Gastro Jan Flashcards
1
Q
FTT What are causes of Failure to Thrive?
A
1.Decreased Intake (common)
- Social (food security)
- Central (satiety signaling)
2.Malabsorption*
3.Hypermetabolism
- Inflammatory (catabolic)
- Neoplastic (consumptive)
- Chronic Disease (combination) IBD, ..
2
Q
FTT What are the causes of protein malabsorbtion?
A
1. Pancreas: proteases
- SI: AA transporters e.g. CF, Schwachman- Diamond
3
Q
FTT What are the causes of Fat malabsorbtion?
A
Biliary:bile emulsifies
Ileum: reabsorbs bile
e.g. cholestasis, CF,
Crohn’s disease
4
Q
FTT What are the causes of Carbohydrate malabsorbtion?
A
Primary causes: enzyme deficiencies rare
e.g. Sucrase-isomaltase, treholase, lactase*
Dietary causes: saturation of normal enzyme levels
e.g. Toddler’s diarrhea
Malabsorption
Duodenum: brush
border hydrolysis
e.g. primary causes vs
dietary causes
5
Q
FTT What are the causes of Panmalabsorption ?.
A
Generalized intestinal inflammation/resection
e.g. Celiac, IBD, lymphangiectasia, immunodeficiency,
intestinal resection
6
Q
Celiac disease What is the cause for Celiac Disease?
A
Autoimmune enteropathy caused by systemically acting antibodies that are formed against gluten ( NOT allergy…causes problems long after substance is removed)
7
Q
Celiac What are the Extraintestinal Manifestations of
Celiac Disease?
A
8
Q
Celiac What Conditions are Associated with Celiac Disease?
A
- IgA Deficiency 30 % chance if IGA in celiac
• 2. Syndromic: Down, Turner Syndrome & Williams
Syndrome
• 3. Autoimmune: T1 DM; Thyroid, liver, arthritis
9
Q
Celiac Transmission risk in families?
A
First Degree Relative with Celiac (1:20 risk)..all have
about 20% risk
10
Q
Celiac What are the Dietary Triggers for Celiac Disease?
A
11
Q
Celiac How do the Screening Bloodwork Test
Compare (TTG IGA vs EMA-IgA)
A
12
Q
Celiac Recommendations for DGP in < 2 and > 2 yrs ?
Deamidated Gliadin Peptide
A
*Must send DGP in patients <2yo (TTG-IgA poor accuracy in this age group)
• >2yo, many false positive DGP tests
• ie. TTG-IgA negative, DGP-IgG positive, biopsy negative - NOT celiac disease
13
Q
Celiac DDx for Patients who report feeling better off gluten?
A
- Nothing
- Celiac Disease (must have 12wk
intake)
• 3.Food intolerances/allergies:
a.Non-Celiac Gluten Sensitivity (NCGS)
b. Wheat allergy
c. Difficulty digesting highly fermentable carbohydrates
FODMAPS
14
Q
Celiac What are FODMAPS?
A
15
Q
IBD How do clinical Fx of CD and UC compare?
A
16
Q
IBD How do Endoscopic Fx of CD and UC compare?
A
17
Q
IBD How do Pathology Fx of CD and UC compare?
A
18
Q
IBD What are the extraintestinal manifestations of IBD?
A
- Eye
- Skin and Rheum
- GIT: Liver, pancreas & biliary
- MSK and hematological
- Oncology and Urologic
19
Q
IBD What are the Eye extraintestinal manifestations of IBD?
A
20
Q
IBD What are the Skin and Rheum extraintestinal manifestations of IBD?
A
21
Q
IBD What are the GIT and MSK extraintestinal manifestations of IBD?
A
22
Q
BD What are the Hem/Oncology and Urologic extraintestinal manifestations of IBD?
A
23
Q
IBD Which Sx correlate with disease activity?
A
peripheral arthritis, Erythema nodosum, anemia
24
Q
IBD Which Sx DO NOT correlate with disease activity?
