC, CMP, culture from central line all lumens, peripheral culture
-Additional infectious work-up as indicated: Respiratory viral panel, stool studies, chest x-ray, urine
-Vancomycin, Cefepime +/- fluconazole
-Antibiotics through central line
-If more than 1 lumen, alternate giving antibiotics through both lumens
-Daily blood culture until negative x48 hours
Our fellowship program is dedicated to teaching. We encourage active learning through case-based discussions, journal clubs, board reviews sessions, and didactics. We ensure our fellows have protected time dedicated to their education outside of their clinical responsibilities. We also recognize that to be an excellent gastroenterologist requires a strong foundation and continuing education in general pediatrics. To that end, we encourage attendance at the many educational opportunities provided by the stellar Brown Pediatric Residency Program including daily morning report and noon conference and monthly Morbidity and Mortality.
Pediatric GI Conferences:
- Monday: Pathology Conference. Review cases and slides from previous weeks endoscopy.
- Tuesday: Pediatric Morbidity and Mortality
- Wednesday: IBD conference. Discuss active IBD cases focusing on diagnosis and management.
- Thursday (8-9 am): GI potpourri including Journal Club, State of the Art attending lectures, Interesting Case Conference, or Adult GI Grand Rounds.
- Thursday (9-10 am): Inpatient Conference. Discuss all consult and GI-service admissions.
- Friday: Pediatric Grand Rounds. Weekly presentations by invited guest speakers distinguished in their field directed towards faculty, fellows, and residents.
Multidisciplinary Conferences:
- GI-Radiology Conference (1 time per quarter)
- GI-Surg Conference (2 times per year)
- GI-Allergy Conference (2 times per year)
- GI-NICU (2 times per year)