GI

Question 1

A concerned parent brings her child to you complaining that he has 2 loose stools /day. Would you Dx diarrhea?

Answer 1

maybe not… it should be >3 LOOSE WATERY stools/day per definition of diarrhea.

Question 2

a child comes in with diarrhea. what are some of your DDx?

Answer 2

1.infectious 2. diet related 3. IBS 4. inflammatory bowel dz 5. meds (abx), 6. celiac dz 7. intussusception 8. appendicitis

Question 3

what is infectious diarrhea due to?

Answer 3

viral, bacterial, systemic

Question 4

what is the common cause of viral diarrhea?

Answer 4

Rota virus

Question 5

what are two possible causes of diet related diarrhea?

Answer 5

1.toddler’s diarrhea 2. cows/soy milk intolerance

Question 6

what do you focus on first for Tx of diarrhea?

Answer 6

focus on hydration PO vs IV

Question 7

what is constipation?

Answer 7

regular passage of firm or hard stools, or the infrequent passage of stools

Question 8

what are 2 types of constipation?

Answer 8

functional vs. organic

Question 9

a child comes in with constipation but you find no anatomical biochemical abnormality. What kind of etiology do you suspect for this constipation?

Answer 9

functional constipation

Question 10

what is organic constipation due to?

Answer 10

anatomic or biochemical cause

Question 11

what is functional constipation?

Answer 11

voluntary holding of stool –there is no anatomical biochemical abnormality–

Question 12

why do some kids voluntarily hold their stool?

Answer 12

neg experience, painful…this may result in stool incontinence (encopresis)

Question 13

when does constipation most likely happen… in kids of course?

Answer 13

intro to solid food, toilet training, start of school

Question 14

What PE do you do for constipation?

Answer 14

abdominal and anus/rectal

Question 15

why do you do abd exam for constipation?

Answer 15

decreases bowel sound and distention may be concerning for obstruction

Question 16

why do you do anus/rectal exam for constipation?

Answer 16

looking for anal fissure, anatomic placement, r/o fecal impaction

Question 17

when you have a pt with constipation, what Dx study do you do to r/o impaction?

Answer 17

plain film of abdomen

Question 18

what do you recommend for management of constipation?

Answer 18

fluids, gradual increase in daily fiber intake, decrease dairy, relieve impaction, laxative, counseling and reward program

Question 19

what should you ALWAYS do for a pt with vomiting?

Answer 19

obtain a reliable history and description of vomits

Question 20

what do you do to check volume status in pt with vomiting when suspecting dehydration?

Answer 20

check mucous membranes, skin turgor, sunken fontanelle, urine output

Question 21

what are some infections that cause vomiting?

Answer 21

gastroenteritis, UTI, Pharyngitis

Question 22

what is GERD?

Answer 22

effortless regurgitation of stomach contents

Question 23

Is GERD always bad?

Answer 23

no…there are some happy spitters

Question 24

How do you know if your pt with vomiting is a happy spitter?

Answer 24

vomit in happy spitters is not forceful

Question 25

if you see hoarseness, dysphagia, respiratory complications with vomiting, is it a happy spitter case?

Answer 25

Nope!

Question 26

if symptoms of vomiting are severe what do you do?

Answer 26

UGI or endoscopy

Question 27

what is Tx for GERD?

Answer 27

H2 blocker or/and PPI therapy

Question 28

what is pyloric stenosis?

Answer 28

increase in size of pylorus muscle causing stenosis of the channel

Question 29

Pyloric stenosis is most common in: a. males b. females c. second born children d. first born children

Answer 29

D. poor first born children.

Question 30

what are clinical presentation of Pyloric Stenosis?

Answer 30

PROJECTILE vomiting after feeding, non-bilious, HUNGRY VOMITER

Question 31

what might you find in PE exam suspecting Pyloric Stenosis?

Answer 31

1. upper abd may be distended 2. prominent peristaltic waves moving from L to R 3. Olive sized mass in RUQ

Question 32

you finish your abd exam and you find an Olive sized mass in RUQ . what does this indicate...most likely?

Answer 32

pyloric stenosis from HYPERTROPHY

Question 33

Is a mass always palpable in pyloric stenosis with hypertrophy?

Answer 33

no...due to early presentation, abd fat, or of course skills of examiner a mass might not be palpable.

Question 34

What is the test of choice for pyloric stenosis?

Answer 34

Ultrasound

Question 35

What can you see in ultrasound of a pt with pyloric stenosis?

