Exam 2 Gastroenterology Flashcards
1
Q
Abdominal history questions: Newborn
A
#Maternal drugs, infection, family hx of GI #Birth weight, gestational age #1st meconium & stooling/voiding patterns #Amount/type of feedings #Spit up or vomiting #Jaundice #Abnormal prenatal or US findings, amniocentesis, genetic workup
2
Q
Abdominal history questions: Infancy
A
#Weight gain & growth pattern #Amount & type of feeding #Food allergies #Stooling/voiding pattern #Spit up or vomiting #Family hx for chronic constipation
3
Q
Abdominal history questions: Early childhood
A
#Weight gain, growth pattern, BMI #Diet hx #Pica #Presence, pattern of abdominal pain #Stooling/voiding patterns: constipation or stool withholding, encopresis or enuresis, blood/mucous in stool #Sx of UTI #Recent illness #Psychosocial stressors (bullying, transition to preschool, family dysfunction)
4
Q
Abdominal history questions: Mid childhood
A
#Weight gain, growth pattern, BMI #Diet hx #Presence, pattern of abdominal pain #Stooling/voiding patterns: constipation or stool withholding, encopresis or enuresis, blood/mucous in stool #Sx of UTI #Recent illness #Psychosocial stressors (bulling, family dysfunction)
5
Q
Abdominal history questions: Adolescence
A
#Weight gain, growth pattern, BMI #Diet history, fluid intake #Body image, risk for disordered eating #Presence, pattern of abdominal pain #Stooling/voiding patterns #Sx of UTI #Menstrual history #Sexual activity, contraception & barriers #Sx or history of STI #Psychosocial stressors, intimate partner violence, bullying
6
Q
Abdominal history questions: environmental
A
#applies to all ages #Home, child-care or school exposures to infectious disease #Family with chronic abdominal pain or diarrhea #Cultural practices for feeding or alternative wellness (DON’T DRINK THE ESSENTIAL OILS!) #Area with endemic food or water borne illness (DON’T DRINK THE WATER!) #Recent camping or backpacking (DEFINITELY DON’T DRINK THE CREEK WATER!) #Exposure to food contaminants (COOK THE PORK) #Environmental lead exposure (DON’T EAT PAINT CHIPS) #Low socioeconomic status #Parental mental health #Sibling with chronic disease/health of family members
7
Q
Abdominal red flag in school age child
A
Waking at night with abdominal pain or stooling
8
Q
Red flag symptoms of recurrent abdominal pain
A
#Involuntary weight loss #Chronic severe diarrhea #GI blood loss #Gynecologic sx #Family hx of IBD/celiac #Nighttime waking #Significant or especially bilious vomiting #Urinary sx #Joint pain, mouth sore, skin rash, unexplained fever (IBD symptoms)
9
Q
Red flag signs of GI disease
A
#Slowing of linear growth #Clubbing #Mouth ulcers #Abdominal mass #Pain radiating to back (pancreases) or groin (renal) #Anorexia, delayed puberty #Hypertension, tachycardia #Perineal changes (tags, fistulas)
10
Q
McBurney’s sign
A
Tenderness with deep palpation of the RLQ
11
Q
Rosving’s sign
A
Deep palpation of the LLQ causes referred pain in the RLQ
12
Q
Rebound tenderness
A
Hurts more when you remove pressure
13
Q
Hepatomegaly
A
Liver palpable more than 3cm below costal margin
14
Q
If explosive stool is elicited by rectal exam, you should suspect this disease
A
Hirschsprung’s
15
Q
Somatic pain
A
#Derived from dermis, soft tissues, and peritoneum #When skin & soft tissue innervations do not match skeletal and peritoneum innervations, you get radiation
16
Q
Visceral pain
A
#parasympathetic system #Also called splanchnic #3 main locations: 1) epigastric, 2) periumbilical, 3)suprapubic #Caused by tension or pressure; cannot sense cutting or burning
17
Q
Psoas sign
A
Pain with left side down right hip extension
18
Q
Obturator sign
A
Pain with flexion, internal rotation of right hip
19
Q
Dunphy sign
A
pain with coughing
20
Q
Markle test
A
pain with heel-drop
21
Q
What does the physical exam look like with appendix anterior to cecum?
