Gastrointestinal

Question 1

vomiting etiology

Answer 1

Vomiting: forceful emptying of gastric contents d/t medullary vomiting center/chemoreceptor trigger zone. projectile/nonprojectile. Newborn: infection, GI/CNS anomalies, errors of metabolism. Young kids: gastroenteritis, GERD, milk=soy allergies, pyloric stenosis, obstruction, intussusception, abuse, cranial mass. Older kids: illness, CNS issue, gastroenteritis, rumination, pregnancy, mesenteric artery syndrome.

Question 2

GERD

Answer 2

passage stomach contents through LES. likely d/t inappropriate relaxation of sphincter, prolonged esophageal clearance, and impaired esophageal mucosal barrier function. s/s: heartburn, regurgitation, weight loss, respiratory problems, choking/gagg/ing/coughing/discomfort during feed.

Question 3

Eosinophilic esophagitis

Answer 3

isolated inflammation of esophagus by an eosinophil. s/s: feeding refusal, FTT, recurrent vomiting, abdominal pain, dysphagia, choking. Differential: GERD. Diagnostic: upper endoscopy & biopsy. Tx: amino acid formula for infants; older child 6 food elimination diet and referral to allergist. PPI and steroids for 12 weeks.

Question 4

Peptic ulcer disease

Answer 4

Primary often duodenal, can recur, more common in adolescents; gastric ulcer often secondary, acute, with triggers like head trauma, burns, steroids, NSAIDs use. stress ulceration occurs within 24 hours of stressful event. Key finding is family history of PUD.

Question 5

Infantile colic

Answer 5

frequent, prolonged, intense crying or fussiness >3 hours a day >3 days a week for 3 months.

Question 6

Pyloric stenosis

Answer 6

narrowing of pyloric channel due to hypertrophy; males more than females and often 1-2months old presentation. S/s: forceful/projectile non bilious emesis, persistent hunger, weight loss, dehydration, giant gastric peristaltic waves and pyloric olive mass. Diagnosed by US and tx is pyloromyotomy.

Question 7

Foreign body

Answer 7

3 common spots for esophageal FB to lodge: thoracic inlet, mid-esophagus near aortic arch, and LES. s/s: choking, gagging, drooling, coughing, dysphagia, food refusal, hematemesis, pain, respiratory s/s if pushing on larynx. Cervical swelling, erythema, subQ crepitation if perforation. Burns/erosions if battery swallowed. If gastric Fb, should pass on its own.

Question 8

Appendicitis

Answer 8

infection of appendix that can rupture by 72hours and cause peritonitis. 4 or more: RLQ pain, rebound pain, heel drop pain RLQ, WBC >10000, shift to neutrophils >75%, n/v, anorexia. Tx: appendectomy, antibiotics, opioids, fluids. f/u in 2-4 weeks post surgery.

Question 9

Gastroenteritis

Answer 9

infection of the stomach marked by n/v/d, cramps, fever. Caused commonly by rotavirus, norovirus, campylobacter, E. coli, salmonella. serious infection: food-borne suspected, bloody diarrhea, weight loss, dehydration, severe pain, fever, lasting several days, Neuro involvement. Diagnostics: PCR, stool cultures for bloody or prolonged diarrhea; electrolytes, CBC, stool exam/pH

Question 10

Inflammatory bowel

Answer 10

Rome criteria is all following 1+ a week for >2months: abdominal pain with 1+: related to defamation, change in stool, change in form of stool, not explained by other diagnoses. etiology genetic and inflammatory, allergic, motility? differential SIBO etc. Tx: increase diet, low FODMAP/polyol, avoid caffeine, sorbitol, fatty food, large meals, gas foods, lactose, and cruciferous veggies; probiotics. Drugs: antispasmodic, peppermint oil, anti-diarrheal, antibiotics, etc.

