BRS- Gastro Flashcards
Percent of diet comprised of carbs? proteins?
carbs: 50%
protein: less than 30% (2.2g/kg in baby, 0.8 in adults)
What are micronutrients
vitamins and trace minerals
Vitamin deficiency assc with night blindness and dry cornea
vitamin A
Vitamin deficiency that leads to low phosphate levels
vitamin D
Vitamin deficiency that leads to poor wound healing, immunodeficiency, skin lesions
zinc
Vitamin deficiency that leads to dermatitis, diarrhea, dementia
niacin (pellagra)
Vitamin deficiency that leads to edema, bleeding gums, poor wound healing
Vitamin C (scurvy)
Describe features of Beriberi + what vitamin deficiency causes it?
cardiac failure
peripheral neuropathy
wernickes
B1, thiamine
Vitamin deficiency that causes dermatitis, glossitis, microcytic anemia, peripheral neuritis
B6, pyridoxine
B12 (aka ____) causes ____ anemia, elevated _____ levels, and ______sx.
cobalamin
macrocytic
methylmalonic acid
neuro
Protein deficiency is called ______. Total calorie deficency causes _____.
protein: kawashiorkor
total: marasmus
Kwashiorkor distinct symptoms (3)
hair loss
abnormal skin pigmentation
abdominal swelling
Three general symptoms of malabsorption
- diarrhea
- FTT
- abdominal distention
Test for carbohydrate malabsorption
- clinitest (tests for reducing sugars)
- pH below 5.6 (bacteria turn sugars to acid)
Three causes of protein malabsorption
- congenital enterokinase deficiency
- protein losing enteropathy
- inflammatory disorders
Test for protein malabsorption
stool levels of a1-antitrypsin
serum levels of albumin
Causes of fat malabsorption
- exocrine pancreatic insufficiency (CF, pancreatitis, schwachman diamond syndrome)
- intestinal mucosal atrophy
- bile acid deficiency
- abetalipoproteinemia
Cause of fat malabsorption assc with acanthocytes on peripheral smear
abetalipoproteinemia
Schawchman Diamond Syndrome:
- inheritance pattern
- labs
- symptoms
- AR
- neutropenia vs pancytopenia
- FTT, fat malabosorption (PI)
Frequency of protein intolerance in children + most common source of reactions
8%, cows milk
2 possible manifestations of protein intolerance
enteropathy (progressive diarrhea)
enterocolitis (acute diarrhea + rectal bleeding)
Protein intolerance prognosis
usually transitory and resolves within 1-2 years
acute symptoms resolve 1-2 weeks after withdrawl of stimulus
How common is celiac disease in the US?
Most common age of onset?
1/250
6 months- 2 years
Biopsy location + findings in celiac disease
small bowel
flat villi, deep crypts, vacuolated epi with lymphocytes
Antibodies assc with celiacs
IgA endomysial
serum tissue transglutaminase
antigliadin IgG
Celiacs long term consequences
growth failure + delayed sexual maturity
Causes of small bowel syndrome
- congential lesions (gastroschisis, volvulus, atresia)
- post op for nec. enterocolitis
- chrons, tumors, radiation
If distal small bowel is missing in SBS, ______ are not reabsorbed
B12, bile acids
Treatment for SBS
- TPN
- small bowel transplant with life threatening rxn to TPN
Complications assc with TPN:
- TPN cholestasis
- gallstones
- renal stones
- baterial overgrowth
- secretory diarrhea
Pathophys of GERD (2)
TLESR
Gastric emptying delay
When does emesis assc with GERD generally resolve
6-12 months of age
How does painful esophagitis present in a baby?
Sandifer syndrome (torticollis, arched back)
Symptoms of esophagitis in older kids:
- chest pain
- morning nausea
- hoarseness
- halitosis
Respiratory sequelae assc with GERD
-upper + lower airway disease worsened with GERD due to induced bronchopulmonary constriction
Describe progression of esophagitis –> cancer
chronic inflammation leads to : squamous cell –> columnar cell (barretts) –> adenocarcinoma of the esophagus
Gold standard for diagnosis of GERD
pH probe measurement
constant measurement of esophageal pH over 18 hours
Conservative management of GERD:
thicken feeds, sit up after feeds
H2 blockers, PPis
Pyloric stenosis:
- MC symptom
- MC sex
- nonbilious projectile vomiting in the second or third week of life
- first born males
PE findings in pyloric stenosis + acid base status
“olive” to the upper right of the umbilicus
visible abdominal peristaltic waves
hypochloremic hypokalemic alkalosis
Gold standard for diagnosing pyloric stenosis
U/S = string sign
Treatment of pyloric stenosis
partial pyloromyotomy
Midgut volvulus:
gut rotates around _____
more common in what population?