A
#Focal RLQ pain #Rosving's sign #McBurney point tenderness
22
Q
What does physical exam look like with appendix retrocecal?
A
#Flank & back pain #Iliopsoas sign #Testicular pain
23
Q
What does physical exam look like with appendix in pelvis?
A
#Obturator sign #Urinary frequency/dysuria #Rectal exam worsens pain
24
Q
One of the most common causes of abdominal pain
A
Food intolerance (not allergy!)
25
Acute gastroenteritis: what is it?
```
#Nonspecific term for gut inflammation
#Most commonly viral, but can be bacterial or parasitic
```
26
Mesenteric adenitis
```
#Begins with splanchnic, crampy periumbilical pain
#No progress to focal peritonitis
```
27
3 types of bowel obstruction
1) Adhesive
2) Complete
3) Partial
28
Key questions to distinguish obstructions
```
#Surgical & infection history of abdomen
#Color of the vomitus
#Presence of gas, liquid, or solid stool passage
```
29
What makes adhesive type obstruction more likely?
Surgery or severe infection of the abdominal cavity
30
Bilious vomiting should raise suspicion for:
Malrotation with volvulus
31
Complete obstruction signs
```
#Bile or fecal vomiting
#No gas or stool per ano
```
32
Partial obstruction signs
#Reduced gas & stool
33
Most common cause of painful bowel obstruction in toddler/preschool kids
Intussusception
34
What's intussusception?
Proximal section of bowel (usually ileocecal valve) telescopes inside more distal section
35
Classic history of intussusception
```
#Pain without focal tenderness
#Recurrent episodes of pain Q15-30 minutes
#Inconsolable
#Legs pulled to chest
#Currant jelly stool is late sign of sloughing bowel
```
36
Two classic inflammatory bowel disease (IBD) patterns
```
#Crohn's disease (CD)
#Ulcerative colitis (UC)
```
37
Crohn's disease
Pan GI inflammatory disease with patchy, noncontiguous regions of inflammation anywhere in the tract, separated by healthy bowel; most commonly presents with abdominal pain
38
Ulcerative colitis
Inflammatory bowel disease extending in contiguous fashion from rectosigmoid region proximally; can be associated with abdominal pain.
39
Charcot triad of hepatobiliary pain
```
#RUQ pain
#Fever
#Jaundice
```
40
Partial or intermittent gallbladder obstruction
Crampy, intermittent, transient pain after fatty food
41
Total or complete gallbladder obstruction
Constant pain, sharp quality, fever &/or jaundice
42
Pancreatic pain
```
#Sharp, constant, epigastric
#Radiating to the left and back
#Exacerbated by food
```
43
Hepatitis lab derangements
```
#Highly elevated AST/ALT
#Lesser derangements of bilirubin
```
44
Hepatitis causes
```
#Toxic ingestions
#Viral stuff like EBV, CMV, hepatitis A, B, C, D and E
```
45
Biliary tract/gallbladder lab derangements
```
#Elevations in total/direct bilirubin
#Elevated alkaline phosphatase
#Elevated gamma-glutamyl transferase (GGT)
#ALT elevated but not as bad as hepatitis
```
46
Acute pancreatitis
Self-sustaining process in which an initial injury leads to loss of ductal integrity, release of exocrine secretions, and autolysis which causes parenchyma destruction
47
Pancreatitis lab studies
```
#Lipase & amylase
#Total bilirubin
#ETOH
#Triglycerides
#Calcium
#CBC
```
48
Cholecystitis is...
inflammation & distension of the gallbladder
49
Types of cholecystitis
```
#Acute vs chronic
#Acalculous or calculous
```
50
Types of gallstones
Cholesterol vs pigmented
51
Cholesterol stones
Greater than 50% cholesterol by weight
52
Pigmented stones
Calcium salts & other anions
53
Acalculous cholecystitis most often seen in...
```
#pediatrics who are critically ill and/or systemic disease
#previously healthy children with acute bacterial, viral, or fungal infect
```
54
Type of gallstones most common in kids
pigmented in 72%
55
Incidence of cholesterol gallstones increases with:
```
#age
#female
#obesity
#Hispanic heritage
#hemolytic conditions
```
56
Lab studies for pediatric cholecystitis
```
#CBC with diff
#AST/ALT
#Total & direct bilirubin
#GGT
#Amylase & lipase
```
57
Cholestasis
Significant decrease in bile flow combined with accumulation of substances within the hepatocytes and bile ducts
58
Cholestatic jaundice...
is always pathologic and indicates hepatic dysfunction
59
Most common cause of obstructive jaundice in the newborn
Biliary atresia
60
Presentation of cholestatic patients
```
#Conjugated hyperbilirubinemia
#Jaundice
```
61
When does jaundice present in biliary atresia?
