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Pediatrics > Gastrointestinal system > Flashcards

Gastrointestinal system Flashcards

1
Q

What is H. pylori

A

gram - microaerophilic bacterium usually found in stomach

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2
Q

Differences in H. Pylori infection in children and adults

A
  • Gastric ulcer is absent
  • duodenal ulcer reduced
  • Treg response increased
  • Th1, 17 responses decreased
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3
Q

ESPGHAN recommendations in testing for H. pylori

A
  • diagnostic testing for h. pylori is usually not recommended in children with abdominal pain
  • when there are first-degree relatives with gastric cancer, test for h. pylori
  • in children with iron-deficiency anemia, we should also test
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4
Q

Extraintestinal manifestations with H. pylori infection

A
  • otitis media
  • upper resp tract infection
  • periodontal disease
  • food allergy
  • SIDS
  • idiopathic thrombocytopenic purpura
  • short stature
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5
Q

Two hypotheses for allergic and autoimmune diseases

A

old friends hypothesis –> nowadays less diversity of human microbiota
hygiene hypothesis –> lack of exposure to a childhood infection, less “good” microbiota

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6
Q

Hygiene hypothesis in allergy and autoimmune diseases

A

allergy: Th1 > Th2
Autoimmune: Th2> Th1

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7
Q

Old friends hypothesis in allergy

A

Th1 > Th2, incr Treg

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8
Q

Definition of Constipation

A

Difficulty with defecation for at least 2 weeks, which causes significant distress to the patient

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9
Q

Diagnostic criteria for funcitonal constipatipn for a child under 4 years

A

must include 2 or more of the following occuring at least once a weel for over a month

  • under two defecations a weeks
  • fecal incontinence over one week
  • history of retentive posturing or excessive volitional stool retention
  • history of painful or hard bowel movements
  • presence of a large fecal mass in the rectum
  • history of a large diameter stool
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10
Q

Diagnosis of functional constipation

A

based on history and physical examination

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11
Q

Constipation risk factors

A
  • Family history

- obesity

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12
Q

Fear to defecate (circle)

A
  • passage of painful stool
  • fear related to defecatin
  • retention of stool
  • increased water reabsorption
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13
Q

What muscles relax during defecation

A
  • m. puborectalis

- m. ext. anal sphincter

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14
Q

Organic constipation causes

A
  1. celiac disease
  2. Hypothyroidism, hypercalcemia, hypokalemia
  3. DM
  4. Dietary protein allergy
  5. Drugs
  6. Botulism
  7. Cystic fibrosis
  8. Hirschsprung disease
  9. Anal achalasia
  10. Colonic inertia
  11. Anatomic malformations
  12. Pelvic mass
  13. Spinal cord anomalies, trauma, tethered cord syndrome
  14. Abnormal abdominal musculature
  15. Pseudoobstruciton
  16. Multiple endocrine neoplasia type 2B
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15
Q

Alarm signs and symptoms in constipation

A
  • constipation starting early in life
  • family history of hirschsprung disease
  • fever
  • failure to thrive
  • bilious vomiting
  • blood in stools in absence of fissures
  • severe abdominal distention
  • abnormal thyorid gland
  • perianal fistula
  • tuft of hair on spine
  • sacral dimple
  • anal scars
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16
Q

Clinical symtpoms of constipation

A
  • difficulty to defecate
  • encopresis
  • abdominal pain
  • enuresis daytime and nighttime
  • UTI
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17
Q

Treatment of constipation

A
  1. Teaching (use toilet 15 min after meal, right position)
  2. Disimpaction
    - PEG or Enema
    - PEG 4000 dose 1-1.5 g/kg/day for 3-6 days
    - PEG 4000 + electrolyt4es
  3. Change diet, surgery if necessary, more medication
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18
Q

PEG

A
  • PEG 4000 or 3500 or 4000 + electrolytes
  • osmotic agent which attach water to stool
  • indicated for children and adults, breastfeeding mothers, pregnancy
  • no reabsorption and biotransformation in gut
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19
Q

Rectal laxatives/ enemas

A
  • NaCl
  • Bisacodyl
  • Mineral oil
  • Na phosphate
  • Na docusate
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20
Q

Oral laxatives

A
  • PEG
  • Lactulose
  • Bulking agents (bran, psyllium)
  • Fecal softeners (mineral oil)
  • Stimulant laxatives (bisacodyl)
  • Senna
  • Na picosulfate
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21
Q

PEG 4000 dosage

A

dispimpaction: 1-1.5 g/kg/day (3-6 days)
maintenance: 0.2-0.8 g/kg/day (over 2 mo)

  • takes 24-48 hours to work
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22
Q

Prebiotics and probiotics in constipation treatment

A

not recommended

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23
Q

Food that increases constipation

A
  • rice
  • chocolate
  • bananas
  • black tea
  • white flour products
  • excessive milk intake
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24
Q

Food that decreases constipation

A
  • plum
  • kiwi
  • apricot
  • coffee
  • decrease weight in obesity
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25
Q

What is celiac disease?

