Gastroenterology+Nutrition

Question 1

Give a ddx for GI emergencies in an infant <3 months

Answer 1

pyloric stenosis, volvulus, malrotation, incarcerated hernia, NEC, NAT, Hirschsprung, gastroenteritis

Question 2

Give a ddx for GI emergencies in an infant >3months

Answer 2

incarcerated hernia, NAT, Hirschsprung, gastroenteritis

Question 3

Give a ddx for GI emergencies in a toddler

Answer 3

appendicitis, HUS, peptic ulcer, constipation

Question 4

Give a ddx for GI emergencies in a school aged child

Answer 4

appendicitis, constipation, peptic ulcer, IBD, pancreatitis, biliary tract disease, HSP

Question 5

Give a ddx for GI emergencies in an adolescent

Answer 5

appendicitis, constipation, peptic ulcer, IBD, pancreatitis, biliary tract disease, HSP, pregnancy, ovarian or testicular torsion, PID

Question 6

What should you be thinking about in a kid with pallor, petechiae, abdominal pain and decreased UOP?

Answer 6

HUS!

-send a CBC w/diff, LDH, haptoglobin, and BMP!

Question 7

What are some potential etiologies for isolated vomiting that you need to rule out?

Answer 7

-increased ICP, obstruction, intussusception

Question 8

What is the presentation of appendicitis?

Answer 8

• older kids present more classically with RLQ pain, vomiting, diarrhea, anorexia
• younger kids are much more likely to have atypical presentations with only some symptoms and are thus more likely to perforate

Question 9

What should you obtain initially to rule out appendicitis?

Answer 9

• Labs: CBC, CRP
• Imaging: US, CT if unclear
• In younger kids a urine can be positive but you still need to consider appendicitis in your differential

Question 10

What is the presentation of volvulus?

What is the complication of volvulus?

Answer 10

• Bright green vomiting in an infant <3months

- Bowel ischemia

Question 11

What is the management of volvulus?

Answer 11

• Diagnosis requires upper GI study, however in an unstable kid:
  1) resuscitation as required
  2) antibiotics
  3) IVF
  4) NG tube
  5) Call surgery!

Question 12

• How alarming is bilious emesis in a neonate?

- What diagnosis should you consider and what is its prognosis?

Answer 12

• Bilious emesis in a neonate is a surgical emergency until proven otherwise!!!
• malrotation progressing to volvulus. The compromise of the vascular supply can lead to bowel necrosis within hours.

Question 13

What are the physical and imaging presentations of Hirschsprung’s disease? What ddx should you consider? What needs to happen?

Answer 13

• Newborn with history of not stooling and a distended abdomen
• X-ray shows proximal dilation of colon with distal narrowing
• Ddx includes cystic fibrosis
• Surgical consult vs GI

Question 14

What is intussusception?
How is it diagnosed?
How is it treated?

Answer 14

• most common obstruction of infants, proximal bowel telescoping over distal bowel
• Get an US and a hemeoccult stool
• Tx with air vs contrast enema
• Recurrence risk highest in the first 24-48 hours s/p treatment, so low threshold to admit for social reasons

Question 15

What are potential etiologies for intussusception?

-In what age group are these most often idiopathic?

Answer 15

Meckel’s diverticulum, HSP, polyps, tumor

-most often is idiopathic in <2yo

Question 16

What is the ARENA pneumonic for HSP symptoms?

Answer 16

Abdominal pain
Rash-palpable lower extremity purpura
Edema
Nephritis-check a urine
Arthralgias/Arthritis

Remember that up to 20% of HSP can be associated with AKI and potentially lead to ckd, so consult nephrology to see this patient

Question 17

What is the presentation of Meckel’s diverticulum?
What is the rule of 2’s?
How is it diagnosed?
How is it treated?

Answer 17

• painless bloody stools, occasionally with hematemesis
• 2% of population, 2yo, 2ft from ileocecal valve
• technetium 99 scan
• resuscitation/transfusion for rapid bleeding, but otherwise will require surgery

Question 18

What are the physical and imaging presentations for NEC?

