Gastroenterology Flashcards
Protein Intolerance (Milk Protein-Induced Enterocolitis)
o Majority of cases result of Milk Protein (can be from mom’s consumption of milk)
o Presents age2-8w
o Eczema
o Enteropathy
Diarrhea, Severe reflux/vomiting, colicky abdominal pain Chronic blood loss in stools can lead to anemia
Protein loss in stools causes FTT & Edema
o Enterocolitis Acute
Diarrhea, painless blood & mucus in stool
Protein loss in stools causes FTT & Edema o Tx
Breastfeeding mother remove protein (Milk & Soy)
Can continue to breast feed
Resolves by 1-2 y/o
Elemental (hydrolyzed) formula
Hirschsprung Disease
o Typically rectosigmoid colon
o Also associated w/ Down Syndrome
o Normal meconium consistency
o S/Sx
Rectal examination reveals tight anal canal may lead to explosive expulsion “Squirt Sign”
Bilious or Feculent vomiting (newborns), abdominal distension, constipation (older children)
Failure to pass meconium Or delayed (>48 h)
o BariumSwallow
Dilated proximal bowel w/ narrow distal segment
o Dx
Screen
Anorectal manometry Diagnostic
Lack of ganglionic cells (NCC migration) on punch biopsy
Duodenal Atresia
o 1⁄4 Down Syndrome
o S/Sx
Bilious Vomiting w/in first 2 days of life Double Bubble Sign on XR
Air w/in distended stomach and proximal duodenum
o HxofPolyhydramnios
o Dx
Prenatal Ultrasound
o Associated with Down Syndrome
o Tx
Nasogastric decompression first IV Fluids & ABx
Surgery
Diarrhea/Vomiting and Dehydration
o Most commonly caused by Viral Gastroenteritis
o Hyponatremic, hypovolemic, hypoosmotic, low urine sodium, low serum osmolarity
Celiac
o Presents between 6m and 2y
o Gluten is in wheat, barley, rye, &oats
o S/Sx
Fatigue, weight loss
Diarrhea, vomiting, bloating
Abdominal pain & large foul smelling stools Dermatitis Herpetiformis
Erythematous Vesicles on extensors o Pruritic
o Associated w/ Vitiligo and T1DM
o Malabsorption
Osteoporosis/osteomalacia
Can lead to iron deficiency anemia
o Dx
Biopsy
Short villi, deep crypts, & vacuolated epithelium w/ lymphocytes
IgA endomysial Ab & Serum Tissue Transglutaminase Ab IgG in IgA deficient pt.
o Tx
Corticosteroids for severe diarrhea
Short Bowel
o Malnutrition with carb & fat malabsorption w/ steatorrhea FTT
o Distalresection
↓ B12 & Bile Acid reabsorption
o Causes
Congenital
Gastroschisis, volvulus, or atresia that require resection Crohn’s, tumors, & radiation enteritis
o Complications
TPN cholestasis w/ resulting Gallstones Bacterial overgrowth
TPN induced Liver failure
o Tx
Early enteral feedings for remaining bowel & liver function Liver transplant
GER
o Normal physiologic state in which stomach contents move retrograde o “HappySpitters” w/out GERD Sx Benign emesis/spitting up Not related to over feeding Resolves by 6-12m o Tx Reassurance Positioning therapy
Colic
o Crying in another wise healthy infant for >3h daily (usuallyevening), >3x per week, for a
duration of >3w
o Tx
Soothing techniques
GERD
o Infantspresentw/
Emesis/spitting up, Suboptimal calorie intake (feeding refusal), & if severe FTT Irritability
Sandifer Syndrome
Torticollis w/ arching of the back from painful esophagitis o Older Children presents w/ Typical GERD Sx
o Causes
Inappropriate Transient LES Relaxation (TLESR)
o Complications
Upper/lower Airway Disease
Induces bronchopulmonary constriction o Riskofaspiration
Chronic Laryngitis
William Martin MD MBA 2016 TTUHSC SOM OC USN
2.23.2015
o Hoarseness,wheezing,vocalcordnodules Barrett’s esophagus
FTT
Esophageal strictures o Dx
pH probe is gold standard
Bronchoscope w/ alveolar lavage when aspiration is strongly suspected o Tx
Conservative
Positioning & meal timing first (before pharmacotherapy)
Thickened feeds
H2 Blockers & PPI
Motility agents
Metoclopromide
o High side effects (1/3)
Drowsy, restlessness
↑ LES tone or Gastric Emptying Surgery
Nisses Funoplication
o Usually followed with gastrostomy tube to maintain