A
primary sclerosing cholangitis (PSC), sacroiliitis, ankylosing spondylitis
25
IBD What are the inv steps for IBD?
**1. Laboratory evaluation**
a. Typical biochemical abnormalities: leukocytosis, anemia, thrombocytosis, hypoalbuminemia, LFT's
b. Serum inflammatory markers: erythrocyte sedimentation rate (ESR) and CRP often elevated
c. Stool:
- Rule out enteric infections, including Clostridium difficile, before endoscopy
- Fecal calprotectin
**2. Endoscopy:** Endoscopy (OGD and colonoscopy) with confirmatory biopsies demonstrating chronic inflammatory changes is diagnostic gold standard
**3. Imaging**
SBFT, CT/CTE, MRI/MRE
US/CE, VCE (video capsule endoscopy)
26
IBD What is the relevance of -Fecal calprotectin?
Elevated concentrations in the stool if GI inflammation is ongoing
Cut off of \>200 to 300 μg/g has been suggested as optimal combination of sensitivity and specificity
Fecal calprotectin cannot distinguish between inflammation from IBD versus infection, malignancy, or nonsteroidal antiinflammatory drug (NSAID) use; cannot determine the location of disease in the bowel; and has been found to be elevated in healthy infants and toddlers
Valuable as a noninvasive marker of disease activity after diagnosis
▪
27
IBD What serologies can be used for UC and Crohns?
Atypical perinuclear antineutrophil cytoplasmic antibodies **(pANCA**) in **UC** and
anti-Saccharomyces cerevisiae antibodies (**ASCA**) in **CD**
N.B. No sufficient data to support IBD serologic testing for screening evaluation of suspected IBD
28
IBD What Rx can be used to reduce remission?
**Induce Remission**
1. **Tube** feeds (common; **Crohn’s** only), less benefit in uC
2. **Corticosteroids** - both, esp in UC, oral budesonide
3. **OTHER**
a. **Mild**: 5-ASA (Mesalamine, sulfasalazine) 1st line in UC less efficacy in Crohns
b. **Severe**: Biologics (BOTH) Infliximab \> Adalimumab
4. **Antibiotics**: Decrease inflammation by decreasing pro-inflammatory bacteria in the GI tract
Perianal disease, abscess, postoperative prophylaxis
29
IBD How to maintain remission?
1. **5-ASA** - mild; UC, less clear in Crohns
2. **Tube** Feeds (Crohn’s only)
3**. Immunosuppresive;**
a. Azathioprine & Methotrexate (moderate)
b. Biologics (severe)
30
IBD What is the DDx for terminal ileitis?
* 1.**Crohn’s & Chronic CGD**
* 2. **Lympho's**; Lymphoma & Lymphoreticularhyperplasia( LN)
* 3. **Infection**: Yersinia Infection...r& TB
* 4. Severe **Eosinophilic** Gastroenteropathy
31
Constipation What are the pathological causes?
**_Idiopathic_**
1. Disease:
Hypothyroidism
• Celiac Disease, CF
2. **Chem**: Lead Poisoning; Medications (chemo)
3. **Elect**:High Ca, Low K
4. **CNS disorders**
o Hirschprung’s
o Cerebral palsy
o Neural tube defects
32
Constipation What are the 4 categories of constipation meedications?
33
GERD What are the DDx for Gastroesophageal Reflux &
## Footnote
Dysphagia?
Physiologic....more relaxation than 4% of the time
* Eosinophilic Esophagitis
* Hiatal Hernia (LES angle affected)
* Gastroparesis (delayed gastric emptying)
* Medications
* Dysmotility
* Gastritis/gastroparesis
Physiologic....more relaxation than 4% of the time
1. **Eosinophilic** Esophagitis
2. **Mechanical**: Hiatal Hernia (LES angle affected)
3. **Pathophysio**:
Gastroparesis (delayed gastric emptying)
Dysmotility
Gastritis
4. **Medications**
34
GERD What are the causes for Delayed Gastric Emptying?
