GASTROENTEROLOGY Flashcards
An exclusively breastfed infant has not stooled
for 5 days with no other symptoms. The stool is
soft with no rectal bleeding. The infant is gaining weight
Reassurance (breastfed infants may go several
days or even a week between bowel movements)
A 1-week-old child with frequent spit-ups,
otherwise doing well
Reassurance (newborn reflux is normal)
A 3-week-old first newborn boy presents with
nonbilious projectile vomiting, hypochloremic,
hypokalemic metabolic alkalosis, and dehydration
Pyloric stenosis
What are the upper GI series useful for?
To rule out anatomic or motility problems. Does
not diagnose reflux
What is the next best step in cases with suspected pyloric stenosis?
Abdominal US (pylorus)
Weight loss, abdominal pain, nausea, effortless
postprandial regurgitation after at least 1 meal
daily for 1 month, regurgitated food occasionally reswallowed, rechewed, or spit out
Rumination syndrome
Child with no known health problem woke up
suddenly vomiting blood. The child is stable and
acting normal. What is the most likely cause?
Epistaxis (nose bleeding is the most common
source in healthy children)
Nausea and vomiting every 1–2 months, each
episode lasts for few hours, otherwise healthy, no symptoms in-between episodes, positive family history of migraine
Cyclic vomiting syndrome
A 7-year-old healthy child, with periumbilical
abdominal pain worse in the morning prior to
school, improves during weekends with normal
growth parameters
Reassurance (functional abdominal pain)
Adolescent presents with recurrent episodes of
abdominal pain, diarrhea, and sometimes
constipation in the previous 3 months. No weight loss and all labs are normal. What is the best treatment?
Peppermint oil, diet modifications, cognitive
behavioral therapy
High achieving adolescent complains of crampy
abdominal pain, diarrhea, and at other times,
constipation; pain is relieved with stooling
Irritable bowel syndrome
A mother brought her toddler with a diaper full of undigested food, the child is holding a large bottle of apple juice
Toddler diarrhea
What is the major concern of using antimotility
drugs such as Loperamide?
May induce ileus
The best management of toddler’s diarrhea
Juice restriction and allow normal dietary fat
Child with a low-grade fever, 6 episodes of
diarrhea, otherwise reassuring medical exam.
What is the treatment of choice?
Oral rehydration therapy (avoid anti-diarrheal
agents)
An infant presents with bright red blood stool,
poor weight gain, diarrhea, and fussiness; the
infant is breastfeeding, supplemented with
standard infant formula; stool guaiac test is
positive
Cow milk protein intolerance
Child with dysphagia, recurrent food impaction;
biopsy shows an increased eosinophil?
Eosinophilic esophagitis
Child accidentally swallowed caustic liquid 6 h
ago, presents with dysphagia, oral pain, chest
pain, nausea, and vomiting
Endoscopy in 12–24 h after ingestion
Adolescent with recurrent headaches takes
ibuprofen as needed, presents with dysphagia and chest discomfort (does not like to drink water with medicine)
Pill-induced esophagitis
4 weeks passed and the coin still in the stomach
with no symptoms
If the coin does not pass through the stomach by 4 weeks or if the patient is symptomatic, removal by endoscopy should be considered
Swallowed a coin, no symptoms, and radiograph showed the coin still in the esophagus
Observe for 12–24 h, removal of the coin if it
does not pass to the stomach or if the patient
became symptomatic
Swallowed a coin, no symptoms, and radiograph showed the coin in the stomach
Checking the stool for passage for 4 weeks, with
weekly radiographs, if indicated
Swallowed a button battery (BB), and passed to
the stomach with symptoms
Immediate removal
Swallowed a coin, excessive drooling, and chest
pain, and radiograph showed the coin still in the
esophagus
Immediate removal
Swallowed a BB that got stuck in the esophagus
Immediate remova
Swallowed a BB, and passed to the stomach
without symptoms
Urgent removal (if age < 5 and BB ≥ 20 mm)
Elective if not moving (checking the stool for
passage for 4 weeks, with weekly radiographs)
The best and most definitive test for peptic ulcer disease
Endoscopy
Swallowed small pieces of magnet metals; the
abdominal radiograph showed the pieces in the
stomach
Immediate remova
An older child with bloating, constant burping,
sharp epigastric pain that awakens the child from sleep
Helicobacter pylori infection
The most common cause of chronic gastritis in
pediatrics
H. pylori
What is the treatment of H. pylori infection?