Present at birth & persists beyond 14 days
62
Classic triad of choledochal cysts
```
#Intermittent abdominal pain
#Jaundice
#Right epigastric mass
```
63
Therapeutic plans for cholestatic conditions focus on what 3 areas?
```
#Palliative or curative interventions in a timely manner
#Mgmt of synthetic dysfunction
#Nutritional supplementation
```
64
Functional constipation
No organic underlying cause
65
Reasons functional constipation might occur
```
#Infants: Changes in diet
#Toddlers: Painful bowel movements
#School age: Changes in routine, lack of privacy at school, stress, comorbidities, postponing defecation while busy
```
66
Encopresis
Fecal soiling around a solid mass of stool in rectum, can be misidentified as diarrhea
67
Complications of constipation
```
#Abdominal pain
#Anal fissures
#Encopresis
#Urinary dysfunction: enuresis, recurrent UTI, lower urinary tract dysfunction
#Rectal prolapse
#Social stigmata/exclusion/bullying
```
68
Constipation: pertinent history questions
```
#passage of meconium at birth
#frequency & nature of stool
#Encopresis &/or blood in stool
#Urinary problems
#Diet history & water intake
#Developmental milestones
#Growth
#OTC or complementary therapies
#Psychosocial
```
69
Functional constipation diagnosis includes 1 month of at least 2 of the following weekly symptoms from infancy to age 4
```
#2 or fewer defecations per week
#History of excessive volitional retention
#Painful or hard bowel movements
#Presence of large fecal mass in rectum
#History of large diameter stools which may obstruct the toilet
#At least 1 episode per week of incontinence after acquisition of toilet training
```
70
What percentage of constipation cases are organic?
5%, very rare
71
Treatments for constipation
```
#Osmotic laxatives (lactulose, PEG, MoM, mag citrate)
#Fecal softeners (mineral oil)
#Stimulant lax (Senna, bisacodyl, sodium picosulfate)
#Rectal lax (sodium phosphate, sodium docusate, bisacody, mineral oil, glycerin)
#Juice (apple, pear, prune)
```
72
Diagnosing fecal impaction
```
#Hard mass in lower abdomen
#Dilated rectum with hard stool on rectal exam
#Excessive stool in distal colon on x-ray
#Encopresis
```
73
Disimpaction regimens over what length of time?
3-6 days, preferably at home to avoid school absence
74
Maintenance therapy for functional constipation
Diet, medication, and behavioral modification
75
What dietary changes may need to happen in functional constipation?
```
#More fiber
#Less dairy
```
76
When do we taper maintenance laxatives?
```
#Normal bowel routine for minimum of 1 month, maintenance regimen in place 2 months
#Discontinue SLOWLY to limit relapse
```
77
Esophageal atresia
Congenitally interrupted esophagus
78
Tracheoesophageal fistula
Communication between trachea, esophagus
79
How many patients with EA have at least one other malformation & what is it usually?