1. Idiopathic
2. **Intestinal effect:**
**a. Ileus**: Post infectious/Post surgery
b. Constipation
c. Inflamatory/immune
d. Neurological
**3. Medication**
35
GERD What are the treatment guidelines for GERD?
36
What are the DDx for Dysphagia & Odynophagia?
37
CMPI What is the incidence and cross reactivity with soy milk?
38
CMPI What are the Signs and Symptoms of Respiratory and Cutaneous IgE and Non IgE CMPI?
39
CMPI What are the Signs and Symptoms of GIT and Unclassified IgE and Non IgE CMPI?
40
CMPI What are the Management goals in CMPI for Breastfed infants?
41
CMPI What are the formula options in CMPI for formula fed infants?
42
GIT Bleeding What are the Causes of Lower GI Bleeding in children?
43
GIT bleeding What are the Causes of upper GI Bleeding in children?
44
GIT bleeding What are the Meckel’s: Rule of 2’s?
45
GIT infections which ones bleed?
46
GIT Infections which ones to treat?
47
FGID What are the Functional GI Disorders?
1. Neonatal/Toddler FGID
2. Childhood/Adolescence FGID
48
FGID What are the Neonatal/Toddler FGID's?
1. Infant Regurgitation
2. Infant Colic
3. Functional Diarrhea
4. Infant Dyschezia
5. Functional Constipation
49
FGID FGID What are the Childhood and adolescent FGID's?
50
FGID How do you approach Functional GI Disorders - OSCE?
51
FGID What is Infant Regurgitation?
Age onset
Frequency
features NOT seen?
52
FGID What are the features of Infantile Colic?
Onset age
Frequency
Featrures NOT seen
53
FGID What are the features of IFunctional diarrhea?
Onset age
Day or night?
Description?
Featrures NOT seen
54
FGID What are the features of Infant Dyschezia?
Onset age
Description?
What may help?
55
FGID What are the features of Functional constipation?
Description?
56
FGID What are the features of Cyclic vomiting?
Description?
What conditions to exclude?
57
FGID What are the features of Functional constipation?
Description?
58
FGID What are the features of Functional dyspepsia?
Description?
59
FGID What are the features of IBS?
Description?
60
FGID What are the features of Abdo migraine?
Description?
61
FGID What are the features of Functional abdo pain?
Description?
62
FGID What are the features of Functional constipation?
Description?
63
FGID What are the features of Non retentive fecal continenence?
Description?
64
Liver Casues of hyperbilirubinemia?
65
Liver Prehepatic Causes of Hyperbilirubinemia?
66
Liver What are Hepatic Causes of Hyperbilirubinemia (IMMIN)
67
Liver Posthepatic Causes of Hyperbilirubinemia?
68
Liver Causes of Neonatal cholestasis?
69
Liver What are the clinical features of liver failure?
70
Liver What are the Management Principles of liver failure?
71
Liver What are the chronic infection srates for Hep by ages?
Infants
1-5 yr
\> 5 yrs
* infants—90%
* children 1-5 yo—25-50%
* older children and adults—6-10%
72
Liver How do you prevent Hep B?
73
Liver What are the 3 disease states with Hep B?
74
Liver What is significance of forllowing hep B markers?
Hep BsAg
Hep Bs Ab
Hep Bc Ag
Hep Bc Ab
75
Liver What is the relavance of the following in Hep B?
Hep B e Ag
Hep B e Ab
Hep B DNA
Hep B genotypes
76
Liver What are Rx options for Hep B?
What are S/E of the drugs?
**1. Interferon-a (IFN- a)**
S/E: neutropenia (39%), fever, myalgia, headaches, arthralgia, anorexia with weight loss, mood changes
2. **Nucleoside analogue** **(e.g. lamivudine)**
• well tolerated, but high mutation rate leading to resistance
77
Liver What are indications for Rx for Hep B?
