GI

Question 1

GERD

Answer 1

Gastric contents back into esophagus. regurgitation is common in 4 months, then tapers down by 15 months. increased muscle tone, chronic supine, altered GI motility worsens it; also associated with H. pylori. FTT, torticollis, hoarseness, anemia, tooth erosion, facial rash, diarrhea, vomiting, early morning vomiting, weight loss, dysphagia, respiratory issues . mostly diagnosed by history. can do PPI for 4 weeks as diagnostic test in older kids. CBC, UA/culture, stool test, test for H. pylori

Question 2

GERD warning signs/red flags

Answer 2

bilious vomiting, GI bleeding, hematemesis, hematochezia, consistently forceful vomiting or onset after 6 months; FTT, recurrent RTI, feeding problems, diarrhea/constipation, fever/lethargy, hepatosplenomegaly, bulging fontanelles/macrocephaly/microcephaly, seizures, abdominal tenderness/distension, documented/suspected metabolic or genetic syndrome.

Question 3

GERD dx

Answer 3

can do esophageal pH as gold standard. can underestimate true incidence. H2 stopped 72hr and PPI for 1 week prior to study. MII can be done that’s more info. endoscopy for biopsy, barium upper GI if obstruction or abnormal anatomy suspected. swallow study.

Question 4

GERD tx

Answer 4

H2RA, PPI, buffering agents, antacids. trial hydrolyzed protein formula 2-4 weeks; increase caloric density. avoid eating 2 hr before bed. supine recommended; left side may help or elevation of head of bed. can do surgery like fundoplication. if PPI: 2-4 weeks, if improves do 8-12 weeks and d/c if relapse consult GI. complication: chronic cough, FTT, irritability, malnutrition; associated with asthma, pneumonia, etc.

Question 5

eosinophilic esophagitis

Answer 5

isolated inflammation of esophagus by a specific WBC. recurrent vomiting/abdominal pain, dysphagia, choking, food impaction. must be diagnosed with upper endoscopy and biopsy. may have edema, furrows, mucosal fragility, whitish exudates, esophageal rings, diffuse narrowing. tx: dietary modification and pharm. elemental diet, empiric dietary elimination, or target food elimination. amino acid based formula most effective for infants. older kids eliminate six food (milk, soy, egg, wheat, peanut/tree, fish/shellfish). nearly complete remission. can do PPI and steroids for 12 weeks.

Question 6

peptic ulcer disease

Answer 6

primary are duodenal, can be chronic with granulation/fibrosis, can recur, more common in adolescents. secondary: gastric, more acute, known causal events. can be d/t head trauma, severe burns, steroids, NSAIDs. stress ulceration usually within 24 hours. family predisposition. protective factors: water insoluble mucous gel lining, local production of bicarbonate, gastric acid regulation, mucosal blood flow. aggressive factors: acid-pepsin environment, H. pylori, mucosal ischemia.

Question 7

PUD s/s

Answer 7

vague, dull abdominal pain. hematemesis/melena. feeding difficulty, vomiting, crying episodes. epigastric pain/nausea. adult: pain alleviated by ingestion of food. wax/wane. pain with eating, dyspepsia, can awaken from sleep. can cause GI bleeding. dull, aching, lasting minutes to hours. if pain awakens child, worsens with food, relieved by fasting, can be GI not psychogenic. dx: endoscopy. do CBC, ESR, can do coags if needed. Xray for perf, upper GI. EGD*. histologic exam and culture biopsies from it are gold standard for h. pylori detection. C-urea breath test is noninvasive for >2 years old. stool monoclonal antibody test to see past or present infection. IgG for exposure.

Question 8

PUD diff and tx

Answer 8

GERD, IBS, GI bleeding, cholelithiasis, pancreatitis, lactose intolerance, hyperkalemia. tx: H2RAs or PPIs. antacids. antibiotics for H. pylori. test of cure is stool antigen or urea breath.

Question 9

irritable bowel syndrome

Answer 9

functional GI disorder. all once a week for 2 months to diagnose: abdominal pain 4 days a month with one of following: relation to defecation/change in stool/passage of mucus, bloating/abdominal distention, dyspepsia. diff: SIBO.

