Gastro Flashcards
Paraffin laxatives are the laxative of choice for use in “body packer” T/F
F - they increase the risk of rupture of the package containing the drugs
Note: whole bowel irrigation with polyethylene glycol can be used if there are no signs of drug-associated toxicity, endoscopy for packages in the stomach can also be used. CT > xray for detection of the packages
Kayser-Fleischer rings are associated with what disease?
Wilson disease classically
Also seen in isolation in primary biliary cirrhosis and cirrhosis of unknown aetiology
Inserting a g tube decreases the risk of reflux T/F
F it increases the chance of reflux or increasing the chance of worsening the disease
Note: in a child with severe reflux who needs a g tube they should get a fundoplication too
Reducing substances in the stool of 0.25 - 0.5% are indicative of carbohydrate malabsorption. T/F
F - 0.25 - 0.5% are SUGGESTIVE of the disease; > 0.75% are indicative of the disease
Alkaline stool is indicative of carb malabsorption even in the absence of reducing substances T/F
F- acidic stools pH < 5.5 (even in absence of reducing substances)
What is the gold std of diagnosis of carb malabs?
Endoscopy + biopsy of small bowel mucosal disaccharidases (rarely actually used)
In the hydrogen breath test an early peak can be due to small intestine bacterial overgrowth. T/F
True (peak can also be caused by carb malabs)
Macroscopic finding on endo for UC vs Crohn’s
UC - friable mucosa and ulcers, interspersed w/areas of regeneration
Crohns - inflamed mucosa, aphthous ulcers, fissures, cobblestoning and strictures
Features of chronic giardiasis infection and its treatment
Symptoms of malabs and nutrient deficiency, Suspect in person w/hx of travel
Metronidazole
Treatment of intestinal lymphangiectasia
Dietary - high protein, very low long chain TG diet (abs by lymphatics) with medium-chain TG supplement (not absorbed by lymphatics)
High protein to make up for losses
Features of intestinal lymphangiectasia
Dilated lymphatic vessels which burst and leak lymphatic fluid into the gut –> protein loss, diarhoea and hypoproteinaemic oedema
What are monogen, caprillon and liquigen
MCT supplements, 1st 2 are formulas
The onset of emesis/reflux after 6 months old or persistent after one year is a red flag sign T/F
T
Aetiology of Kwashiorkor?
Protein deficiency with adequate calorie intake
In Kwashiorkor there is atrophy of muscle and subcutaneous tissue T/F
F - the subcut tissue/adipose tissue is spared.
Other features: localised or generalised oedema, hepatomegaly due to fatty infiltration of the liver, sparse easily pluckable hair, hyper pigmented hyperkeratosis and macular rashes, atrophied tongue and lymphatics
What is marasmus?
Severe calorie deficiency and body weight less than 60%.
Note: there is excess loss of subcut tissue and muscle
Coeliac disease is assoc with hyposplenism T/F
T
Paralytic ileus is a manifestation of CF T/F
F - patients can have mec ileus, paralytic ileus when there is no physical obstruction but occurs secondary to dysfunction of the nerves and muscles of the intestine (eg post op)
Other GI manifestations of CF - rectal prolapse, ileal atresia, neonatal hepatitis, pseudo bartter syndrome
What is the most common age for rectal prolapse?
Most common in preschool age group, < 4 yr
Majority of cases are in first year of life
What is the mgmt of rectal prolapse?
1st line is conservative: tx of underlying cause and reduce straining (dietary advice + short course of laxatives)
Surg mgmt is occasionally required for some resistant or recurrent prolapses or if it assoc with pain or ulceration
Causes of rectal prolapse?
Idiopathic
CF (10% of cases of prolapses; 20% of pts with CF)
Increased intra abdominal pressure ( constipation, chronic cough, toilet training)
Diarrhoeal disorders: acute infection or malabs
Rectal polyps
Malnutrition/anorexia
Child abuse
What finding on upper GI imaging is diagnostic of mal rotation?