For children \>2 yo:
1. HBsAg+ for \>6 months
2. ALT\>2X normal and evidence of viral replication
(HBeAg+ or HBV DNA \>4 log if HBeAg-ve)
OR
**Chronic hepatitis** on liver biopsy
Rx with eitehr Interferon OR Lamuvudine..
78
Liver What are the surveillance recommendations for Px treated for Hep B?
1. **Exams**; regularly for chronic liver disease
2. I**mmunisations:**
• Immunize household & patient against Hepatitis A
3. **Labs:**
a. Measure ALT q6 mths in \>2yo
b. Measure HBeAg and HBeAb yearly in
patients with normal ALT
c. AFP annually
4. **Imaging**: U/S annually
5. **Liver biopsy** and consider treatment in
children \>2yo with ALT \>1.5x normal
79
Liver What is prognosis for treated Hep B?
1. **Spontaneous seroconversion** and clearance 70-
80%
2. Risk of **Hepatocellular Carcinoma**
(HCC) is **15-35**X greater than noninfected
population
- Lifetime risk of HCC or cirrhosis is
15-25%
80
Liver What type of virus is Hep C
What is the Prevalance in children?
RNA virus ( Hep B is DNA)
Prevalance:
0. 2% of children 6-11yo and
0. 4% of children 12-19yo
81
Liver Hep C
Spontaneous clearance rate?
Cirrhosis risk
Genotype - no of types, types in N america and importance?
**Spontaneous clearance** in children is
_20% in first 3 years_ of life, up to _50% by age 18_
**Cirrhosis** takes 10-20 years to develop, if ever
**6 genotypes**, 1-3 common in North America
• 1 carries _worst prognosis_
82
Liver How do you Dx Hep C
1. **Hepatitis C Ab** (high false +ve)
2. Confirm with **Hepatitis C PCR** and **genotype**
3. In _at risk infants,_ continue screening until at least 18
months of age with two –ve **Hepatitis C** **Ab’s** test in a row
....note..Persistence of maternal antibodies, lack of measurable self antibodies suggests spontaneous clearance
3. **Liver biopsy** controversial
83
Liver What are the guidelines for treatment for Hep C?
84
Liver What are the focus areas for Liver Transplant Longterm Followup?
1. **Neurodevelopment**
2. **Medication**: Side effects/adherence
3. **Transplant:**
a. Secondary graft dysfunction LFT's
b. Chronic GVHD
c. Infections - common, opportunistic
d. Thrombosis
85
**Pancreatitis Acute management?**
Pancreatitis
* Acute management
* Fluids (1.5-2x maintenance)
* Enteral nutrition early
* If not tolerated, NJ tube feeding
* If still not tolerated, TPN
* Watch for complications (SIRS response)
* 1. **Fluids** (1.5-2x maintenance)
* 2. **Enteral nutrition** early
* If not tolerated, NJ tube feeding
* If still not tolerated, TPN
3. Watch for complications (SIRS response)
4. Analgesia
86
Pancreatitis What are the causes of chronic pancreatitis?
87
Celiac How do you handle a child who is TTG IGA +ve?
TTG+ve?
**•\> 10 x ULN** Can offer n**on-biopsy diagnosis** if:
•Anti-EMA positive (from separate sample)
AND
* **HLA-DQ2** or **HLA-DQ8** positive (“permissive haplotype”)
* \<10x ULN Must do upper endoscopy with duodenal biopsies
Alway srefer to gastreoentrologistfor discussion
88
Celiac How do you screen for high risk patients for Celiac with no symptoms?
“Screen”
•1. TTG/IgA,
OR
2.H**LA-DQ2/HLA-DQ8** testing TTG/IgA if either present
89
90
Celiac How do you manage a child at risk of celiac with no Sx who tests +ve for TTG IGA?
1. **\>3 x ULN** and/or Anti-EMA positive Must do EGD with duodenal biopsies
2. \< **3 x ULN,** Anti-EMA negative - Repeat ATTG q3-6 mo
91
Food Allergy What are the most used screening tests for food allergies?