feedings/nutrition while stomach adjusts to ↓ volume
Choledochal Cyst
o Congenital abnormality of biliary ducts
Dilation of intra or extra-hepatic biliary ducts or both o S/Sx
Infants
Jaundice, acholic stool (like biliary atresia)
Children
Abdominal pain, jaundice, recurrent pancreatitis, dark urine ↑Bilirubin
o Dx
US or MRI
Cystic Extrahepatic mass
Hypertrophic Pyloric Stenosis
o Projectile Vomiting Nonbilious
Early in life, three to five weeks
Hypokalemic, hypochloremic, metabolic alkalosis (loss of H+)
High PCO2
Hypokalemia results from ↑ aldosterone in response to volume
depletion from vomiting
HCl, H2O, and NaCl lost in vomit
Will still seem hungry
o Risk Factors: w/ Trisomy 18, first born male, erythromycin, formula feeding
o Physical
Olive Mass (epigastric/RUQ)
Peristaltic Wave in abdomen after feedings
o Dx
US
Thickened and elongated pylorus Barium Swallow
May show string sign
o Small amount of barium getting past
o Tx
Correct electrolytes/dehydration (DON’T OPPERATE IF ELECTROLYTE
ABNORMALITIES)
Must correct, IV hydration + Potassium
Partial pylorectomy
Malrotation of the Gut & Midgut Volvulus
o Bilious vomiting
Intussusceptions
o Peak5to9m
Before age 2 typically
o Ileocolic intussusceptions most common
Viral Gastroenteritis can also cause a lead point through inflammation of the Peyer’s patches
Hematomas from HSP & Mekel’s can also serve as lead points o S/Sx
Sudden crampy/colicky abd pain
Periods of Colic and then normal behavior (playing laughing) or
lethargic
Vomiting
Currant Jelly Stools (Bloody Mucus) from edema and sloughing of mucosa
Sausage shaped mass in RUQ o Dx
US
Target Sign
o Tx
Air/Contrast enema is gold standard
Avoid hydrostatic if prolonged, perforated, or peritonitis o Air is preferred
Coil Spring Sign
May reduce the intussusceptions (therapeutic)
AbdominalRigidity
Peritoneal Process
Restlessness
Colicky Pain
Constant Abdominal Pain
Suggests strangulation or torsion
Intestinal Obstruction PE
High pitched bowel sounds, abdominal distension, tenderness, & visible peristalsis
Peritonitis
↓/absent bowel sounds
Rigidity w/ guarding
Rebound Tenderness
Appendicitis
Pain referred to T-10 (umbilicus) PE Tenderness @ McBurng’s Guarding Rebound Tenderness ↑ WBC and neutrophils
Acute Pancreatitis
Uncommon in children Causes Trauma #1, idiopathic #2, infection S/Sx Pain @ periumbilicus & epigastric o Radiatestoback Severe w/ blood along the fascial planes o Gray Turner Sign Bluish discoloration of the flanks o Cullen Sign Bluish discoloration of periumbilical Labs ↑ Amylase ↑ Lipase Abdominal US for Dx CT for complications Pseudocyst formation Tx ABx if Necrotizing Small Pseudocyst can resolve on own, but large ones may require
Cyclic Vomiting Syndrome (CVS)
o Acute and frequent vomiting that resolves spontaneous w/ no Sx in between episodes o FHxofmigraines o Thought to be linked to abdominal migraines o Dx Criteria ≥3 episodes in 6-month Easily recognizable to family Lasts 1-10d Vomiting ≥4 times/hr @ peak No Sx in between episodes No underlying condition o Tx Antiemetic (ondansetron [Zofran]) If FHx of migraines: Sumatriptan
Cholecystitis
o Inflammation of the gallbladder Most commonly w/ stones Less commonly w/out (Acute Acalculous Cholecystitis) o Uncommon in children unless: CF, TPN, or Sickle Cell o RUQPainw/Guarding o +Murphy’sSign Palpation of the RUQ upon inspiration, intense pain, inspiration ceases o Imaging US Stone or thickened GB Wall Cholescintigraphy may be useful o Mild ↑ LFT & TB o Tx ABx Cholecystectomy if peritonitis
Constipation
o Risk factors: Dairy, toilet training, school entry o S/Sx
Abdominal pain, passage of pellet like stools, 48h)
Increase fiber, limit cow’s milk, laxative (polyethylene glycol, mineral oil)
IBD
o Peaks 15 to 20 y/o & @ 50 y/o o Includes Crohn’s Disease Ulcerative Colitis o Tx Immunosuppressive Agents Induce long term remission Corticosteroids For acute exacerbation & induce remission
