Gastroenterology Flashcards
What are the medications considered for prophylaxis in cyclical vomiting syndrome?
- < 5yo - cyproheptadine
- > 5yo - amitryptiline
What are the indications for fundoplication?
- Life-threatening complications of GERD after failure of optimal medical treatment
- Symptoms refractory to optimal therapy
- Chronic condition with a significant risk of GERD related complications
- Need for chronic pharmacotherapy
What is the diagnostic criteria for cyclical vomiting syndrome?
- 5+ attacks in any interval, or a min of 3 episodes during a 6mo period
- Recurrent episodes of intense N/V lasting 1h to 10d and occurring at least 1 wk apart
- Stereotypical pattern and symptoms
- Vomiting during episodes occurring 4+ times/hr for 1+ hours
- Return to baseline health between episodes
- Not attributed to another disorder
What is the gold standard way to diagnose biliary atresia?
Intraoperative cholangiography and histologic examination of the duct remnant
What are the most common causes of constipation in the neonatal period?
Hischsprung disease
Pseudo onbstruction
Hypothyroidism
What are bacteria that can be transmitted in unpasteurized cow’s milk?
Yersinia, campylobacter, salmonella, listeria, E coli
What are autoimmune diseases associated with celiac disease?
- Type 1 DM
- Hashimoto / Autoimmune thyroid
- Autoimmune hepatitis
- Autoimmune cholangitis
What are the extraintestinal manifestations of celiac disease (in descending order of strength)?
- Dermatitis herpetiformis
- Dental enamel, hypoplasia of the permanent teeth
- Osteopenia/osteoperosis
- Short stature
- Delayed puberty
- Iron deficiency anemia
- Hepatitis
- Arthritis
- Epilepsy with occipital lobe
What is the differential diagnosis for terminal ileitis?
- Crohn’s
- Lymphoma
- Yersinia infection
- TB
- Chronic granulomatous disease
- Severe eosinophilic gastroenteropathy
- Lymphonodular hyperplasia (normal finding seen om imaging)
What is the differential diagnosis for constipation?
- Functional
- CNS: Hirschsprung’s, CP, neural tube defect
- Endo: hypothyroidism
- Metabolic: hypercalcemia, hypokalemia
- Resp: CF
- Drugs: meds (oncologic), lead poisoning (classic question!)
- GI: celiac disease
What is the therapy for H pylori?
- ANTIBIOTICS (total 14 days) tailored to susceptibilities:
- Unknown susceptibilities: PPI + amoxicillin + metronidazole
- Susceptible to CLA and MET: PPI + amoxicillin + clarithromycin
- Resistant to CLA/susceptible to MET: PPI + amoxicillin + metronidazole
- Resistant to MET/susceptible to CLA: PPI + amoxicillin + metronidazole
- Resistant to CLA/MET: PPI + amoxicillin + metronidazole x 14 days
- Monitor success of therapy at least 4 weeks following therapy by noninvasive testing with urea breath test or 2-step monoclonal stool antibody test
- Must wait 2 weeks after PPI stops and 4 weeks after antibiotics for retesting
What are indications for testing for H pylori? What is the diagnostic test of choice?
Indications:
- Children with gastric or duodenal ulcers
- Refractory iron deficiency anemia
- ITP
- NOT INDICATIONS: functional abdominal pain, short stature
Dx test: Endoscopy and biopsy
- Testing should be performed in children with gastric or duodenal ulcers identified on endoscopy only
- Dx: either +BCx or H pylori gastritis on histopathology with at least 1 positive biopsy-based test
- Should take at least 6 biopsies on endoscopy, additional biopsies for rapid urease test and culture
What is the differential diagnosis for dysphagia?
-
Intrinsic mechanical obstruction:
- Stricture (secondary to esophagitis - chronic GERD, eosinophilic esophagitis, chronic infections, secondary to esophageal foreign body or caustic ingestion)
- Eosinophilic esophagitis (EOE)
- Achalasia
- Web
- Tumor
- Schatzki ring
-
Extrinsic mechanical obstruction:
- Compression from vascular rings
- Mediastinal lesions
- Vertebral abnormalities
How is the diagnosis of pancreatitis confirmed?
- Need 2 of 3 of the following:
- Abdominal pain
- Serum amylase and/or lipase >3x ULN (lipase is most sensitive)
- Imaging compatible with pancreatitis (AUS primarily, CT/MRI for more complicated cases)
- First-time presentations should include liver enzymes (ALT, AST, GGT, ALKP, bilirubin), triglyceride level, and calcium level
What is the diagnostic criteria for ARFID?
- Eating or feeding disturbance (i.e., apparent lack of interest in eating or food; avoidance based on sensory characteristics of food; concern about aversive consequences of eating) as manifested by persistent failure to meet appropriate nutritional and/or energy need associated with:
- Significant weight loss (or failure to achieve expected weight gain or faltering growth in children)
- Significant nutritional deficiency
- Dependence on enteral feeding or oral nutritional supplements.
