GI Flashcards
Clinical sx of fat soluble vitamin deficiency
A = night blindness, xerophthalmia, keratomalacia, follicular hyperkeratosis D = osteopenia, rickets, craniotabes, rachitic rosary E = sensory/motor neuropathy, ataxia, hemolytic anemia K = hemorrhagic disease
4 types of polyps
- Malignant
- Hamartomatous (benign)
- Hyperplastic
- Inflammatory
Juvenile polyposis syndrome: (a) criteria x2, (b) inheritance pattern, (c) importance of dx, and (d) name a classic syndrome
(a) 5 or more polyps in colon/rectum PLUS at least 2 affected family member
(b) autosomal dominant
(c) risk of malignant potential
(d) Peutz-Jeghers
How to differentiate a coin on XR between being in esophagus vs trachea?
- Esophagus: en face in AP
- Trachea: en face in lateral
What organs are involved with (a) fat, (b) protein, and (c) carbohydrate metabolism?
(a) Biliary, pancreas, ileum
(b) Pancreas, small intestine
(c) Duodenum
What is celiac disease?
Autoimmune enteropathy - systemic Ab against gluten
Extra-intestinal manifestations of celiac disease (x10)
- Dermatitis herpetiformis
- Dental hypoplasia
- Osteopenia
- Short stature
- Delayed puberty
- Iron deficiency anemia
- Arthritis/arthralgia
- Epilepsy with bilateral occipital calcifications
- Peripheral neuropathy
- Isolated hepatitis
If suspecting celiac disease in a child <2 years, what test do you do?
DGP = deamidated gliadin peptide
IBD picture that INVOLVES the terminal ileum
Crohn’s
IBD picture that INVOLVES granuloma formation
Crohn’s
IBD associated with PSC
UC
During what point in IBD treatment do you include steroids?
To induce remission
What management medication is used exclusively in (a) Crohn’s and (b) UC?
(a) Enteral nutrition
(b) 5-ASA
DDx for organic constipation causes
- GI: Hirschprung’s, Celiac d/z, CF
- Endo: Hypothyroidism, hyperCa, hypoK
- Neuro: CP, neural tube defects
- Meds/ingestions: lead
Two investigations to consider if GERD is not improving despite dietary modifications + medical therapy?
- Endoscopy
- 24h pH / impedance probe
Process of diagnosis required for EoE
- First EGD: >15 eos/HPF
- x8 weeks of PPI
- Repeat EGD: If continues to be high = dx!
Ddx for dysphagia
- Painful swallowing = candida, reflux esophagitis
- Difficulty swallowing = EoE, anatomical obstruction (sling, ring, stricture), achalasia, esophageal motility d/o
Although tx for EoE is unclear - what to consider for (a) young child and (b) older child
(a) amino acid diet
(b) steroids
What should you advise mothers to take in setting of milk elimination diet?
1000mg Ca
In maternal diary elimination diet - what is the expected washout period for immediate + late symptoms?
- Immediate = 5 days
- Late = 2 weeks
DDx for upper GI bleeding in children/adolescents
- Vascular: AVM, varices
- GI: MW tear, hemobilia, esophagitis/gastritis (NSAIDs, H. pylori, ulcers)
- Trauma: FB, ingestion
First line treatments for H.pylori
- PAC = PPI, amox, clarithro
- PAM = PPI, amox, metro
Infectious causes of bloody diarrhea
- Shigella
- Salmonella
- E.coli
- Yersinia
- Campylobacter
Criteria for Functional Constipation - Rome Criteria
> 1 month of at least 2 of the following:
- <2 BM’s per week
- Painful/straining with hard BM’s
- Large diameter BM’s (blocking toilet)
- At least 1 episode/week of fecal incontinence
- Evidence of excessive stool retention, retentive posturing or volitional with-holding
- Large fecal mass in rectum
Criteria for infantile colic
- Symptoms must start + stop while infant is <5 months old
- Recurrent/prolonged episodes of infant crying, fussing, or irritable without any obvious cause
- > 3 hours/day for at least 3 days per week for at least 1 week in duration
- No FTT, fever, or illness
Criteria for Cyclic Vomiting Syndrome
- At least 2 episodes of severe nausea + hyperemesis lasting hours to days
- Return to usual health in between episodes
- Episodes are stereotypical
- No attributable to another medical condition
Criteria for IBS
-Symptoms at least 4 times per month with at least one of the following: changes in stool form, changes in frequency, and related to defecation
Criteria for functional abdominal pain
- Symptoms at least 4 times per month
- Episodic or continuous abdo pain
- No other medical explanation available
Two main locations for peptic ulcers and characteristics of disease in those locations (primary vs secondary, acute vs chronic)
- Duodenum: by the bulb, primary, chronic
- Stomach: lesser curvature, secondary, acute
Example of a hyper-secretory state that causes PUD
Zollinger-Ellison Syndrome
Clinical presentation of PUD
- Bleeding: hematemesis, melena, iron deficiency anemia
- Pain: epigastric (dull, ache, improves with food), resolves with anti-acid, nocturnal