Amoxicillin or metronidazole + clarithromycin +
PPI for 2 weeks
Infant suddenly develops bilious vomiting,
abdominal distension, tenderness, and fussiness. What is the diagnostic test of choice?
Upper GI series with follow through
In the infant above, the GI series shows a bird’s
beak sign of the second portion of the duodenum
Volvulus
Intermittent crampy abdominal pain, lethargy,
bilious vomiting, and a palpable mass in the right upper quadrant
Intussusception
What is the best initial diagnostic test of choice in cases of intussusception?
Abdominal US (target sign, reflecting a segment
of bowel trapped within a distal segment of
bowel)
What is the therapeutic procedure of choice in
cases of intussusception?
Air contrast enema (diagnostic and therapeutic)
Down syndrome, bilious vomiting, double bubble sign on KUB
Duodenal atresia
A mother brought her 9-month-old girl with a
diaper full of red, maroon stool; the physical
exam is normal, and the infant is feeding well and smiling (she is receiving an antibiotic for AOM)
Most likely the medicine, e.g., cefdinir may
change the stool color to maroon color (bloodlike color)
A 2-year-old boy, frank rectal bleeding, anemia,
no pain, no other symptoms
Meckel diverticulum
What are the 2 most common ectopic tissues
found in Meckel diverticulum?
Gastric and pancreatic
Most common cause of rectal prolapse in the
USA
Constipation
Infant, failure to thrive, rectal prolapse
Cystic fibrosis
How is Meckel diverticulum diagnosed?
Technetium 99 scan
Rectal bleeding, large and hard stool in the diaper
Anal fissure
The most common cause of rectal bleeding in
infants
Anal fissure
A 2-year-old boy with chronic constipation,
ineffective laxatives, fails to pass meconium in
the first 48 h of life, explosive stools on rectal
exam, KUB showed very distended colon
Hirschsprung disease
A 48-h old boy did not pass the meconium; the
abdomen is slightly distended
Hirschsprung disease
Most accurate diagnostic test for Hirschsprung
disease
Full-thickness rectal biopsy performed by surgery
Persistent epigastric abdominal pain, vomiting;
the pain is referred to the back, tenderness in the epigastric region, elevated amylase, and lipase enzymes
Acute pancreatitis
Child with type 1 diabetes mellitus and recurrent abdominal pain
Celiac disease
Child with Down syndrome, intermittent
abdominal pain, and failure to thrive
Celiac disease
Jaundice, abdominal pain, and fever
Cholangitis
Child with a history of recurrent abdominal pain
presents with fever, abdominal pain, bloody
diarrhea, migratory arthritis, erythema nodosum,
ankylosing spondylitis, elevated ESR, positive
P-ANCA
Ulcerative colitis
Recurrent aphthous ulcers, abdominal pain,
weight loss, perianal lesions, positive anti-
Saccharomyces antibodies
Crohn’s disease
Hydrops of the gallbladder can be seen in
Kawasaki disease
What is the most common complication of
cholelithiasis?
Pancreatitis
Jaundice, abdominal pain, and a palpable mass in the right upper quadrant
Choledochal cyst
Conditions associated with an increased incidence of cholelithiasis
Sickle cell anemia, chronic total parenteral
nutrition (TPN), adolescent pregnant females
A 3-year-old boy presents with failure to thrive,
difficulty walking; the metabolic panel shows
elevated aspartate transaminase (AST) and
alanine transaminase (ALT). Total bilirubin,
prothrombin time, blood glucose, TSH and free
T4 are all normal, negative hepatitis viral panel.
What is the test of choice in this case?