- Marked interference with psychosocial functioning.
- The disturbance is not better explained by lack of available food or by an associated culturally sanctioned practice.
- The disturbance does not occur solely in the course of anorexia nervosa or bulimia nervosa, and body weight and shape are not distorted.
- The eating disturbance is not attributable to a concurrent medical condition or not better explained by another mental disorder.
What is a Meckel’s Diverticulum?
Incomplete obliteration of omphalomesenteric duct during 7th wk GA
What are the recommendations for how public policy can address issue of increased dietary intake of sodium for children?
-Advocate and support government policies designed to reduce sodium consumption from processed foods, including:
- Setting mandatory sodium reduction targets for the food industry,
- Regulating the marketing of foods high in sodium to children and youth, and
- Requiring front-of-package labeling for foods high in sodium.
-Apply nutritional guidelines or standards, including sodium guidelines, available from regional or provincial health departments to:
- Procured and prepared food served to children in public institutions, such as childcare settings and hospitals, and
- Food available for sale or served in schools, especially in cafeterias and vending machines.
What are the recommendations for how pediatricians can address issue of increased dietary intake of sodium for children?
-Assess each family’s dietary habits and educate parents, caregivers and youth on how to reduce their dietary sodium intake using:
- The recommended sodium intake ranges (Table 1) and the resources below
- The Nutrition Facts Table and the % Daily Value for sodium on pre-packaged food labels
What is the recommendation for iron supplementation in infants with low birth weight?
- Low BW infants + BF (<2.5kg):
- 2-2.5kg: iron supps 1-2mg/kg/day x6mo
- <2kg: 2-3mg/kg/day x1y
- Low BW + formula fed:
- 2-2.5kg: if formula gives 1-2mg/kg/day then no supps
- <2kg: if formula gives 2-3mg/kg/day, then no supps
What is the recommendation for vitamin D supplementation for kids in Canada?
Vitamin D dosage should be 400 IU per day for all infants during the first year, with an increase to 800 IU per day from all sources between October and April north of the 55th parallel (approximately Edmonton) and between the 40th and 55th parallel in individuals with risk factors for vitamin D deficiency other than latitude alone.
How should one be restested for H pylori to ensure eradication?
Monitor success of therapy at least 4 weeks following therapy by noninvasive testing with urea breath test or 2-step monoclonal stool antibody test
What is the differential diagnosis for neonatal cholestasis?
- Infections – UTI, E coli, sepsis, TORCH, adenovirus
- Biliary atresia
- Choldochal cyst
- A1AT deficiency
- Hypothyroidism
- Galactosemia
- Mitochondrial
- PFIC
- Treatable causes: biliary atresia, sepsis, galactosemia, tyrosinemia, panhypopit, bile acid synthetic defects, obstructive gallstones
In what syndromes is the incidence of Hirschsprung increased?
T21, Joubert, Smith-Lemli-Opitz, Shah-Waardenburg, MEN2, NF, neuroblastoma, CCHS, urogenital, CVS abnormalities
What is the differential diagnosis for hyperbilirubinemia?
Pre-hepatic
- Hemolytic
- Extracellular (e.g. sepsis/DIC, ABO/Rh)
- Intracellular (membranopathy, hemoglobinopathy, enzymopathy)
- Non-hemolytic
- Physiology (50%) → usually first 14 days
- Hypothyroid
- Breast milk
- Gilbert’s syndrome
Hepatic causes (*should have increased ALT)
- Infectious – Viral (TORCHES, adeno, parvo, echo), bacterial, fungal, parasites (e.g. flukes)
- Meds, ingestions, toxins
- Metabolic – A1AT, hemochromatosis, Wilson’s, carbs, fats, protein, mitochondria
- Inflammatory – AIH, NAFLD/NASH
- Neoplastic (primary, mets hematologic)
Post-hepatic causes
- Post-hepatic = obstructive
- Biliary atresia
- Choledochal cyst
- CF
- Gallstones
- Primary sclerosing cholangitis
- Neoplastic
- Inspissated bile syndrome
- Genetic (PFIC)
In what situations could pediatricians recommend the use of probiotics?
- Physicians can consider recommend probiotics to:
- Prevent antibiotic-associated diarrhea
- Shorten duration of acute infectious viral diarrhea
- Prevent NEC in preterm infants at risk of NEC
- Decrease symptoms of colic
- Decrease some symptoms of IBS
- Insufficient evidence to suggest for the prevention of atopic disease
- Be aware probiotics carry small risk of invasive disease to immunocompromised children
What are the recommendations for physical activity for children with JIA?
- Can safely participate in sports without disease exacerbation.
- Should participate in moderate fitness, flexibility and strengthening exercises.
- Can participate in impact activities and competitive contact sports if their disease is well controlled and they have adequate physical capacity.