Ulcerative Colitis
o Limitedtocolon o Continuous & Limited to the Mucosa Mucosa is friable and bleeds o Typically bloody diarrhea w/mucosa At least 3-4w o Ranges in Severity Rectal Bleeding, diarrhea, abdominal pain, Hypoalbuminemia o P-ANCA o Complication Toxic Megacolon ↑ Risk for Colorectal Cancer o Tx Sulfasalazine Can be cured w/ total proctocolectomy, but reserved for intractable colitis Immunosuppressive Agents & Corticosteroids
Crohn’s Disease
o Any segment (mainly terminal Ileum)
Can have mouth ulcers
o Skip lesions & segmental inflammation o Transmuralinflammation
Fistulas, Crypt Abscesses, Strictures o Malabsorption
Vit B12, Zinc, Folate, Fe2+
o Perianal disease (verycommon) often precedes intestinal disease
Skin Tags, abscesses, fistulas
o ExtraintestinalManifestations
Much more common than in UC
FUO, arthritis, mouth ulcers, skin manifestations (erythema nodosum), weight
loss, malaise, and growth retardation
o Anti-SaccharomycescerevisiaeAb o Granulomas(30%)
o Imaging
String Size
Thickened bowel folds w/ narrowing of the tract
o Tx
Metronidazole
When fistulas presents
Esp. w/ inflammation
Immunosuppresive Agents & Corticosteroids
Azathioprine, cyclosporine, tacrolimus, TNF-α
GI Bleed
o Hematemesis Coffee ground appearance o Hematochezia Bright red, lower GI or significant rapid upper GI o Melena Dark tarry, upper GI (proximal to Ligament of Treitz) o Occult bleeding from GI Guaiac + False + o Ingested iron False - o Large amounts of ingested Vit. C
Upper GI Bleed
o Swallowed maternal blood o Endoscopy if active bleeding w/hemodynamic changes o Tx Initial: Fluid Bolus w/ IV access Octreotide for varices PPIs Arteriographic embolization for serious bleeding Vascular malformations
Necrotizing Enterocolitis (NEC)
Consider in any newborn w/ rectal bleeding, feeding intolerance, & abdominal distension
More common in prematures & Low birth weight
Immaturity of the stomach plus exposure to bacteria from enteral feeds leads to
bowel inflammation and damage
Caused by local ischemia, dilation, and infarction of loops of bowel
S/Sx
Abdominal distension, Hematochezia (or occult blood), pneumatosis
intestinalis (air in the bowel wall, double line/train track appearance)
Blood in NG tube
Complications
Intramural air spreading to portal vein (venous portal gas)
Later on intestinal perforation
o Pneumoperitoneum
Breast feeding reduces the risk of NEC
Tx
Mild
o Decompression, electrolyte repletion, IV ABx, serial abdominal exams checking for perforation
Severe (perforation)
o Severe if perforation (free air on lateral decubitus or under
diaphragm), fixed dilated bowel on serial X-rays, abdominal wall
cellulitis
o Surgical resection and reanastomosis (exploratory laparotomy)
Following surgery, parenteral feeds for 14d Allows for bowel rest
Juvenile Polyps
Lower GI bleeding: #1 cause beyond infancy (>5y?) Bleeding is painless, intermittent, & often streaky Tx Colonoscopy w/ polypectomy
Allergic Colitis
Sensitization to milk protein
Infectious Enterocolitis
Salmonella, Shigella, Yersinia, & E. Coli
Meckel’s Diverticulum
Outpouching terminal ileum
Infants 2% (typically
HUS
Intestinal ulceration & infarction of the bowel cause bleeding
Hepatocellular Enzymes
o AST Sensitive, but not specific o ALT Specific for liver disease o LDH Nonspecific for liver disease, but may serve as a marker for liver necrosis
Biliary Enzymes
o Alkaline Phosphate
↑ in Biliary Disease
Can also be ↑ in Rapid Growth, Renal/GI disease, & trauma
o Gamma Glutanyl Transpeptidase &5NT
↑ Biliary disease
5NT more specific than GGTP for biliary tract disease
Infant Jaundice
o ↑TB
Clinically evident TB > 3
o Kernicterus
Risk w/ indirect hyperbilirubinemias ≥20 Risk factors
Sulfisoxazole and other drugs that bind albumin and ↑ dissociation of bilirubin
Metabolic acidosis, ↑ bilirubin dissociation
Hypoalbuminemia
Sepsis
o Interrupts BBB
Phenobarbital induces glucuronyl transferase