Question 10

IBS treatment

Answer 10

fiber supplement, fermentable oligo-di-monosaccharides and low FODMAP diet and polio diet; avoid trigger foods (caffeine; sorbitol; fatty food; large meals; gas-producing foods; lactose intolerance; cruciferous vegetables); probiotics, drugs, biopsychosocial.

Question 11

celiac disease

Answer 11

gluten sensitivity enteropathy, immune mediated. often co-occurs with other autoimmune diseases. classic features: diarrhea, steatorrhea, weight loss, growth failure.

Question 12

lactose intolerance

Answer 12

abdominal pain, diarrhea, nausea, flatulence, bloating after ingesting lactose. intestinal bacteria metabolize excess lactose creating methane, co2, hydrogen that causes flatulence. primary is more common in non caucasian. secondary more common in infancy. allergy protein CMPI (nonallergic hypersensitivity) and allergy CMA (antigen mediated). CMA develops in neonatal, peaks infancy, remits childhood. FPIES non igE mediated food allergy; acute in 1-6 hours, chronic is d/t continuous use of food. often seen when introduced to formula or solids. most common are cows milk and soy proteins. rice and outs too. n/v, lethargy, FTT, pale, dehydration, hypotension, poor nutrition. definitive dx via challenge. replace fluids, remove causative food.

Question 13

dx for malabsorption disorders

Answer 13

occult blood, stool tests and cultures, spot stool a1-antitrypsin level; sweat chloride test, CBC with diff, iron, folic acid, ferritin. electrolytes, vitamins, LFP, HIV, small bowel biopsy, KUB, US, bone age
Celiac: serologic testing, gluten testing, tTGA and EMA. lactose intolerance: lactose hydrogen breath test gold standard. trial free diet 2 weeks. bone density. allergies: elimination diet, allergy test, IgE antibodies. for allergies: restrict milk from mother’s diet if breastfeeding, if formula do extensively hydrolyzed formula or AA formula (don’t use soy based if <6mo).

Question 14

Crohns

Answer 14

starts 10-20y. affects any part of GI system, often terminal ileum/colon. segmental, skip lesions; granulomas in mucosa >cobblestone appearance; serpiginous ulcers; strictures/stenoses, fistulas, perianal abscesses or skin tags. abdominal pain, diarrhea, anorexia, weight loss. can have eye issues.

Question 15

ulcerative colitis

Answer 15

10-20y; affects colon and rectum; ill backwash; may have proctitis; continuous distal to proximal; superficial inflammation of mucosa with friable tissue and granularity, loss of vascular pattern; small perianal skin tags. abdominal pain with or around stooling, bloody diarrhea, urgency, tenesmus. primary sclerosis cholangitis more likely.

Question 16

Crohn s/s and dx

Answer 16

low grade fever, weight loss, delayed growth, arthralgias, pain umbilical and RLQ. anorexia, malabsorption, diarrhea, jaundice , oral pathos ulcers, tobacco use, family hx. dx: ESR, CRP, CBC, cultures, protein, albumin, stool tests, X-ray for bone age, ileocolonscopy first step*.

Question 17

Crohn tx

Answer 17

steroid management. 5-aminosalicylates, immunomodulators for severe or steroid dependent. biologic agents (infliximab can induce remission). abx for acute infections. adjunctive therapy like GH. surgery may be needed for refractory. progressive and without cure.

Question 18

ulcerative colitis s/s and dx

Answer 18

fever, weight loss (less than Crohn), delayed growth, arthritis, anorexia, diarrhea, lower abdominal cramping, LLQ pain, pain with stooling and gas, stool with bright red blood and mucus, nocturnal stooling, oral aphthous ulcers, skin lesions. dx: CBC, stool for WBCs/blood/culture, fecal calproctectin assay.

Question 19

ulcerative colitis tx

Answer 19

colonoscopy, biopsy. mild to moderate: topical mesalamine, oral 5-aminosalicylates, topical steroids. moderate to severe: systemic steroids 1-2 weeks then taper; thiopurines (can cause non Hodgkin lymphomas, thrombocytopenia, n/d, arthralgia, fever); biologic agents for induction of remission, steroid topical, cyclosporine. probiotics, curcumin (turmeric), iron supplements. diet high in protein and carbs, normal fat, decreased roughage. low lactose. may need surgery.