- Should be encouraged to be physically active as tolerated. Those with moderate to severe impairment or actively inflamed joints should limit activities within pain limits.
- Should gradually return to full activity following a disease flare.
- Should take individualized training (especially for children with severe joint disease) within a group exercise format for physical/social benefit. Physiotherapists on paediatric rheumatology health care teams should coordinate individual exercise programs.
- Should have radiographic screening for C1–C2 instability before participation in collision/contact sports if they have neck arthritis. If present, further evaluation is required.
- Should wear appropriately fitted mouth guards during activities with jaw and dental injury risk (per general population), especially if they have jaw involvement.
- Should wear appropriate eye protection (per general population) during activities with ocular injury risk
What are the recommendations for physical activity for children with Hemophilia?
- Should receive appropriate factor prophylaxis to reduce the risk of bleeding in sport.
- Should undergo vigilant assessment of joint and muscle function before sport selection. If restrictions are required, physicians should counsel children and their families about safe alternatives.
- Should be carefully assessed before allowing participation in contact or collision sports such as martial arts, hockey or football. Consultation with a sport medicine physician and/or paediatric hematologist may help.
- Require written strategies (coach, parent or school) before sport participation to prevent or treat bleeds.
- Should wear protective equipment, undergo physical therapy or take prophylactic factor replacement therapy.
- Require factor replacement, ice, splinting and rest to manage acute bleeds. Physical activity should be avoided until joint pain or swelling has resolved. Return to sport requires individualized assessment and appropriate rehabilitation
What are the recommendations for physical activity for children with asthma?
- Are able to participate in any physical activity if symptoms are well controlled. Swimming is less likely to trigger EIB than running.
- Should keep an accurate history of symptoms, trigger exposures, treatments and course of recovery from episodes of bronchospasm.
- Should be diagnosed with EIB by a drop in FEV1 (10% to 15%) after a 6 min to 8 min exercise challenge and a positive response to beta-2 agonist medication. Eucapnic voluntary hyperventilation testing is recommended in athletes.
- Should use leukotriene inhibitors, inhaled corticosteroids and/or long-acting beta-2 agonists for optimal long-term disease control, and avoid overuse of short-acting beta-2 agonists.
- Should take inhaled beta-2 agonists 15 min to 30 min before exercise.
- Should not scuba dive if they have asthma symptoms or abnormal PFTs.
- Who compete nationally or internationally require a therapeutic use exemption with confirmation of asthma and/or EIB to use certain medications. Consultation with a sport medicine physician is suggested.
What are the recommendations for physical activity for children with cystic fibrosis?
- Should be encouraged to participate in any physical activity. Consultation with a sport medicine physician or paediatric respirologist is suggested.
- Should have individualized exercise programs that include strength training.
- Require supervised or unsupervised home exercises that elevate heart rate by 70% to 80% of maximum to increase aerobic exercise tolerance.
- Who cough during exercise should not necessarily stop activity.
- Those with severe CF should undergo exercise testing to identify maximal heart rate, levels at which oxygen desaturation and ventilation limits occur, exercise related bronchospasm and response to therapy.
- Should absolutely avoid scuba diving → risk of pneumothorax!
- Should drink flavoured sodium chloride-containing fluids above thirst levels to prevent hyponatremic dehydration. Those with diabetes mellitus require additional carbohydrates during prolonged exercise.
- With an enlarged spleen or diseased liver should avoid contact or collision sports
When can pediatricians consider recommending probiotics?
- Prevent antibiotic-associated diarrhea
- Shorten duration of acute infectious viral diarrhea
- Prevent NEC in preterm infants at risk of NEC
- Decrease symptoms of colic
- Decrease some symptoms of IBS
What is the differential diagnosis for hepatomegaly?
- Hepatitis (inflammation)
- Storage disorders
- Glycogen (GSD)
- Lipid (Gaucher, NASH)
- Protein (A1AT)
- Iron (hemochromatosis)
- Infiltrative
- Benign liver tumors
- Malignant liver tumors
- Disseminated tumors
- Biliary obstruction
- Post-hepatic obstruction
- Cardiac (Right HF)
- Thrombus (hepatic vein, IVC)
- Intrahepatic (sinusoids)
What are the treatment recommendations for hepatitis B?
- For children >2yo:
- HBsAg+ for >6mo
- ALT 2x normal +
- Evidence of viral replication (HBeAg+ or HBV DNA >4 log if HBeAg-)
- OR Chronic hepatitis on liver biopsy
- Treat with either IFN-alpha or lamivudine
- 20-58% spontaneous conversion / clearance
What are the screening recommendations for children with Hepatitis B?
- Measure ALT q6months in children >2yo
- Measure HBeAg and HBeAb yearly in patients with normal ALT
- Liver biopsy in children >2yo with elevated ALT
- Examine for chronic liver disease
- Immunize household
- Immunize patient against Hepatitis A
- Alpha fetoprotein & ultrasound annually