Creatinine phosphokinase (CK) (muscular
dystrophy most likely)
What are the sources of transaminases (ALT and
AST)? It is important to consider other sources of transaminases if they are elevated and the liver function is normal
Liver, heart, muscles, kidney, and brain
The best laboratory test for acute hepatitis A
Anti-HAV IgM
A mom is asking about prophylaxis for her
4-month-old child after she was recently
diagnosed with hepatitis A?
Administer IG as prophylaxis (< 1 year)
Prophylaxis of a 3-year-old child exposed to a
documented case of hepatitis A in a child care
center
Hepatitis A vaccine (> 1 year)
All hepatitis viruses are composed of RNA except
Hepatitis B virus is composed of DNA
Which virus infection must have hepatitis B?
Hepatitis D
Child with a family history of lupus disease
presents with jaundice, hepatomegaly, weight
loss, loss of appetite, positive anti-smooth muscle antibodies
Autoimmune hepatitis
One week with jaundice, hepatomegaly, slightly
elevated ALT and AST, prolonged PT that is not
responding to IV vitamin K, and recurrent
hypoglycemia
Acute hepatic failure
An 8-year-old boy has recurrent jaundice, slightly elevated indirect bilirubin; physical examination and all other labs are normal
Gilbert syndrome
A 1-day-old boy with intense jaundice,
unconjugated bilirubin is 25 mg/dL, and no
conjugated bilirubin; and poor response to
phototherapy
Crigler–Najjar syndrome type I (exchange
transfusion is warranted)
Mild conjugated hyperbilirubinemia with black
liver
Dubin–Johnson syndrome
An infant with jaundice, dark urine, light-colored
stool, hepatomegaly, and elevated conjugated
bilirubin
Biliary atresia
What is the most valuable study for neonatal
biliary atresia?
Percutaneous liver biopsy
If liver biopsy confirmed biliary atresia, what is
the next appropriate test?
Intraoperative cholangiography
Adolescent presents with depression, psychosis,
and elevated liver enzymes
Wilson disease
Which mineral is affected in Wilson disease?
Copper (excess)
How to establish the diagnosis of Wilson disease
Ceruloplasmin < 20 mg/dL. Hepatic copper
> 250 ug/g dry weight. Urine copper
> 100 ug/24 h. Presence of Kayser–Fleischer
rings
Broadened forehead, jaundice, pulmonary
stenosis, and butterfly hemivertebrae
Alagille syndrome
Abdominal mass, elevated liver enzyme, and high serum alpha-fetoprotein
Hepatoblastoma
A 3-month-old, failure to thrive, extreme pruritus, steatorrhea, very high-conjugated
bilirubin, hepatosplenomegaly, mutilated skin, elevated serum alkaline phosphatase, and normal gammaglutamyl transferase (GGT)
Progressive familial intrahepatic cholestasis
(PFIC) type 1
Prognosis of all forms of PFIC
Lethal during childhood unless treated early
Hematochezia, intestinal polyp, pigmented penile lesion, large head, café-au-lait spots, intellectual disability
Bannayan–Riley–Ruvalcaba syndrome
> 5 juvenile polyps
Juvenile polyposis
What is the next step in children with ≥ 5
juvenile polyps or any number of adenomatous
intestinal polyps?
Genetic testing
100 or more adenomatous polyps in the large and/ or small intestines
Familial adenomatous polyposis
Intestinal polyps, osteoma of the mandible,
papillary carcinoma of thyroid, and
hepatoblastoma
Gardner syndrome
Intestinal polyps and brain tumor
Turcot syndrome
Intestinal polyps, hematochezia, mucocutaneous freckling, and a family history of polyposis
Peutz–Jeghers syndrome (increases the risk of
cancer)
Hamartomas involving many areas of the body,
e.g., skin, oral mucosa, thyroid, breast, and colon
Cowden syndrome
Associated risks of Cowden syndrome
Cancer, e.g., thyroid cancer
Hemihypertrophy, very large extremities,
epidermal nevus, hamartomatous polyps,
intellectual disability
Proteus syndrome
Potential risks of Proteus syndrome
Deep vein thrombosis (DVT) and
thromboembolism
The best diagnostic test for lactose intolerance
Hydrogen breath test