Answer 35

elongation and thickening of the pylorus

Question 36

What do you have to look for on UGI of a pt with possible pyloric stenosis?

Answer 36

the string sign on UGI

Question 37

What is the management of pyloric stenosis?

Answer 37

1. IV fluid and electrolyte resuscitation 2. pyloromyotomy 3. wait for the EXCELLENT prognosis

Question 38

What is a pyloromyotomy anyway?

Answer 38

incision down to the mucosa and fully across the length of the pylorus

Question 39

what is congenital atresia?

Answer 39

one or more segments of bowel may be missing and/or obstructed

Question 40

what are three types of congenital atresia?

Answer 40

Duodenal, jejunoileal,colonic

Question 41

what type of congenital atresia is a/w congenital abnl such as down syndrome?

Answer 41

duodenal

Question 42

what is the common etiology of congenital atresia?

Answer 42

it is common with prenatal hx of polyhydramnios

Question 43

what is the most important clinical presentation of congenital atresia?

Answer 43

bile-stained vomiting begings within first 24 hrs.

Question 44

A new born has failed to pass meconium. what is your first thought for DX?

Answer 44

congenital atresia

Question 45

What dx studies do you order when suspecting congenital atresia?

Answer 45

first abd plain film and upper GI series/contrast enema to confirm or identify the exact area.

Question 46

You see a DOUBLE BUBBLE sign on abd xray of a pt. what is your dx?

Answer 46

duodenal congenital atresia: due to gas and dilation in both stomach and duodenum

Question 47

You see adilated loops of bowel and air fluid levels on abd xray of a pt. what is your dx?

Answer 47

jejunoileal/colonic congenital atresia: dilated loops of bowel and air fluid levels

Question 48

what would ultimately resolve the congenital atresia?

Answer 48

you manage via iv fluid to correct electrolytes but surgery intervention is the ultimate.

Question 49

what is prognosis for surgery intervention for congenital atresia?

Answer 49

>90% survival

Question 50

what is a complication of midgut malrotation?

Answer 50

volvulus: narrow mesenteric base increase small bowel mobility

Question 51

what is volvulus?

Answer 51

small intestine twists around SMA causing vascular compromise

Question 52

midgut malrotation is not an emergency. is it?

Answer 52

Yes!!!! it is a surgical emergency because it can lead to necrosis, perforation, peritonitis, sepsis, and you being sued!

Question 53

a 14 day old pt comes in with BILIOUS vomiting, abd pain and HEMATOCHEZIA what are you thinking of?

Answer 53

midgut malrotation w/wo volvulus

Question 54

you do an abd exam on a week old infant and you see abd distention and VISIBLE PERSITALSIS. what are you thinking of for Dx?

Answer 54

midgut malrotation ...at least

Question 55

what dx studies do you do when suspecting midgut rotation and why?

Answer 55

UGI to see obstruction and displacement of duodenojejeunal jxn to the RIGHT of the spine

Question 56

why would you order barium enema for dx of midgut malrotation?

Answer 56

if DX in question or to confirm dx (cecum in RUQ)

Question 57

what is tx of midgut malrotation?

Answer 57

surgery with a good prognosis in 90% of pts

Question 58

what is intussusception?

Answer 58

invagination of one portion of intestine into another usually PROXIMAL to ILEOCECAL VALVE.

Question 59

what is the most frequent cause of intestinal obstruction in the first 2 years of life?

Answer 59

intussusception. Remember it is rare in newborns.

Question 60

a 1.5 yo pt comes in for abd cramp where he draws his legs to the chest. his mom also reports vomiting, not feeding, and currant jelly stools. what is your DX?

Answer 60

intussusception

Question 61

what are you looking to find in abd exam when suspecting intussusception?

Answer 61

tender/distended abd and a sausage shaped mass in upper mid abd secondary to swollen bowel

Question 62

what dx studies when suspecting intussusception?

Answer 62

1. abd ultrasound 2. Barium enema (dx and therapeutic ~90%) 3. air enema ( to avoid risk a/w perforation)

Question 63

how do you manage intussusception?

Answer 63

1. IV fluid 2. emergent surgical consult 3. reduction w/barium enema 4. SURGERY if BE unsuccessful

Question 64

Can you skip reduction in managing intussusception?

Answer 64

NOPE! if reduction not performed, can be fatal

Question 65

what is meckel's diverticulum?