How is it treated?

Answer 18

• Newborn unable to tolerate PO, distended abdomen, potentially bloody stool
• xray showing pneumatosis intestinalis (free air in bowel wall)
• NG decompression, IV fluids, IV antibiotics, surgical consult

Question 19

How does omphalitis present?
How should it be managed?
What complication can it lead to?

Answer 19

• erythema past the umbilical stump extending to surrounding abdomen ussually in a newborn born with abnormal cord cutting procedures or delay >3wks for cord to fall off, fussy, vomiting, unable to tolerate PO
• Surgical consult+full septic workup
• cellulitis at the cord has the potential to travel up remnants of the omphalomesenteric duct and get to hepatic vasculature–>sepsis

Question 20

How does pyloric stenosis present?
How is it diagnosed?
How should it be treated?

Answer 20

• infant with progressive nonbilious projectile vomiting, patient is dehydrated with a hypochloremic metabolic alkalosis
• Donut sign on US
• Give IVF and consult surg

-pro tip-if it only hits the bib, not projectile vomiting

Question 21

Give a ddx of extra-abdominal causes of abdominal pain

Answer 21

pneumonia, strep pharyngitis, flu, kidney stone, ovarion or testicular torsion, PID, metterschmerz/menstrual cramps, DKA, malignancy

Question 22

What children require supervision during mealtime to prevent choking?

Answer 22

-Any child <3yo or with oromotor developmental delay following 3yo

Question 23

• What are elemental formulas?
• When are they used?
• Give examples of elemental formuls

Answer 23

• elemental formulas are available in which the source of protein is a hydrolyzed casein or amino acids. The fat blend is a mixture of medium-chain and long-chain triglycerides, whereas the carbohydrate content is mostly corn syrup solids.
• These formulas are commonly used in situations where the gastrointestinal tract is compromised
• Examples: Neocate, Elecare, Pure Amino, Extensive HA

Question 24

• Which formula has the highest concentration of medium chain triglycerides?
• When is this useful?

Answer 24

• Portagen is a formula that contains the highest amount of medium-chain triglyceride oil (85%)
• most commonly used for patients with fat malabsorption and cholestatic liver disease

Question 25

-What is an appropriate strategy to tell parents to avoid constipation in a child who takes rice thickened formula 2/2 reflux?

Answer 25

-Switch to oatmeal thickened formula

Question 26

• Prior to ordering labwork or imaging on a patient presenting with abdominal pain that is afebrile, has poorly localized pain, and an unimpressive physical examination, what PE maneuver should you perform?
• Why?

Answer 26

• Rectal exam!
• A rectal examination is important in detecting an anal fissure or a dermatitis that may lead to painful defecation and retention of stool. The presence of hard or large stools in the rectal vault supports the diagnosis of constipation.

Question 27

Who is more likely to have an identifiable lead point for intussusception? Older vs younger children

Answer 27

older children

Question 28

• What are symptoms of shigellosis?
• What is typical on labwork?
• How should you manage a patient with stool culture proven shigellosis or a patient with suspected shigellosis 2/2 to community outbreak?

Answer 28

• Although many patients with Shigella have mild, clinically nonspecific gastroenteritis, the classic gastrointestinal manifestations of this illness is bacillary dysentery, associated with fever, crampy abdominal pain, bloody and/or mucoid stool, and tenesmus. Intestinal perforation is a rare complication.
• Patients with Shigella typically have a relatively low WBC (<10.000 cells/mm3) with a left shift. Bacteremia is seen much less commonly than in patients with Salmonella gastroenteritis.
• In patients with Shigella gastroenteritis, antibiotic therapy is felt to be beneficial because therapy shortens the duration of diarrhea and eradicates the organism from the stool. Antimicrobial therapy does not appear to increase the risk of S. dysenteriae-related hemolytic-uremic syndrome

Question 29

Give a differential diagnosis for painless rectal bleeding

Answer 29

• older children-meckel’s diverticulum

- infants-allergic collitis