Question 11

Intussusception

Answer 11

telescoping of intestine into a distal segment. usually ileocolic. commonly between 5-10months. mostly <2 years of age. s/s: intermittent colicky abdominal pain, vomiting, bloody mucous stools. Currant jelly stool. may have history of URI, may have lethargy. sausage like mass in RUQ.

Question 12

Functional abdominal pain

Answer 12

recurrent abdominal pain with no organ etiology. 4x a month for >2mo: pain not related to physiological events, not enough criteria for IBS/abdominal migraine, or dyspepsia; no medical explanation by evaluation.

Question 13

Crohn’s Disease

Answer 13

IBD. onset 10-20 years; affects any part of GI tract but often terminal ileum or colon; segmental skip lesions; cobblestone bowel wall, fistulas/abscesses/strictures/ulcerations, granulomas all the way through. abdominal pain, diarrhea, anorexia, weight loss. can have eye conditions. etiology: likely d/t environmental exposure triggering abnormal immune reaction in susceptible person.

Question 14

Ulcerative Colitis

Answer 14

IBD. onset 10-20 years. Colon and rectum, continuous distal to proximal, superficial inflammation of mucus with exudates/granularity; loss of vascular pattern; perianal skin tags. abdominal pain around stooling, bloody diarrhea, urgency, tenesmus. Sclerosing cholangitis. fever, weight loss, delayed growth, arthritis, anorexia, lower abdominal cramping, LLQ pain,

Question 15

Acute diarrhea causes

Answer 15

Nonabsorbable solutes in GI tract; osmotic diarrhea. nutrient malabsorption, infection by bacteria or viruses. Mutations in ion transport proteins, alterations in intestinal surface or functional ability due to inflammation or surgical procedures. change in motility. <2year old, more than 10ml/kg diarrhea daily (5-6 stools), or >2 years >4 times in 24 hours up to 14 days.

Question 16

Celiac Disease

Answer 16

gluten sensitivity, frequently with other autoimmune issues. higher in C-section babies. appears 6mo-2 years often. s/s: diarrhea, steatorrhea, growth failure, weight loss. Tx: <10mg gluten = gluten free diet.

Question 17

Lactose intolerance

Answer 17

sensitivity to lactose, s/s: abdominal pain, diarrhea, nausea, flatulence, bloating after eating lactose. d/t lack of lactase enzyme. > osmotic diarrhea. Primary or secondary from small bowel injury, also congenital or developmental. Tx: avoid lactose, lactase supplements, adequate calcium/vD.

Question 18

Dehydration

Answer 18

loss of water/ECF. mild <3% weight loss kids and 5% infants, moderate 6% kids 10% infants, or severe >9% kids, >15% infants. typically due to infection. use CR, skin turgor, RR to assess.

Question 19

GERD diagnostics

Answer 19

esophageal pH gold standard for diagnosing. Differentials: gastroenteritis, overfeeding, obstruction, infection, pertussis, otitis media, appendicitis, migraine, medications, ingestion, neurological issues

Question 20

GERD treatment

Answer 20

PPI, H2 blockers, antacids. trial extensively hydrolyzed protein formula up to 1month in formula fed infants. increase caloric density. position infants supine, children elevated HOB, no eating 2hr prior to sleep. Surgical: fundoplication.

Question 21

PUD protective and aggravating factors

Answer 21

Protective: water-insoluble mucous gel lining, local production of bicarb, regulation of gastric acid, adequate blood flow. Aggressive factors: acid-pepsin environment, H. Pylori infection, mucosal ischemia.

Question 22

PUD s/s and diagnostics

Answer 22

dull abdominal pain, hematemesis or melena. Infants: feeding difficulty, vomiting, crying episodes. older: epigastric pain and nausea. Adult s/s of alleviated pain with eating food not present in most children. Diagnostics: endoscopy/biopsy test of choice. if mild, CBC and if sick serology, ICU I, coags, ABG, UA, serum gastrin (d/c PPI 2 weeks prior). Can do x-ray or upper GI series. EGD is choice.