- GI: nausea, fullness
Complication of PUD - that would present with emesis
Gastric outlet obstruction secondary to inflammation + edema
H. pylori - when (in relation to PPI and Abx) and how to do test of cure?
- When: 4-6 weeks post-Abx, 2 weeks post-PPI
- UBT or stool antigen
Complication of H. pylori (apart from PUD)
Gastric cancer
Initial test for celiac disease
TTG-IgA with total IgA
Ddx for hepatomegaly (x5 main categories)
- Inflammation
- Storage: glycogen (GSD), protein (A1AT), lipid (NASH), iron (hemochromatosis)
- Infiltrative: tumors
- Biliary obstruction
- Post-hepatic obstruction: right heart failure, thrombus, sinusoidal
Pre-hepatic causes of hyperbilirubinemia
Hemolytic: intrinsic + extrinsic causes, sepsis
Non-hemolytic: physiologic, BM jaundice, hypothyroidism
Hepatic causes of hyperbilirubinemia
- Infections: TORCH, viral
- Inflammation: AI, NASH
- Infiltrative: malignancy, metabolic
- Medications
Post-hepatic causes of hyperbilirubinemia
- Biliary atresia
- Hypoplasia
- Choledochal cyst
- Gallstones
- PSC
- Malignancy
In hyperbili secondary to a hepatic cause, what lab value must you have?
-Elevated ALT
Causes of neonatal cholestasis
- Biliary atresia
- Choledochal cyst
- Infections - TORCH, viral, sepsis, E.coli
- A1AT
- Hypothyroidism
- Galactosemia
- Tyrosinemia
- Mitochondrial
If suspicious for neonatal cholestasis, what should you give right away while determining etiology?
Vitamin K - protect from ICH
What is Alagille Syndrome?
Intrahepatic bile duct paucity
DDx for acute liver failure
- Infection: viral hepatitis, viral illness (EBV, CMV, parvo, parecho, HSV, HHV-6, VZV)
- Autoimmune: AI, GALD
- Metabolic: Wilson disease, fatty liver, galactosemia, tyrosinemia, hereditary fructose intolerance, mitochondrial
- Malignancy: HLH, leukemia, lymphoma
- Vascular: shock, Budd-Chiari syndrome
- Meds: tylenol overdose
- Idiopathic
Most common neonatal cause of acute liver failure
GALD = gestational alloimmune liver disease
What kind of virus is hep B?
DNA
For prevention of hep B in an at risk infant
Vaccine + immunoglobulin within 12 hours
What is HBcAg and what does it represent?
= protein that the virus creates during infection
-Will only be positive if there is a TRUE infection (not vaccine)
What type of Hep B infection do you have if: HBsAg+, HBsAb+, HBeAg+, HBeAb-
Chronic infection
Complication/risk x2 for hep B
- Cirrhosis
- Hepatocellular carcinoma
Dx for infant without constipated stools but ++ straining/crying with passage of stool
Infant dyschezia = discoordination between relaxation of external anal sphincter + contraction of pelvic muscles
What kind of virus is hep C?
RNA virus
When do you discontinue hep C screening for at risk infant?
- At least 18 months old
- x2 negative Ab screens consecutively
x3 types of gallstones
- Cholesterol
- Brown pigment - think enteric bacteria
- Black pigment - think blood
Management of infant GERD
- Dietary elimination
- PPI
- Reconsider dx with endoscopy and/or 24h pH impedance probe
- Alternative strategies: surgical (fundo), transpyloric or jejunal feeding
What is a complication of GERD for older children that we should monitor (when?) and consider?
Barrett esophagus = precursor for gastric adenocarcinoma
-Start monitoring ~10 years of age
Associated conditions with Celiac Disease (includes x3 main categories)?
- Selective IgA deficiency
- Autoimmune: T1DM, thyroiditis
- Genetic: T21, Turner’s, William’s
If the patient is IgA deficient, what is the next best test for celiac screen?