Question 20

Failure to thrive

Answer 20

lack of weight gain proportional to age. d/t inadequate caloric intake, inadequate absorption, or excessive expenditure. onset 2weeks -4 mo more often d/t congenital disorders, serious illness, or deviant parental interactions. after that more likely feeding issues. dx: weight <80% median weight for length, or <80% ideal weight, or <10th percentile. BMI <5th. s/s poor weight gain, poor intake, vomiting, food refusal or fixation, abnormal practices, gagging, irritability, chronic problems, psychosocial. vomiting and abdominal distention significant for potential organic cause. can be do to crohn, pyloric stenosis, lactose issues, Hirschsprung, hepatitis, biliary disease, cardiac issues, DI, CKD, asthma, CF, altered hormones, CP, parasites, genetic, malignancy, lack of nutrition, sickle cell, SGA, anorexia nervosa, depression,

Question 21

FTT dx/tx

Answer 21

feed assessment, 24hr diet recall for infants, 3 days older children. can do BMP, vitamins, CBC/ ESR, UA/cultures, stool tests, TSH, proteins, US, bone age, GH as indicated. restore nutritional intake and rehab, supplement vitamins, calorically enriched formula. expected weight gain birth-3mo is 25-30g/day, 3-6mo is 15-20g/day, 6-12mo 10-15g/day, 12mo+ 5-10g/day. eval weight gain q1-3 weeks.

Question 22

constipation

Answer 22

encopresis is fecal soiling or incontinence. constipation is retained hard infrequent stool. dx includes 2+ occurring at least once a week for one month minimum: <2 stools a week if >4 years; 1 episode incontinence a week; retentive posturing or retention; painful/hard BM; large fecal mass in rectum; large diameter stools. can be d/t inadequate fluids, dehydration, change in diet. secondary: painful BM, anal fissures, neuro issues, meds, endocrine. irregular toileting patterns, abuse, absorbed in play, behavior issues, school toilet situations. s/s abdominal distention, tenderness on palpation, mass at midline in suprapubic area, nasal fissures, sacral dimple, diminished reflexes = neuro.

Question 23

constipation dx/tx

Answer 23

dx; KUB and lab studies not recommended unless alarming signs. diff: stenosis, spina bifida occult, spinal cord dysplasia, HD, DD, hypothyroid, hypercalcemia, CP, CF. tx: PEG solutions, biofeedback. behavioral therapy. timed urination. enemas only if PEG doesn’t work. maintenance meds continue 2 months and don’t stop until 1 month no issues. if can’t wean, go back to last successful dose and give another 2 weeks. best treatment is prevention.

Question 24

diarrhea common causes

Answer 24

carb malabsorption, protein sensitivity, excessive intake of fluid/formula, post enteritis, infections, CF, neuroblastoma, Hirschsprung, enteropathies, celiac, GVH, autoimmune, radiation tx, too much juice, munchausen, IBS, encopresis, laxative use.

Question 25

diarrhea tx

Answer 25

peppermint oil, zinc. use good hand washing and sanitation. exclusive breastfeeding first 6months, then supplement. rotavirus vaccine.

Question 26

chronic diarrhea

Answer 26

loose stool <10ml/kg/day and less than 200g/24hr in older kids. d/t mucosal factors or intraluminal factors. toddler’s diarrhea is benign. 3+ watery stools a day for >2 weeks. 10 watery/runny stools with undigested food is more typical of toddler’s diarrhea. red flags: hematochezia/melena, persistent fever, weight loss, anemia. dx: CBC, UA/culture, stool culture/pH, occult blood, leukocyte, fat and fecal elastase; ESR/CRP, HIV/CMV, sweat test, hormonal studies.

Question 27

chronic diarrhea tx

Answer 27

toddler’s: normalize diet, removing offending foods, eliminate sorbitol and fructose; reduce fluid intake to <90ml/kg/day; increase fat intake and fiber. treat carb malabsorption by decreasing lactose/sucrose. refer to GI: newborns in first hours of life, growth delay/failure, abnormal physical findings, severe illness.