A
  • autoimmune-mediated systemic disorder
  • elicited by gluten and related prolamines (wheat, barley, rye)
  • in genetically susceptible individuals
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26
Q

Celiac disease is characerized by

A
  • presence of variable combination of gluten dependent clinical manifestations
  • CD antibodies (EMA, tTG, DGP)
  • HLA-DQ2 or DG8 halotypes
  • Enteropathy
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27
Q

HOw celiac disease is affecting the whole body

A
  • General: grwoth and pubertal delay, malignancies, anemia
  • Gut: diarrhea, vomiting, malnutrition, weight loss, hepatitis, cholangitis
  • Skin: dermatitis herpetiformis, aphthous stomatitis, hair loss
  • Bone osteoporosis, fractures, arthritis, dental anomalies
  • CNS: ataxia, seizures, depression
  • Heart: carditis
  • Reproductive: miscarriage, infertility
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28
Q

Risk groups of celiac disease

A
  • type I diabetes
  • thyroid disease
  • Sjörgens syndrome
  • Down syndrome
  • IgA deficiency
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29
Q

Gluten consists of:

A
  • Prolamins and Glutenins
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30
Q

Different types of prolamines

A 
Wheat: gliadin
Barley: hordein
Rye: secalin
Oats: acenin
Corn: zein
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31
Q

Spectrum of gluten-related disorders

A
  1. celiac disease
  2. wheat allergy
  3. non-celiac gluten sensitivity (NCSC)
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32
Q

What is non-celiac gluten sensitivity

A
  • adverse reactions to gluten or other wheat proteins
  • overlaps with IBS and food hypersensitivities
  • GI and extra-intestinal symtpoms
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33
Q

Three cohorts of cases in celiac disease

A
  1. Born before WWI: few chances to rech adult age
  2. Born after WWII: many classical cases, mostly pediatric age
  3. Born in the last three decades: full chance of surviving and reachign adult age, more and more atypical
34
Q

genetics of celiac disease

A
  • polygenic disease
  • most important factor HLA locus chromoseome 6p21.3
  • HLA is necesasry, but nut sufficient
35
Q

Classification of celiac disease

A
  1. symptomatic CD
    - Typical CD: GI symtpoms
    - atypical CD: non-GI symptoms
  2. Asymtpomatic CD
    - silent disease
    - latent disease
    - potential disease
36
Q

Clinical picture of CD

A
  • diarrhea
  • weight loss
  • muscle wasting
  • failure to thrive
  • vomiting
  • constipation
37
Q

Silent celiac disease

A

mostly in risk groups

  • fist degree relatievs
  • patients with other autoimmune disease
  • other associated conditions (down syndrome)
38
Q

Celiac disease complications

A

Early complications:

  • malabsorption
  • anemia
  • hypoproteinemia
  • coagulopathies
  • Rickets
  • failure to thrive

Late complications:

  • autoimmune diseases (thyroid, Sjörgens)
  • Osteoporosis
  • liver damage
  • gynecological disorders
  • neurological disorders (calcifications, cerebellar pathology)
  • malignant diseases (EALT, CIT carcinoma)
39
Q

Lactose intolerance in CD

A
  • sometimes the leading symtpom
40
Q

Diagnosis of CD (ESPPGHAN)

A
  1. tTG2 IgA > 10x UNL and normal total IgA
    and
  2. EMA IgA positive
  3. aTG2 IgA < 10x UNL and normal total IgA
    and
  4. Duodenum biopsy (marsh 2,3)
41
Q

Golden standard of diagnosis of CD

A

Intestinal biopsy –> tissue diagnosis

42
Q

Diagnostic criteria of CD

A

1 biopsy and serological markers AGA, EMA, t-TG

43
Q

Histological changes in CD

A

mucosal atrophy, villous atrophy, crypt hyperplasia, IEL count

44
Q

Marsh classification in CD

A 
type 0: preinfiltrative phase
type 1: infiltrative phase
type 2: infiltrative-hyperplastic phase
type 3: (a,b,c): destructive phase
type 4: atrophic-hypoplastic phase
45
Q