Answer 65

embroyonic remnant of the omphalomesenteric duct or Vitelline duct

Question 66

what does an abnormal pouch/opening from small intestine called?

Answer 66

Meckel's diverticulum

Question 67

where do you expect to fine Meckel's diverticulum?

Answer 67

usually located mid to distal ileum

Question 68

what is the dz of 2's?

Answer 68

meckel's diverticulum

Question 69

what does the dz of 2's mean?

Answer 69

2% of population 2:1 M:F 2% become symptomatic <2yo more symptomatic

Question 70

what are some clinical presentation of meckel's diverticulum?

Answer 70

painLESS rectal bleeding obstruction (volvulus or intussusception) DiverticulITIS (may look like Appendicitis)

Question 71

What dx studies do you order when suspecting meckel's diverticulum?

Answer 71

Technetium-99 scan (meckel's scan)

Question 72

You are about to dx a pt with Meckel's diverticulum but you are also thinking of something else. what is that dx?

Answer 72

acute appendicitis

Question 73

You have dx a patient with Meckel's dovertoculum. what's next?

Answer 73

Surgical resection of the diverticula and the omphalomesenteric remnant.

Question 74

you just sent a pt for surgery b/c of meckel's diverticulum. the family asks you about the prognosis. what do you say?

Answer 74

prognosis is excellent!!

Question 75

what is hirschsprung dz?

Answer 75

congenital aganglionic megacolon

Question 76

hirschsprung dz occurs secondary to what?

Answer 76

absence of ganglion cells in mucosal and muscular layers of colon and begins in DISTAL bowel usually RECTOSIGMOID

Question 77

in hirschsprung dz pt does not have ganglion cells in parts of colon. So what?

Answer 77

peristalitic waves cannot extend beyond this zone of denervation and the bowel may become obstructed

Question 78

what kind of obstruction is a/w hirschsprung dz?

Answer 78

``` functional obstruction (REMEMBER hirschsprung dz is ORGANIC CONSTIPATION) ```

Question 79

SPASM and abnl motility in affected portion of the colon is a/w what?

Answer 79

hirschsprung dz

Question 80

what is most common cause of LOWER bowel obstruction in neonates?

Answer 80

hirschsprung dz

Question 81

hirschsprung dz has concurrence with which of the chromosomal abnormalities?

Answer 81

down syndrome

Question 82

a new born fails to pass meconium within the first 24 hr, followed by bilious vomiting, abd distention, reluctance to feed. there is no hematochezia and visible persitalsis. abd xray does not show double bubble. What is your dx?

Answer 82

hirschsprung dz

Question 83

Can you dx hirschsprung dz if pt has passed meconium?

Answer 83

YES!! new born may passes meconium with symptoms developing later. pt may present with progressive constipation and partial obstruction.

Question 84

what are PE findings when suspecting hirschsprung dz?

Answer 84

abd distention anal canal may feel narrow on rectal exam anal canal and rectum devoid of fecal material-->gush of stool when finger removed

Question 85

gush of stool when finger removed on rectal exam is a/w what?

Answer 85

hirschsprung dz

Question 86

what dx studies when suspecting hirschsprung dz?

Answer 86

rectal bx--confirms absence of ganglion cells

Question 87

how do you manage hirschsprung dz?

Answer 87

1. resection of aganglionic segment | 2. colostomy

Question 88

what do you need to consider when thinking of colostomy for hirschsprung dz?

Answer 88

1. allow pt to recover before reparative surgery | 2. colorectal anastomosis performed later

Question 89

what is inflammatory bowel dz?

Answer 89

immune mediated inflammation of GI including ulcerative colitis and crohn's

Question 90

cobblestone appearance is a/w what dz?

Answer 90

crohn's dz

Question 91

erythematous and friable mucosa with small erosions is a/w what dz?

Answer 91

ulcerative colitis

Question 92

how do you treat inflammatory bowel dz?

Answer 92

dz maintenance 1. 5-ASA (sulfasalazine, asacol) 2. immunimodulating agents (6-MP) 3. biologics (remicade) 3. steroids

Question 93

when do you use steroids for inflammatory bowel dz?

Answer 93

during flares

Question 94

what are the concerns for using steroids for inflammatory bowel dz?

Answer 94

bone density and growth and development

Question 95

What often results from functional constipation in children?

Answer 95

stool incontinence (encopresis) often results from functional constipation

Question 96

Corkscrew sign on Xray is a/w ?

Answer 96

Volvulus