Normal Physiologic Jaundice
First 2-4d of life (peak)
No higher than 12 mg/dL
Disappears by 1w
Rate of rise
Breastfeeding Jaundice
Inadequate calories & dehydration Breast feeding failure: inadequate feedings, poor latching ↑ enterohepatic circulation o Indirect Hyperbilirubinemia Signs of dehydration o Decreased wet diapers o May not regain birth weight o Brick red urate crystals in diapers Typically second to fourth day (first week) Tx Rehydrate w/ fluids or formula Lactation consult o Should be breastfeeding ever 2-3h for 10-20mins each breast Threshold for phototherapy o 4dold >20 Threshold for transfusion therapy o 4dold >25
Breastmilk Jaundice
Enzyme in milk is inhibitor of glucuronyl transferase
↑ indirect bilirubin
Gaining weight, no signs of FTT
Typically during second week (>7d) Tx
If Pathological (~17-20) DC breast feeding for 1 to 2d, formula then
o Resume breast feeding after precipitous drop in TB w/out fear of
rise to toxic levels
Reassurance if levels are not too high
Cholestatic Jaundice
Retention of bile in liver
Direct Bilirubin > 2
Cholestasis
> 50% caused by neonatal hepatitis or Biliary Atresia
If suspect cholestasis, HIDA Scan
Inspissated Bile Syndrome
Associated w/ Hemolysis or very large hematoma
Starts w/ ↑ Indirect, but switches to ↑ direct as the liver ramps up
UDP-Glucuronyl Transferase Deficiencies
Gilbert's Syndrome 50% Enzyme Mild Jaundice w/ stress or poor nutrition Crigler Najjar Indirect Hyperbilirubinemia TypeI o 100%Enzymeabsent o AR o Kernicterus caused by ↑ TB Type II o 90%EnzymeDeficient o AD o Bilirubin lvls are variable w/ ↓ chance of Kernicterus
Biliary Atresia
o Progressive fibrosclerotic changes of extrahepatic bile ducts
o Presents w/in first 2m of life
o S/Sx
Jaundice, dark urine, acholic (pale) stools Moderate ↑ TB
Direct Hyperbilirubinemia
Rapid progression w/ Bile duct obliteration & cirrhosis by 4m Hepatomegaly, Ascites, Coagulopathy, Edema
o Some have associated Polysplenia Syndrome
Bilobed lings, abdominal Heterotaxy, & situs invertus
o Dx
First perform US
Lack of Gallbladder and Triangle Sign
Will also catch other Gall Bladder DO
Hepatobiliary Scintigraphy
Failure of tracer excretion from liver
Intraoperative cholangiogram w/ Laparotomy to examine biliary tree (gold
standard)
o Tx
Kasai Portoenterostomy
Establishes bile flow by attaching intestinal loop to porta hepatis
Success is highest if
Heb B Tx
Tx
All newborns of mothers w/ active Hep B (HbsAG, HBeAG + esp.) receive HBIG (Hep B immune globulin) & Vaccine
Autoimmune Hepatitis
o Destructive&Progressive
o ↑ serum transaminases, hypergammaglobulinemia, auto-Ab o Types
Type I
Type II o Females before o S/Sx 50% w/ Antinuclear Ab (ANA) or Anti-Smooth muscle Ab More common than Type II Anti-Liver Kidney Microsomes? puberty Acute Hepatitis Mimics viral hepatitis 50% Chronic liver disease Mild to Moderate Jaundice o Tx Corticosteroids Immunosuppressive Agents Azathioprine 6-MP
Lead Poisoning Tx
Remove from environment.
Esophageal Atresia
o Vomiting, choking, coughs w/ first feeds
o Frothing at mouth
o May have respiratory distress, abdominal distension depending on fistula
presence/location
o Associated w/ VACTER Constellation
Vertebral anomalies, anal atresia, cardiovascular anomalies, transesophageal fistula, renal/radial anomalies
Usually accompanied by tracheoesophageal fistula leading to abundance of gas in GI tract
o Immediate coiling of nasogastric tube confirms
Mallory-Weiss Tear
o Lower esophageal tear from forceful retching w/ or w/out vomiting Hematemesis
Painless bleeding
Beckwith-Wiedmann Syndrome
o Overgrowth Syndrome w/ predisposition to neoplasms Neoplasms Wilm’s Tumor & Hepatoblastoma o Screening w/ Abdominal US and AFP Large-sized patients Hemihyperplasia Macrosomia Macroglossia Liver/Kidney enlargement Hyperinsulinism Hypoglycemia at birth Midline abdominal defects Omphalocele, umbilical hernia