Celiac disease diagnosis - genetics

A

HLA DQB1 typing

  • DQ SSP Low Resolution kit
  • PCR
  • HLA DQB1 alleles
46
Q

Treatment of CD

A
  • life-long glluten-free diet

- 20 ppm (mg(kg) of gluten

47
Q

Cured by gluten free diet (GFD)

A
  • celiac enteropathy
  • dermatitis herpetiformis
  • celiac hepatitis
48
Q

Not cured by GFD

A
  • IDDM
  • Autoimmune thyroiditis
  • Sjörgen
  • Biliary Cirrhosis
  • Autoimmune hepatitis
49
Q

GFD may help

A
  • Gluten ataxia
  • epilepsy with endocranial calcificaitons
  • Chronic Autoimmune Urticaria
  • Hypoparathyroidism
  • Macroamylasemia
  • Myocarditis/ ICD
50
Q
  1. crohns disease
  2. Ulcerative colitis
  3. Indeterminate colitis
A

all part of inflammatory bowel disease

  1. Crohn’s: can affect any part of the intestine, associated with discontinuous transmural lesions of the gut wall
  2. Ulcerative colitis: lesions are continuous and superficial and inflammation si confined to colon and rectum
  3. Indeterminate colitis: colitis with overlapping fetures of ulcerative colitis and Crohn’s
51
Q

Histology of Crohn’s disease

A
  • Deep fissure ulcers
  • patchy involvement of mucosa with normal mucosa in between
  • chronic inflammatory infiltrate throughout wall of bowel
52
Q

Histology of ulcerative colitis

A
  • Mucosa diffusely inflamed, no islands of normal mucosa
  • undermining horizintal ulcer
  • generally ulcers no deeper than submucosa
53
Q

Pathogenesis of IBD

A
  • not clear yet
  • heterogenous diseases characterized by exaggerated T cell response to the commensal enteric flora developed in genetically susceptible hosts
  • -> luminal microbes
  • -> genetic susceptibility
  • -> immune response
  • -> environmental triggers
54
Q

Inflammatory markers in Crohns disease and ulcerative colitis

A

Chrons:
IL1, IL 12, TNFa, IFNg, Th17/23

Ulcerative colitis
IL5, IL10

55
Q

TNF importance in Crohn’s disease

A
  • T cells are activated and release TNFa
  • IL6 and IL1 are released
  • Inflammatory cell adhesion
  • Leukotrienes, superoxides, NO and prostaglandins…
  • inflammation and tissue damage of intestinal submucosa
56
Q

Genetics of IBD

A
  • chromosome 16
  • NOD2 or CARD15
  • cytoplasmic molecule involved in the sensing of microbial cell-wall components
  • 3 single nucleotide polymorphisms independent risk factor for CD in caucasians
57
Q

Early-onset disease (NOD2 mutation) in IBD

A
  • more agressive
  • greater family history
  • greater need for surgery
  • smaller bowel disease
58
Q

NOD2/ CARD15 variants in IBD

A
  • younger age of onset
  • presence of ileal involvement
  • tendency to develop strictures and fistulizing disease
59
Q

Pediatric IBD Genotype / Phenotype

A
  • Pediatric onset: M>F
  • Childhood early onset < 10 years: colonic -predominant
  • Children age < 5 yers: colonic- only disease, higher proportion of UC and indeterminate colitis
60
Q

Ulcerative colitis clinical features

A

50-60% mild disease:

  • rectal bleeding
  • diarrhea (insidious onset and with hematochezia)
  • abdominal pain
  • usually confined to distal colon and responds well to therapy

30% moderate disease:

  • bloody diarrhea
  • cramps
  • urgency to defecate
  • abdominal tenderness
  • anorexia, weight loss, low-grade fever and mild anemia

10% severe:
- over 6 bloody stools a day, abdominal tenderness, fever, anemia, leukocytosis, hypoalbuminemia

5% extraintestinal manifestations are dominating:

  • growth failure
  • arthropathy
  • skin manifestations
  • liver disease
61
Q

Crohn’s disease clinical features

A

Symptoms with small bowel involvement:

  • malabsorption includign diarrhea
  • abdominal pain
  • growth deceleration, weight loss
  • anorexia

Symtpoms involving colon:

  • bloody mucopurulent diarrhea
  • crampy abdominal pain
  • urgency to defecate
  • perianal disease: painful defecation, brigth red rectal bleeding, perirectal pain
62
Q