Normally the duodenal-jejunal flexure should be to the LEFT of the transverse process of L1 vertebrae at the height of the pylorus.
Flexure seen anywhere else depicts mal rotation
In infants with reflux what % will be symptoms free by 1 yr?
90%
Surgical mgmt of constipation?
Appendicostomy/MACE
Used for anterior enema
What is the risk of recurrence of appendicitis in a pt managed conservatively for an appendix mass?
Roughly 17%
Interval appendicectomy is controversial
What is the initial surgical mgmt of a type A esophageal atresia?
Laparotomy and open gastrostomy
Need to establish enteral feeds before a primary anastomosis at 3-6 months.
Note: lack of gas in the abdo indicates a pure TEF
Commonest cause of hepatitis in childhood?
Hep A
What two criteria must be present for a child >12 to be started on orlistat?
- Must have failed lifestyle, behavioural, dietary and exercise interventions
- Must have medical co morbidities secondary to their obesity - ortho, sleep apnoea or severe psychological issues
Typical presentation on juvenile polyp?
Present around 2-6 yrs with bright red painless blood per rectum
Double bubble is the classic xray finding of what pathology?
Duodenal atresia
Note: will also see an absence of distal gas
In a neonate gas should be seen in the stomach immediately after birth, ileo-caecal valve by 6 hours and rectum by 24 hours. In malrotation will see double bubble and gas distally
Lab abnormalities in pyloric stenosis?
Met alk with hypoK and hypoCl
Rose thorn ulcers in barium enema what disease?
Crohns disease
Pseudopolyps UC or Crohns?
UC
As is red-raw mucosa and evidence of colonic dilatation
Dietary fiber and increased fluids are the first line treatment of idiopathic constipation T/F
F - these changes should be encouraged but will also need laxatives
A + pANCA is more common in Crohns or UC?
UC (> 70%)
Crohns < 10%
How should malrotation be diagnosed?
Upper GI contrast
Note: barium enema is not as reliable
Most cases of duodenal atresia occur as isolated abnormalities T/F
T
In a pt with LFTs significant for an elevated alk phos only what lab test can help differentiate etiologies?
PTH
DDx: rickets (elevated PTH) and transient hyperphosphatasia (normal PTH)
Patients with HLA + IBD are more likely to have other autoimmune aetiologies T/F
T
What is the typical drug of choice for treatment of shigella infection?
Quinolones (eg ciprofloxacin)
note treatment only indicated in severe cases (ie if bloody diarrhoea)
Which shigella is assoc with HUS?
S dysenteria, especially type 1
Which shigella is assoc with post infectious arthritis?
S flexneri
Note: esp in HLA B27 individuals
Which shigella is more common in the developed world sonnei or flexneri?
Sonnei
Note this also causes the mildest form of infection
When does type 1 Crigler Najjar syndrome typically present? What type of hyperbili is it?
Typically presents in first few days of life as a severe unconjugated (indirect) hyperbili. Tx is phototherapy and plasmapheresis
Note: type 2 tends to present later and is treated with phenobarb
Is gilbert syndrome causes what type of hyperbili?
Unconjugated
Note: unconjugated bili is not excreted in the urine
Which type of bilirubin is excreted in the urine
Conjugated
What is the first line treatment of crohns disease? Are there any exceptions?
Polymeric diet > Elemental diet
Polymeric is better tolerated orally than elemental so usually try this first
If there is rectal disease iv steroids is first line
An infant has pale stools and dark urine, conjugated hyperbili what is the next step in mgmt? Organise a HIDA scan or immediate referral to nearest liver unit?
Immediate referral
Should get specialist eval prior to HIDA scan
Possible complications of gastro-oesophageal reflux which does not resolve by 1 yr old
Recurrent otitis media
Pneumonia
Poor dentition
Apnoea
In a patient with suspected coeliac disease but anti IgA tTC that are elevated but less than 10 times the upper limit of normal what is the next step in mgmt?