TTG-IgG
Timing of follow-up BW for Celiac Disease
- TTG q6 months
- If controlled, can go to yearly
What type of IBD is more likely to have associated uveitis?
Crohn’s
What type of IBD is more likely to have associated ankylosing spondylitis?
UC
Extra-intestinal features of IBD
- MSK: arthralgia/arthritis, ankylosing spondylitis, osteopenia, clubbing
- Derm: aphthous stomatitis, erythema nodosum, pyoderma gangrenosum
- Optho: iritis, uveitis, episcleritis
- Heme: hypercoag, anemia
- Renal: nephrolithiasis
What x5 features of Crohn’s disease precludes a possible diagnosis for UC?
- Fistulizing disease
- Large, inflamed perianal skin tags
- Deep ulcerations, cobble-stoning, or stenosis in small bowel or upper GI tract
- Evidence of jejunal or ileal inflammation
- Granuloma
Initial investigations for a patient with likely IBD apart from screening BW
- Stool infectious studies
- Fecal calprotectin
- Small bowel imaging (US/MRE)
- EGD + colonoscopy
- Pre-treatment eval: infectious w/u with Mantoux, CXR
Side effects (x10) of CC’s
- Growth delay
- Hypertension
- Bone loss
- Hyperglycemia
- Hirsutism
- Acne
- Weight gain
- Cushinoid facies
- Mood disturbance
- Sleep disturbance/insomnia
- Cataracts
- Leukocytosis
- Infection
What to add when patient is on MTX?
Folate
x6 complications of IBD that are potentially life threatening/serious?
- Colon cancer
- GI hemorrhage
- Perforation
- Obstruction
- Toxic megacolon
- Fulminant colitis
What typically occurs earlier in life - CMPA vs FPIES?
CMPA
FPIES - what is the typical window of time of symptom onset from ingestion of food?
1-6 hours post-ingestion
Is FPIES IgE-mediated?
No
Recommended PEG dosing for disimpaction vs maintenance therapy?
- Disimpaction = 1.0-1.5 g/kg/day x3-6 days
- Maintenance = 0.4-1.0 mg/kg/day x at least 2 months
x1 serious complication of Hirschsprung Disease (+symptoms associated)?
=Hirschsprung-associated enterocolitis (HAEC)
-acute diarrhea, explosive stools, abdo distention
Initial steps in approach to rectal prolapse
- Assess for any associated diagnosis: constipation, diarrhea, parasitic infections, malnutrition
- If <4 years old –> conservative tx until 4 years old
- If >4 years old –> conservative tx x1 year
- Consider CF screen
Initial investigations to consider if patient meets criteria for CVS?
- lytes
- glucose
- Cr, urea
- UGI series to r/o malrotation
What kind of caustic injury occurs with (a) acidic vs (b) alkaline substances?
(a) coagulation necrosis - more superficial
(b) alkaline - liquefaction necrosis - rapid transmural inflammation
x3 polyposis syndromes
- Juvenile Polyposis Syndrome
- Peutz-Jeghers Syndrome
- Familial Adenomatous Polyposis
Juvenile Polyposis Syndrome - inheritance pattern, x1 thing at risk for, extra thing to look for on exam, diagnosis criteria?
- AD
- GI malignancy
- Telangiectasia
- 1 of 3: 5 or more JP’s in colon/rectum, JPs in other GI areas, or any number of JP’s plus +fmhx
Peutz-Jeghers Syndrome - inheritance pattern, x2 thing at risk for, thing to look for on exam, diagnosis criteria?
- AD
- malignancy, intussception
- mucosal pigmentation/freckling
- Diagnosis: 2 or more PJS polyps, any number of PJS polyps +fmhx, mucocutaneous pigmentation +fmhx, any numbers of polyps w/ mucosal pigmentation
Familial Adenomatous Polyposis - inheritance pattern, x2 malignancies at risk for, diagnosis criteria?
- AD
- Colon cancer, hepatoblastoma
- > 100 colorectal adenomatous polyps
King’s College Criteria for acetaminophen related acute liver failure
-Arterial pH <7.3
OR
-INR >6.5 and serum Cr >300 and grade 3-4 encephalopathy
Laboratory definition for conjugated hyperbilirubinemia
> 17 mmol/L
>20% of total
x8 causes of neonatal cholestasis to NOT miss!!