55%, usually cardiovascular
80
Prenatal red flags for EA
```
#Polyhydramnios
#Absent or small stomach bubble on US
```
81
Signs of EA after birth
```
#Excessive salivation that does not clear with suctioning
#Choking
#If they feed, difficulty swallowing with vomiting, coughing, cyanosis & respiratory distress
#If distal TE fistula, abdominal distension from air in stomach
```
82
VACTERL malformations
```
Vertebral: hypoplastic vertebrae
Anorectal: Anal atresia
Cardiac: ASD, VSD, PDA, tet of Fallot
Tracheoesophageal fistula
Esophageal atresia
Renal: Obstructive uropathy
Limb: Radial hypoplasia
```
83
Consultations necessary for EA/TEF
```
#Tertiary care center
#GI & surgery
#Cardiology consult
```
84
Duodenal atresia
Neonatal malformation where duodenum fails to recanalize
85
Anomalies associated with duodenal atresia
```
#Cardiac: ASD, VSD, PDA
#Anorectal: imperforate anus, vestibular anus, cloaca
#Intestinal: malrotation, Meckel diverticulum, small intestine atresia, annular pancreases, TE fistula
#Genitourinary: ectopic kidney, incomplete duplex system
#Chromosomal: Trisomy 21 (Down syndrome)
#Hepatic: anterior portal vein
```
86
Duodenal atresia US sign
```
"double bubble": proximal bubble is distended stomach, narrower pylorus, and distal bubble dilated proximal duodenum
#Can be seen via US or MRI in 2nd trimester
```
87
Duodenal atresia x-ray
```
#Double bubble again
#No distal gas: if there is, malrotation with volvulus should immediately be suspected
```
88
Most important test prior to surgery for DA
Echocardiogram because possible cardiac anomalies
89
Most common site of esophageal foreign body
Thoracic inlet, between clavicles on x-ray
90
Symptoms of esophageal foreign body
```
#Dysphagia
#Drooling
#Pain
#Emesis/hematemesis
#Anorexia/weight loss
#Stridor/cough/resp distress
#Sore throat/CP
#Unexplained fever
```
91
Symptoms of lower GI tract foreign body
```
#Ab pain or distension
#Emesis, hematemesis
#Melena
#Unexplained fever
#Weight loss
```
92
What foreign body in particular is an emergency?
Button battery: high pH associated with rapid mucosal injury
93
What does a button battery look like on x-ray?
Halo sign, double density circumference not seen in coins
94
Most common pathogens for gastroenteritis
```
VIRUSES!
#Rotavirus
#Adenovirus
#Astrovirus
#Calicivirus
#Coronavirus
#Sapovirus
#Parvovirus
```
95
Bacterial pathogens for gastroenteritis
```
#Staph
#E. coli
#Campylobacter
#Salmonella
#Shigella
#Yersinia
#Vibrio parahaemolyticus
#Aeromonas
#Bacillus cereus
#Clostridium perfringens
#C. diff
```
96
Most common sx of gastroenteritis
```
#Fever
#Vomiting
#Diarrhea
Not necessarily simultaneously
```
97
Definitions of diarrhea
```
#Normal BM with increased frequency & greater water content
#Stool output greater than 3 episodes daily
```
98
Acute diarrhea
Less than 14 days
99
Persistent diarrhea
Greater than 14 days
100
Chronic diarrhea
Greater than 30 days
101
GER vs GERD
Gastroesophageal reflux is passage of gastric contents into the esophagus; this becomes GERD when associated with symptoms &/or complications
102
Anatomical components of reflux barrier
Lower esophageal sphincter, crural diaphragm, phrenoesophageal ligament, angle of His
103
Physiologic components of reflux barrier
Esophageal peristalsis, esophageal mucosal resistance, acid neutralization by salivary & esophageal secretions
104
Most common surgical intervention for GERD
Nissen fundoplication
105
Most common cause of colon bleeding worldwide
Infectious colitis
106
For hemodynamic instability d/t GI bleed, initial approach:
```
#Get an IV
#Give fluids
#Normal saline, lactated Ringers, or PRBC
```
107
What's octreotide for?
Decrease CVP, useful in managing bleeding esophageal varices prior to EGD
108
Intestinal failure
```
#Inability of intestine to digest and absorb adequately for fluid/electrolyte demands
#May be d/t underlying congenital disorder or surgical resection
```
109
Hepatitis
Inflammation of the liver
110
Acute hepatitis
< 6 months
111
Chronic hepatitis
> 6 months
112
Silent hepatitis
Elevated aminotransferase levels incidentally noted
113
Symptomatic hepatitis signs
```
#Jaundice
#Fever, joint pain
#RUQ pain
#Generalized weakness
#Malaise, altered mental status
#Nausea & vomiting
#Kidney failure
#Elevated CNS pressure
#Cardiovascular collapse
```
114
Physical hepatitis findings
```
#Nothing, or...
#Jaundice, palmar erythema
#Spider angiomas
#Asterixis
#Joint inflammation
#Ab distention
#Hepatosplenomegaly
#Ascites
#Edema
#AMS
#Ecchymosis
#Poorly reactive pupils
```
115
What's jaundice?