SMA (assc with Laads bands); males
Normal rotation of gut in utero
-counterclockwise around SMA at 10 weeks
Diagnosis of volvulus
UI contrast imaging shows ligament of treitz right/ jejunum to the right of midline
Classic symptom malrotation:
sudden (bilious) vomiting in otherwise healthy baby
Treatment of malrotation:
surgery +/- TPN
Cause duodenal atresia + assc condition
failure of small bowel to recanalize at 8-10 weeks
downs syndrome
Clinical features duodenal atresia
- polyhydramnios in utero
- scaphoid abdomen
- emesis/ FTT
- double bubble sign on imaging
Treatment duodenal atresia
surgical
Jejunoileal atresia:
cause
symptoms
dx
mesenteric vascular accident
bilious vomiting in first few days of life
radiographs show air fluid levels at lower SI
Treatment of jejunoileal atresia
surgical resection and anastomosis
Peak incidence of intussusception; MC location
5-9 month old males; ileocolic
How commonly is lead point identified in IS
5% of cases (ie Meckels diverticulum)
Clinic features of intussusception
- currant jelly stool
- sudden onset colicky pain
- sausage shaped mass
Dx and tx of intussusception
-constrast enema to dx, acutally relieves 80-90% cases, surgical treatment of remaining cases
Acute abdomen:
- signs of intestinal obstruction
- signs of peritonitis
obstruction: high pitched bowel sounds
peritonitis: diminished or absent bowel sounds, rigidity
In an acute abdomen, CONSTANT pain suggests _____.
-strangulation, torsion
Labs for acute abdomen:
- CBC
- U/A
- AST/ALT
- amylase/ lipase
- pregnancy, STDs
Peak incidence of appendictis occurs at what age?
10-12 years
How soon after onset of symptoms does perforation occur in appendicitis?
+ Location McBurneys
36-48 hours
2/3 between umbilicus and ASIS
1 and #2 causes of pancreatitis in kiddos:
- trauma
- idiopathic
Two PE “signs” assc with pancreatitis
Gray Turner- blueish flank regions
Cullens- bluish periumbilical region
What lab is most specific for pancreatitis?
lipase (elevated longer than amylase as well)
Describe pseudocyst assc with pancreatitis
collection of fluid containing pancreatic enzymes, self resolves in most cases
MC management of pancreatitis
supportive
Two types of cholecystitis
- calculous
- acalculous (salmonella, shigella, e coli)
Three conditions predisposing kiddos to chole
SCA
prolonged TPN
CF
Describe “sign” assc with chole:
Murphys- pain with inspiration, causes inspiratory effort to stop with palpation of RUQ
Define Chronic abdominal pain:
3+ consecutive months pain
Function CAP more common in what sex?
females
Describe functional CAP symptoms
5+ year old with periumbilical pain that does not interfere with sleep
CAP caused by IBS presents how?
-infraumbilical + stool alterations
Screening tests for CAP
- CBC, AST/ALT, BMP
- CRP, ESR
- H pylori
- Lactose breath testing
Prognosis CAP
25% persists into adulthood
MCC encopresis
severe constipation (liquid stool leaks around a hard mass of retained stool through distended AR canal)
Cause of more frequent stools in infant
breast feeding
Average # stools in baby, 1 year, kiddo
baby: 4x/day, 2x/day 1 year, 1x/day kiddos
adults= variable (3x/day–>week)
MC form of constipation in kiddos
FFR, caused by sentinel event
if organic, MC is hirschsprungs
Symptoms of prolonged FFR:
- encopresis
- fecal halitosis
- anorectal distention
Define delayed meconium passage
more than 48 hours after birth
Some important systemic causes of constipation
7
- DM
- hypothyroid
- lead poisoning
- botulism
- CF
- dehydration
- celiacs
IBD age of onset
bimodal (15-20, 50+)
Males more commonly suffer from which IBD?
CD has 2:1 male: female predominance
Location of inflammation: CD/UC
CD: transmural
UC: mucosa
Which has skip lesions? UC/CD?
UC: contiguous
CD: skip lesions
Complications of UC:
toxic megacolon
risk colon cancer
pyoderma gangrenosum
sclerosing cholangitis
Location of intestine affected by UC:
rectum –> colon, can get proctitis vs pancolitis
Location of intestine affected by CD:
any part, most commonly terminal ileum
Which IBD is assc with abscesses/ fistulas etc?
CD
Antibodies assc with UC
ANCA, 80% of cases
Antibodies assc with CD
antisaccharomyces cerevisiae, 70% cases
Rectal bleeding is more common in which IBD?
UC
Medical treatment for mild IBD
sulfasalazine
Treatment of perianal involvement in IBD
metronidazole
How is intractable colitis cured in UC?
total proctocolectomy
Which is surgery not commonly used in CD?
high recurrence rate post bowel resection
Melena is suggestive of blood proximal to _____.
Ligament of Treitz
GI bleed is confirmed by _____.
Cause of false negative (1).
Cause of false positive (3)
guiac testing
false negative: excess vitamin C
false positive: beets, iron, red meats, etc.