Duodenal biopsy
Note: if elevated > 10 times the upper limit of normal can do a biopsy OR further bloods tests (if + anti IgA endomysial and either HLA DQ2/DQ8 can confirm without biopsy)
What is the most common cause of pancreatitis in children?
Idiopathic
What substance is the most appropriate to measure in a faecal sample to confirm diagnosis of protein losing enteropathy?
Alpha 1 antitrypsin
Note: if thinking specifically of IBD can check calprotectin
Triangular cord sign on ultrasound is seen in what pathology
Biliary atresia
Note: represents the fibrous ductal remnant of the extrahepatic bile duct
Which is the most common type of tracheo oesophageal fistula?
Type C (atresia with distal fistula)
Which type of TOF does not have bowel gas?
Type A (isolated atresia) Type B (atresia with proximal fistula)
Bloody diarrhoea is more common in the presentation of UC or crohns?
UC
How much small bowel is a neonate born with? If a patient has a small bowel resection what is the cut off under which they would require TPN?
Normal 250cm
Less than 100cm an infant will require TPN.
Buzz word: stools that get looser as the day progresses
Toddler’s diarrhoea
What age is associated with a poor prognosis in HUS?
Age > 5
What type of pathogen is associated with a poor prognosis in HUS?
Non-shiga toxin HUS
Involvement of which arteries is associated with a poor prognosis in HUS?
Involvement of mediums sized arteries.
Prolonged oliguria or anuria is associated with poor prognsis in HUS T/F
T
Severe hypotension is assoc with poor prognosis in HUS T/F
F - severe HTN, especially late onset is assoc with poor prognosis
Other factors: severity of CNS symptoms, persistent consumption of clotting factors, extensive glomerular involvement (> 80%)
Lab findings and pathology in Vit D dependent rickets type I vs type II
Type I: 1a hydroxylase def –> cannot convert 25 -OH vit D to 1, 25. Hence will have a low 1,25
Type II: absent receptors –> high 1,25
Dubin Johnson is associated with what type of hyperbili?
Conjugated
Hence it is excreted in the urine
Rotor is associated with what type of hyperbili?
Conjugated
When is the peak age of HUS?
1-2 yrs old
Incomplete obliteration of the vitelline duct leads to what pathology?
Meckel’s diverticulum
Risk factors for pyloric stenosis?
Maternal smoking Eldest child IUGR Pre term Bottle feed
Villious atrophy is a specific finding in coeliac disease T/F
F - it is found in coeliac disease but it is non specific. Also seen in Crohns, lymphoma, eosinophilic gastroenteritis, giardiasis, tropic sprue
4 typical features of coeliac disease on biopsy
- Intra epithelial lymphocytosis
- Lamina propria plasma cell infiltrate
- Crypt hypertrophy
- Subtotal or complete villous atrophy
Is there any dietary intervention that may reduce the duration of crying in infantile colic?
Yes, there is some evidence for using whey hydrolysate milk instead of regular cows milk formula
Excessive iron intake can reduce Zn absorption and vice versa T/F
T - they both use transferrin for transport
Mgmt of GI reflux in an otherwise well infant after a breastfeeding assessment has been carried out.
Alginate trial for 1-2 weeks
C/I to enema in investigation of intusseception?
Signs of peritonitis or perforation, including currant jelly stool
Presentation of a choledochal cyst in an infant?
RUQ mass (not always present but high suggestive of the diagnosis when it is) Elevated conjugated bili and jaundice Can have severe liver dysfunction and hence ascites and coagulopathy
In coeliac disease is CRP typically elevated or normal?
Typically normal
Note: this can help differentiate between IBD in an exam
Hypoglycaemia is a recognised complication of refeeding syndrome T/F
F - hyperglycaemia is a known complication, it is caused by inadequate insulin supply.
Treatment of cows’ milk protein allergy?