Yellow skin discoloration because of excess bilirubin in the serum
116
What's hyperbilirubinemia?
Serum bilirubin above the normal value, may CAUSE jaundice
117
Physiologic jaundice
Elevated bilirubin in first 3-5 days which gradually declines
118
What's kernicterus?
Irreversible encephalopathy secondary to hyperbilirubinemia
119
What chromosomal abnormality could lead to hemolysis, leading to hyperbilirubinemia?
G6PD, occurring in 13% of AA males, 60-70% of Kurdish Jews
120
When gathering information for a history related to the abdomen of a newborn, it is important to address maternal drug use, family history of GI conditions, birth weight and gestational age, amount and type of feedings, spit up vs. vomiting, jaundice and abnormal prenatal findings. What additional question should be asked?
First meconium and stooling/voiding patterns
121
When assessing a patient for biliary or liver disease, what labs would you order?
AST, ALT, GGT, and bilirubin. Also general labs for infection/inflammation like CBC, CRP, and ESR
122
What is the progressive squeezing pattern of the small bowel that is designed to propel chyme forward?
Peristalsis
123
What is the largest absorption site of water and electrolytes in the gut?
The colon
124
When concerned for diarrhea with history of consumption of contaminated water, which stool test should be ordered?
Ova & parasite testing
125
Describe a positive Rovsing sign:
Deep palpation of the left lower quadrant causing referred right lower quadrant pain
126
Intermittent abdominal pain associated with intussusception is due to what?
Intussuscepted bowel becomes ischemic, and each wave of peristalsis brings further pain
127
What is the most common cause of obstructive jaundice in newborns?
Biliary atresia
128
What is encopresis?
Fecal soiling around a solid stool mass in the rectum
129
What is the most sensitive marker of dehydration in infants?
Tachycardia
130
What is the most common cause of colonic bleeding?
Infectious colitis
131
What can a rapid drop in previously elevated aminotransferases may indicate in the face of hepatitis?
Improvement/recovery or Worsening hepatic failure if accompanied by rising PT and/or rising conjugated bilirubin and collapsing liver size
132
When do a newborn’s bilirubin level peak?
Peak of 5-6 mg/dL in first 2-5 days of life
133
Ulcerative colitis classification
```
#Ulcerative proctitis (<15cm of rectum)
#Left sided colitis (rectal, sigmoid, & descending)
#Pancolitis (past the splenic flexure)
```
134
Intestinal symptoms of IBD
```
#Abdominal pain (95%)
#Diarrhea, hematochezia(77%, 50%)
#Perirectal inflammation with fistula (25%)
#Fever
#Malnutrition
#Weight loss
```
135
Labs for IBD
```
#CBC with diff (anemia, thrombocytosis 2ndary to inflammation, WBC may or may not elevate)
#ESR (elevated in 80% of CD, 40% UC)
#CRP (active inflammation)
#Albumin (low d/t malnutrition)
#LFTs
```
136
What type of medications are used for frontline therapy for induction of remission in moderate or severe inflammatory bowel disease?
Corticosteroids
137
Pharmacological categories for IBD therapy
1) Aminosalicylates
2) Corticosteroids
3) Immunomodulators
4) Biologic agents
5) Antibiotics
6) Probiotics
138
Should steroids be used chronically for IBD?
NOPE, because multiple adverse effects: osteoporosis, glucose intolerance, Cushing, hypertension, garbage mood, adrenal insufficiency & pancreatitis. None of which is great.
139
Necrotizing enterocolitis
Inflammation & necrosis of the bowel wall
140
What's the most common condition in the neonate leading to surgical resection in intestinal failure?
Necrotizing enterocolitis. Affects 7% of all preterm neonates weighing between 500-1500 gram
141
Presentation of intestinal failure
```
#Malabsorptive diarrhea
#Sepsis
#Dehydration
#Electrolyte abnormalities
#Malnutrition
#Vomiting
```
142
What's intestinal adaptation & how do we achieve it?
After a resection, the lengthening of remaining intestine to promote increased absorption and nutritional status, and we get this through consistent enteral feedings. FILL THEM GUTS
143
What's small intestine bacterial overgrowth?
SIBO is another possible cause of feeding intolerance and failed intestinal adaptation after bowel resection. Antibiotics (metronidazole, rifaximin, amox/clav) help with this.