Causes of upper GI bleeding: (4)
- swallowed blood
- ulcers
- mechanical (mallory weiss)
- varices
How is ongoing bleding of the upper GI tract assessed?
NG tube + inspect nose, oropharynx for sources
Labs for diagnosing GI bleed/ stability
CBC, Hb, platelets, coag, AST/ALT, BUN(elevated)
Fluid bolus dose for stabilization in acute GI bleed
20 ml/kg normal saline
Drugs for treating GI bleed (4)
- octreotide to constrict varices
- abx for H. pylori
- H2i/PPi for gastritis/esophagitis/ ulcers
Newborn + rectal bleed always think _____.
Kid + rectal bleed think _____.
Nec enterocolitis
juvenile polyps most common source in kids
Causes of lower GI bleeding (6)
- necrotizing/ infectious enterocolitis
- Juvenile polyps
- allergic colitis
- meckels diverticulum
- HUS, HSP
- IBD
CBC findings in HUS
- microangiopathic hemolytic anemia
- thrombocytopenia
HSP is \_\_\_\_\_ mediated. Sx include (4)
- IgA
- rash at buttocks, arthralgias, renal involvement, GI bleeding
Tissue + most common location of Meckels diverticulum
- ectopic gastric tissue
- MC in terminal ileum
Presentation of Meckels diverticulum
acute painless rectal bleed
Three liver enzymes + which is most sensitive/ specific
- AST (senstitive)
- ALT (specific)
- LDH
Three biliary enzymes
- alk phos
- gamma glutamyl transpeptidase (GGTP)
- 5 nucleotidase (5NT)
Enzyme responsible for bilirubin conjugation
UDP glucuronyl transferase
How to measure liver fxn
- albumin
- prothrombin time
- lactate
- ammonia
Define infant jaundice
-more than 3mg/dl bili after the neonatal period
Cholestatic jaundice is retention of _____.
It is defined as ______.
bile in the liver
more than 2mg/dL conjugated bili, or greater than 15% total bili being conjugated.
Percentage of neonates with unconjugated jaundice?
Pattern of spread
50%
cranial to caudal
Test of choice for suspected cholestasis
HIDA scan
Three pathologic causes of decreased UDP glucuronyl transferase
- Gilbert, 50% enzyme reduction, mild, jaundice with stress
- Crigler Najar I, AR, 100% reduction
- Crigler Najar II, AD, 90% reduction
Causes of newborn cholestasis (6)
+ which is most common?
- infection
- mechanical obstruction
- a1at deficiency
- TPN assc disease
- metabolic derangements
- idiopathic hepatitis**
Neonatal hepatitis: cause predominant sex incidence diagnosis prognosis
idiopathic male 1/5k-10k exclusion, biopsy self resolves in 70%
How commonly is jaundice seen in neonatal hepatitis during week 1 of life?
50% of cases, 33% asx until FTT/ more liver symptoms later
Treatment for neonatal hepatitis
ursodeoxycholic acid
transplant when refractory
Biliary atresia:
incidence
most common age of presentation
dx
1/10,000
2/3 present between week 4-6 of life
intraoperative cholangiogram
Biliary atresia:
- treatment
- prognosis if left untreated
Kasai portoenterostomy by 50-70 days of life, transplant if failed or repeated cholangitis occurs
complete obilteration and cirrhosis by 4 months if not treated.
Alagille Syndrome
- inheritance pattern
- chromosome
- gene
AD, 20, jagged 1 gene
List features of Alagille syndrome
- cholestatic liver disease
- debilitating pruritis
- unusual face
- cardiac disease
- renal/eye/MSK abnormalities
- FTT
Two major strains of hep viruses affected kids
A, B
What virus types are hep ABCDE
A-picorna B- DNA C- flavi, RNA D- delta, RNA E- hepe, RNA
What hep strain causes disease in 50% of adolescents in undeveloped countries? Also causes hepatic failure in 20% preggos.
Hep E
Route of infection for:
A,E
B,C
A,E: fecal oral
B,C: vertical, body fluids, parenteral
Antigens positive in early Hep B infxn
HbsAg, HbeAg
Antibody assc with vaccination AND/ OR live infection, against Hep B
HbsAb
Antibody assc with LIVE infection
HbcAb
Antibody assc with lade infection of Hep B
HbeAb
Early and late antibodies assc with Hep A infection
IgM, persist for 6 months
IgG, life long, late
Hep type most responsible for transfusion assc hepatitis
Hep C
Hep D requires _____ to replicate
HbsAg
Type 1 autoimmune hepatitis antibodies
ANA, ASMA
Type 2 autoimmune hepatitis antibodies
antiliverkidney
anti liver cytosol type 1
Most common population suffering from autoimmune hepatitis
females, pre-pubertal
PResentation of autoimmune hep
50% acute hep, 50% chronic liver disease
Nonhepatic signs autoimmune hep
rash, nephritis, vasculitis, arthritis
Three labs used to dx autoimmune hep
autoantibodies
elevated liver enzymes
hypergammaglobulinemia