Types of Crohn’s disease

A
  1. Inflammatory
  2. Structuring
  3. Penetrating (fistulae)
63
Q

Causes for growth failure in Crohn’s disease

A
  • malabsorption (Fe, Zn, folate, Vit. B12…)
  • inadequate nutrient intake
  • increased losses
  • increased metabolic demands
64
Q

IBD skin and oral manifestations

A
  • erythema nodosum
  • pyoderma gangrenosum in CD
  • Aphthous lesions in mouth
65
Q

IBD ophthalmologic manifestations

A
  • Episcleritis
  • Anterior uveitis
  • increased intraocular pressure and cataracts in children receiving corticosteroid therapy
66
Q

IBD joint manifestation

A
  • arthritis (in children may occur years before GI symtpoms develop)
  • ankylosing spondylitis
67
Q

IBD Hepatobiliary disease manifestation

A
  • intrahepatic manifestations: chronic active hepatitis, granulomatous hepatitis, amyloidosis, fatty liver, peri cholangitis
  • extrahepatic manifestations: primary sclerosing cholangiitis

children may present with liver disease first
increased serumaminotransferases are common

68
Q

IBD urologic manifestations

A
  • nephrolithiasis
  • hydronephrosis
  • enterovesical fistulae
69
Q

IBD Thromboembolic manifestations

A
  • DVT
  • Pulmonary embolism
  • Neurovascular disease
  • Vasculitus affecting both the systemic and cerebral circulation
70
Q

Other IBD extraintestinal manifestations

A
  • pancreatitis
  • fibrosing alveolitis
  • interstitial penumonitis
  • pericarditis
  • peripheral neuropathy
71
Q

Crohn’s disease classification

A

A1a: 0-10 years
A1b: 10-17 years

L1: distal 1/3 ileum
L2: colonic
L3: Ileocolonic
L4a: upper disease proximal to ligament of treitz
L4b: upper disease to ligament of treitz and proximal to distal 1/3 of ileum

B1: nonstricturing and nonpenetrating
B2: stricturing
B3: penetrating
B2B3: stricturing and penetrating

G0: no evidence of groth delay
G1: grwoth delay

72
Q

Ulcerative Colitis Classification

A

E1: Ulcertive proctitis
E2: Left sided UC (distal splenic flexure)
E3: Extensive (hepatic splenic flexure)
E4: Pancolitis (proximal to hepatic flexure)
S0: never severe
S1: ever severe

73
Q

Pediatric Crohn’s Disease Activity index (PUCAI)

A

mild: 10-27.5
moderate: 30-37.5
Severe: 40-100

74
Q

Pediatric Ulcertive Colitis Activity Index

A

under 10: no activity

mild: 10.34
moderte: 35-64
severe: over or equal to 65

75
Q

Ulcerative colitis complications

A
  • toxic megacolon
  • perforation
  • inflammatory poyps (pseudopolyps)
  • Colonic carcinoma
  • hemorrhage
76
Q

Diagnosis of IBD

A
  • history
  • fullness or mass in right lower quadrant –> CD
  • ractal examination (fissures, fistulas)
  • growth
  • feces examination to rule out other causes
  • colonoscopy with colonic and terminal ileal biopsies

Laboratory:

  • CBC: hypochromic, microcytic anemia, thrombocytosis, elevated ESR, elevated CRP
  • serum proteins
  • fecal calprotectin –> nonspecific marker for colonic inflammation

Radiological:

  • MRI
  • US
  • CT
77
Q

Endoscopic findings in ulcerative colitis

A

mild: Erythema, decreased vascular pattern, mild friability
Moderate: marked erythema, absent vascular pattern, friability, erosions
Severe; spontaneous bleeding, ulcerations

78
Q

Treatment of UC

A
  • 5- ASA orally
  • 5- ASA enemas

if no improvement after 7-10 days:

  • i.v steroids
  • then tiopurine for maintenance

if no improvement:

  • anti-TNF and cyclosporines
  • then anti TNF and thiopuring for maintenance

infliximab??

79
Q

Treatment of CD

A
  • exclusive enteral nutrition or steroids (budenoside) (prefer exclusive enteral nutrition!!!)
  • Corticosteroids only for induction or remission, not for maintenance
  • Asatriopin or methotrexate for the maintenance of remission
  • TNFa antagonists (infliximab)
  • psychosocial support
80
Q

Crohn’s disease maintenance

A
  • partial enteric nutrition may be an option together with other medications to maintain remission

Pediatrics (11 decks)

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