144
What is Hirschsprung disease?
Absence of ganglion cells of the enteric nerve plexus of the intestines. No peristalsis means it's functionally an obstruction. Yikes.
145
Short segment Hirschsprung
Limited to rectosigmoid colon, 75-80% of patients
146
Long segment Hirschsprung
Extends proximally to the sigmoid, 20-25% of patients
147
Classic Hirschsprung presentation
Failure to pass meconium in 1st 8 hours of life
148
What diagnostic is confirmation of Hirschsprung’s disease?
Rectal biopsy
149
Ileus
Functional obstruction occurring when peristalsis is impaired. The guts ain't movin'
150
Causes of functional bowel obstruction
```
#abdominal surgery
#peritonitis
#sepsis
#trauma
#meds
#metabolic imbalance (hypokalemia, hyponatremia, hypomagnesemia, acidosis)
```
151
Causes of mechanical bowel obstruction
```
#postoperative adhesions
#hematoma
#intussusception
#distal intestinal obstruction syndrome
#malrotation with volvulus
#tumors
#bezoar
#congenital abnormalities: duodenal atresia, duodenal web, annular pancreas, jejunoileal atresia
```
152
S/s of bowel obstruction/ileus
```
#Variable depending on length of affected bowel
#Abdominal distension
#Absent/hypoactive BS
#Constant pain worsening with increased distension
#Vomiting (LATE SIGN)
```
153
3 categories of intussusception
1) idiopathic
2) lead point
3) post surgical
154
Idiopathic intussusception
We don't know, but they've often had a viral gastroenteritis or upper respiratory infection (what the heck)
155
Lead point intussusception
An identifiable cause exists in the mucosa: Meckel diverticulum, polyps, duplication cyst, hemangioma, etc
156
Post surgical intussusception
R/t anesthesia's effect on intestines and manipulation of bowel during surgery
157
Intussusception presentation
```
#crampy ab pain which comes in waves
#emesis
#bloody stool
#RLQ mass
```
158
Initial treatment of intussusception
Enema! Contrast, air, or saline is instilled and it pushes the intussuscepted tissue proximally
159
If the enema doesn't work on the 3rd try for intussusception...
Surgery time!
160
How long do we wait between enema reduction attempts for intussusception?
2-6 hours
161
Most common complication associated with intussusception
Recurrence
162
What's a malrotation?
Abnormal rotation and fixation of the bowel during embryologic development
163
What's a volvulus?
When malrotation is present and midgut twists in a clockwise direction around the superior mesenteric artery, leading to occlusion
164
We don't know the incidence of malrotation. Why?
Most people are asymptomatic with it.
165
What syndromes increase incidence of malrotation?
```
#Heterotaxy
#Trisomy 13, 18, and 21
#Marfan
#Prune belly
```
166
Other anatomic abnormalities associated with malrotation
```
#Diaphragmatic hernia
#Duodenal web
#Abdominal wall defects (gastroschisis, omphalocele)
```
167
What's the treatment for malrotation and/or volvulus?
Surgery! But people argue over whether to correct an asymptomatic malrotation
168
Pyloric stenosis
Circumferential muscle hypertrophy of the pyloric sphincter, causing obstruction of gastric outlet
169
Hallmark symptom of pyloric stenosis
```
#Non-bilious, projectile, progressive vomiting 30-60 minutes after feeding
#Usually between 2-6 weeks, but maybe as late as 3 months
```
170
What's pylorospasm?
Spasmodic contraction of the pylorus that's not coordinated with gastric emptying. This can look like pyloric stenosis.
171
How do we confirm pyloric stenosis?
Ultrasound! Findings of a pylorus muscle wall thickness ≥ 3mm and pyloric channel length ≥ 15mm is diagnostic
172
Do we operate on pyloric stenosis?
Yes but it's not emergent
173
How do we diagnose acute pancreatitis?
1) Abdominal pain
2) Elevation in serum pancreatic enzymes
3) Radiologic findings
174
Conjugated hyperbilirubinemia occurs for 4 reasons:
```
#Increased bilirubin production
#Hepatocyte injury
#Bilirubin transporter defects
#Obstruction
```
175
In infants < 2 months old, what should always be considered in light of conjugated hyperbilirubinemia?
SEPSIS!