- Galactosemia
- Tyrosinemia
- Bile acid synthesis defects
- Obstructive
- Biliary atresia
- Bacterial sepsis
- Panhypopit
- Gallstones
Most common cause of neonatal cholestasis
BA
First tier investigations after confirming cholestasis in a neonate
- CBC
- Lytes, glucose
- INR, albumin
- LE’s
- Alpha-1 antitrypsin
- NMS
- Urine: UA, Cx, reducing substances
- BCx
- US
What is the most common genetic cause of liver disease in pediatrics?
Alpha-1 antitrypsin deficiency
Gilbert Syndrome - clinical presentation, bloodwork results, and tx
- Presentation: recurrent episodes of jaundice triggered by dehydration/fasting/exercise/illness, otherwise asymptomatic
- BW: unconjugated hyperbili, normal CBC/smear/retic/LE’s
- No tx needed
What is the most common non-traumatic surgical emergency in children?
Appy
Alvarado score for pediatrics
- Migratory R iliac fossa pain
- N/V
- Anorexia
- Tender to R iliac fossa (2)
- Rebound tenderness to R iliac fossa
- Fever
- Leukocytosis (2)
- Left shift
Possible = 5-6
Probable = 7-8
Very probable = >9
Ix to consider with an appy (imaging + BW)
- CBC, UA, B-hCG
- US
- CT
Tx strategies for an appy
- Simple: laparoscopic, non-operative (IV Abx x24-72h then PO x1 week)
- Perforated: non-operative, IV Abx, drainage
Common age range for intussception
3 months to 3 years
What are two predisposing factors for lymphoid hyperplasia causing intussusception?
- Recent resp illness = adeno
- Recent diarrhea illness = entero
Pathologic lead points in intussusception
- Meckel’s**
- Polyps, hamartoma
- Intestinal duplication
- HSP
- Appendix
- Hemangioma
- FB
- Ectopic mucosa
- Malignancy
Most common type (or location) for intussusception
Ileocolic
Gold standard Ix for intussusception as well as f/u confirmatory test
- US = target sign
- Air/contrast enema
Absolute contraindications (x3) for non-operative reduction of intussusception
- Peritonitis
- Persistent hypotension
- Free air
Recommendations on prophylactic medications to start for CVS patients (a) <5 years old and (b) >5 years old
(a) Cyproheptadine
(b) Amitryptilline
What vitamin toxicity can lead to intracranial hypertension and papilledema?
Vitamin A
Patient known to eat hair and presents with symptoms of a partial bowel obstruction?
Trichobezoar
What associated anomalies are part of Alagille Syndrome - vertebrae, CVS, renal, face
- Butterfly vertebrae
- PPS
- Renal dysplasia
- Triangular face
If gastric button battery + outpatient observation algorithm, when would you repeat the XR if no passage in stool?
- In 48 hours if BB >20mm
- In 10 days if BB <20mm
x2 possible options for treatment of EoE in a teenager
- Elimination diet
- Oral fluticasone
How long to treat constipation for?
x6 months
Primary cause of PUD
H pylori
Secondary causes of PUD
- Stress
- Meds
- Systemic macrocytosis
- Short bowel syndrome
- Hyper-secretory states
Predominant location + acute or chronic for H. pylori
Duodenal, chronic
Best blood test for PLE
Alpha 1 antitrypsin
C Diff treated with PO Flagyl. Now recurred with 5> stool and positive toxins (2 months later). What to do? A- Observe B- PO Flagyl C- PO Vanco D- IV flagyl, PO vanco
PO Flagyl - CPS Statement recommends using the same initial treatment again
- What are the indications for probiotics?
a. Treating C. Difficile diarrhea
b. Preventing antibiotic associated diarrhea
c. Reducing the intensity of viral diarrhea in immunocompromised children
d. Preventing atropic dermatitis
B
What is NOT part of Cystic Fibrosis:
(a) Gastric ulcer
(b) Abnormal gallbladder function
(c) Portal hypertension
(d) Ileocecal mass
(a)
Why do we wean PPI for GERD?
Can have rebound gastric hypersecretion
What x3 things do PPI put you at risk for?
PNA, NEC, UTI
What is the magic important number you need to keep in mind to determine if conjugated bilirubin is significant?
> 17 mmol/L (or 20% but not used as much)
Meat impaction - dx?
EoE
Only factor not made in liver?
8
Best synthetic lab function of liver
INR
When can you return to school with hep A?
7d since last diarrhea
How to remove trichobezoar?
laparotomy
What med can you try for post-viral gastro gastroparesis?
domperidone