Question 23

GERD differentials and management

Answer 23

GERD, IBS, GI bleed, cholelithiasis, cholecystitis, pancreatitis, lactose intolerance, hyperkalemia, hypercalcemia. Tx: H2RAs, PPIs, antacids. antibiotics for H. Pylori.

Question 24

FB diagnostics management

Answer 24

X-ray. Remove esophageal foreign body with endoscopy. if gastric, allow to pass by 2-3 days.

Question 25

Intussusception diagnostics/management

Answer 25

US to diagnose. also air contrast enema. differentials: incarcerated hernia, testicular torsion, gastroenteritis, appendicitis, colic, intestinal obstruction. Tx: ER surgery consult. fluid replacement, gastric decompression. reduction with air contrast enema. surgery if perforated etc. IV antibiotics. close follow up within 72 hours.

Question 26

Functional abdominal pain red flags

Answer 26

Local pain away from umbilicus, pain with change in bowel habits, with night awakening, repetetive/significant emesis and bilious, constitutional s/s, <4 years of age. fever, bloody stools, weight loss, organomegaly, perirectal abnormalities, joint issues, ventral hernias of abdominal wall.

Question 27

Functional abdominal pain diagnostics/tx

Answer 27

CBC, ESR, CRP, UA, h. pylori labs, endoscopy, US. can trial 3 days of lactose free. fecal calprotectin assay. differentials: UTI, GI tract issues, malabsorption issues, lactose intolerance, constipation, SIBO, depression, etc. Tx: psychosocial help, limit meds, blander diet, acupuncture, massage, etc. explore triggers. distract.

Question 28

Eval for lactose intolerance/celiac

Answer 28

WBCs, occult blood, culture, fecal fat collection, a1-antitrypsin level, sweat chloride test, stool O&P. vitamins, small bowel biopsy, can do abdominal x-ray or biopsy or US. celiac eat gluten each day for a week prior to test and draw EMA and labs. bone density. lactose hydrogen breath test gold standard for kids for lactose intolerance. differentials: FTT, colic, diarrhea, CF, GERD, SIBO, IBD.

Question 29

Crohn’s disease s/s

Answer 29

obstructive s/s with meals, bloating, early satiety, pain umbilical region and RLQ, anorexia, malabsorption, diarrhea, jaundice, oral aphthous ulcers, fever, weight loss, delayed growth, arthralgia. fistulas, skin tags, fissures. Diagnostics: ESR, CRP, albumin, protein, vitamins, CBC, liver enzymes. stool studies, bone density. Ileocolonoscopy or esophageal endoscopy.

Question 30

Crohn’s differentials and treatment

Answer 30

Diff: rheumatoid arthritis, SLE, hypopituitarism, appendicitis, PUD, obstruction, lymphoma, anorexia, sarcoidosis. Tx: referral to pedi GI MD. steroids. possible enteral nutrition if at risk or malnourished. 5-aminosalicylates, immunomodulators, biologic agents.

Question 31

ulcerative colitis diagnostics/tx

Answer 31

CBC, ESR, protein, CRP, stool, colonoscopy, perinuclear neutrophil cytoplasmic antigen. Differentials: infections, colitis, Crohn. Tx: mild to mod: topical mesalamine, oral 5-aminosalicylates, topical steroids. mod-severe: systemic steroids, thiopurines, biologic agents, cyclosporine, probiotics. iron, cumin. Diet high in protein and carbs but low in fat and roughage. may need surgery.

Question 32

Gastroenteritis differentials/management

Answer 32

Hirschsprung colitis, opiate withdrawal, toxic ingestions, hyperthyroid, adrenogenital syndrome. Tx: maintain hydration, parenteral if impaired circulation, <4-5kg, child <3 months, lethargy. Maintain nutrition, abx judiciously (for G. lamb, V. Cholerae, Shigella. Salmonella in infants, E. coli and Yersinia for sickle cell.) HIV children can benefit from cotrimoxazole and vitamin A. Loperamide >3 years if indicated. Careful with OTC d/t salicylate and Reye syndrome. Probiotics.