If formula feed - switch to amino acid based formula (note hydrolyzed formula may still have a small amount of cows milk protein)
If breast feed - mother to go a strict cow milk free diet
Which is more likely to affect growth UC or Crohns?
Crohns
Dietary mgmt of a chylothorax?
High amount of MCTs (monogen or liquigen) + low fat diet
Avoid LCTs, using MCTs bypasses the lymphatic system
Dietary mgmt of MCADD
Normal diet but should not go a long time in between eating, frequent drinks contains glucose polymer and restriction of fat when unwell
When treatment is indicated for campylobacter infection what abx should be used?
Azithromycin or erythromycin
fluoroquinolone are 2nd line.
Note: usually self limited and tx only recommended if prolonged course or chronic illness/immunosuppressed
3 main features of Shwachman-Diamond syndrome
- Pancreatic insufficiency
- Bone marrow dysfunction - typically neutropaenia –> recurrent infections
- MSK abnormalities due to growth plate and metaphyses dysfunction, leads to risk of pathological fx
Risk factors for jejunal and ileal atresia?
Low birth weight
Multiple births
Maternal tobacco and cocaine use
Risk factors for SMA
Rapid weight loss
Anorexia nervosa
Surgery (esp for scoliosis)
Classic presentation of SMA?
Acutely features of bowel obstruction
Or chronic issues of early satiety and postprandial epigastric pain
Pain often relieved by left lateral decubitus, prone or knee chest position
Note: mgmt is conservative (NG tube, eat upright, gain weight) surgery is rarely indicated
What antibiotic is commonly associated with oesophagitis?
Doxycycline
Also aspirin, ibuprofen, ferrous sulfate, K supplement and bisphosphonates
Classic lab abnormality in Wilsons disease
Elevated urine Cu
Decreased serum Cu and ceruloplasmin
Tx of Wilsons disease?
Cu chelator (D -penicillamine + pyridine) Zn can also be used (traps Cu in enterocytes)
Features of Allgrove syndrome?
Achalasia Alacrima (decreased/absent tears) Adrenal insufficiency (Autonomic dysfunction) AKA triple A syndrome
Note: other features - intellectual disability, developmental delay, dysarthria, deafness
What are the 3 main clotting factors that may be normal in liver failure?
Tissue factor (expressed on surface of many cell types) vWB factor (produced in endothelial cells and megakaryocytic) Factor 8
Features of Niacin deficiency?
Pellegra - dermatitis, diarrhoea and dementia.
Note: Vit B3; may be described as lethargic, irritable with a depressed, apathetic affect
Pellegra is associated with consumption of what grain?
Corn
As it does not have sufficient amount of niacin (when compared to rice or wheat for example)
Hypergammaglobulinaemia is seen in autoimmune hepatitis T/F
T
It is due, at least in part, to the anti smooth muscle, anti LKM, ANA and antimitochondrial antibodies.
Note: Liver biopsy revealing mononuclear and plasma cell infiltration of the portal tracts is helpful in diagnosis too
Hep C is associated with what skin disorder?
Porphyria cutanea tarda
Note: lesions can be triggered by alcohol, Fe ingestion and oestrogen
Hep B is associated with what skin disorder?
Papular acrodermatitis (Gianotti-Crosti)
Types of autoimmune hepatitis in children and their presentation?
Type I: presents in 10-20 yrs of age, more common in females
Type II: more severe, presents in younger children
Features: constitutional features fever, fatigue, malaise; RUQ pain; nausea; decreased appetite and jaundice.
Tx: immunosuppression. Type II usually life long treatment; type I might be able to wean off
Note: type III does not occur in children
Premature infant with oedema, thrombocytosis and haemolytic anaemia in 2nd month of life. What vit def?
Vit E
Note: transfer of mat vit E does not occur until 3rd trimester. Long term def leads to neuro dysfunction
Features of pyridoxine def in infant?
Irritable with seizures and sensory ataxia
