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GI Flashcards

1
Q

6 year old with periumbilical pain yesterday, now presents with RUQ tenderness and guarding, but no rebound tenderness…best diagnostic test to determine if surgery is necessary?

A

CT with contrast, because best way to rule out appendicitis is via CT with contrast

-Don’t be tricked into steering way from thinking appy just because there is no rebound tenderness and going after ruling out something like Yersinia, mesenteric adenitis, or Crohn’s

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2
Q

Name 10 causes of acute abdominal pain.

A
  1. Appendicitis
  2. Pain from pneumonia
  3. Post-Op Intestinal Obstruction
  4. Constipation (Cyst-ovarian)
  5. Mesenteric adenitis
  6. Mono
  7. Pancreatitis
  8. Hepatitis
  9. Infection (UTI)
  10. Trauma
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3
Q

What needs to be considered in any child presenting with an acute abdomen?

A

Appendicitis

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4
Q

What is the usual age in which appendicitis presents?

A

More common in kids over 2, but can present in infants too

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5
Q

What is the diagnostic spot for pain in appendicitis?

A

McBurney’s point

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6
Q

Where is McBurney’s point?

A

1/3 the way between the ASIS and umbilicus

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7
Q

Name some symptoms associated with appendicitis.

A

Pain in the RLQ, nausea, vomiting, anorexia, low-grade fever

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8
Q

What is the psoas sign associated with?

A

Appendicitis

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9
Q

What is the psoas sign?

A

Pain when straightening out the leg

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10
Q

Name 2 XR findings in appendicitis.

A
  1. Sentinel loop

2. Absence of air in the RLQ

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11
Q

What is a hardened mass (usually of stool) seen on XR in appendicitis?

A

Fecalith

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12
Q

What is the most common finding on XR for appendicitis?

A

NEGATIVE…don’t be fooled into thinking it isn’t an appy just because the XR is negative

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13
Q

True or False: A child who wishes to eat is unlikely to have an appendicitis?

A

True

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14
Q

Is severe vomiting associated with appendicitis?

A

Not always

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15
Q

Does a normal WBC count rule out appendicitis?

A

No

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16
Q

Acute abdominal pain with a history of cough and other respiratory signs…what test do you use to diagnose the problem?

A

Pneumonia…CXR

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17
Q

Post-op patient with acute abdominal pain?

A

Obstruction

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18
Q

What is seen on XR with post op intestinal obstruction?

A

Obstructive gas pattern

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19
Q

What is the first thing you do with post-op intestinal obstruction?

A

Bowel decompression

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20
Q

Causes of acute abdominal pain?

A 
"CAMP HIT"
Constipation (Cyst-Ovarian)
Adenitis (Mesenteric)
Mono
Pancreatitis
Hepatitis
Infection (UTI)
Trauma
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21
Q

What includes all children who have abdominal pain for which a specific cause cannot be identified?

A

Recurrent or chronic abdominal pain

Some kids will have an etiology (like celiac) while some kids will continue with pain for which no cause can be found.

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22
Q
  1. Recurrent pain in the upper abdomen or periumbilical pain.
  2. Pain isn’t relieved with defecation or changes in stool pattern.
  3. No organic cause of explanation for symptoms
A

Functional dyspepsia

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23
Q

How long do the symptoms of functional dyspepsia have to be present before a diagnosis can be made?

A

At least once per week for at least 2 months

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24
Q

What do you think if they describe a kid with recurrent pain in the upper abdomen or periumbilical pain, pain isn’t relieved with defecation or changes in stool pattern, and no organic cause of explanation for symptoms who has a recent history of acute viral gastroenteritis?

A

Gastroparesis (this will be described after the viral illness has resolved)

Not functional dyspepsia

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25
Q

True or False: If the test for H. Pylori is poitive in the context of recurrent abdominal pain, does that mean there is a causal relationship?

A

False (so routine testing for H. Pylori in a question involving a patients with functional dyspepsia will likely be wrong)

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26
Q

What is H. Pylori associated with?

A
  1. Low socioeconomic status (especially those living in crowed housing)
  2. Immigrants from developing countries
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27
Q

If routine testing for H. Pylori indicated in someone with functional dyspepsia?

A

No… can consider if patient is an immigrant from a developing country or is of low socioeconomic status

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28
Q

Name some red flags and systemic findings that point away from functional dyspepsia.

A

Pain radiating to back, bilious vomiting, bloody emesis, difficulty swallowing, melena, weight loss, fever, night sweats, anemia

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29
Q

What is treatment for functional dyspepsia (non-pharmacological)?

A
  1. Eliminating items that can exacerbate symptoms: NSAIDs, spicy foods, soda (caffeine)
  2. Small more frequent meals
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30
Q

What are some pharmacological treatment options for functional dyspepsia?

A

H2 antagonists or gastric PPIs

*Can also consider a low dose antidepressant (works in adults, not proven in kids)

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31
Q

How long/frequent must there be symptoms for irritable bowel syndrome?

A

Once a week for at least 2 months

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32
Q

Name symptoms and findings consistent with irritable bowel syndrome.

A
  1. Abdominal discomfort improved with defecation
  2. Change in stool frequency
  3. Change in stool consistency
  4. No organic explanation for symptoms
  5. Straining or bowel urgency
  6. Feeling of incomplete evacuation
  7. Passage of mucus
  8. Bloating
  9. Abdominal distention
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33
Q

What are some red flags in the clinical description that point away from IBS?

A
  1. Pain limited to night time
  2. Unexplained weight loss
  3. Oral ulcers
  4. Rash
  5. Pallor
  6. Bloody stools
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34
Q

What is the more likely diagnosis if they are describing GI issues in a kid with additional systemic signs like anemia, fever, arthritis, delayed puberty, short stature, or family history?

A

IBD

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35
Q

What are 2 non-pharmacological ways to manage IBD?

A
  1. Dietary changes

2. Addressing psychological issues

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36
Q

What are some dietary changes that can help with IBD?

A

Reducing sorbitol (stuff in sugar free candy), fructose, and gas-forming foods (like brussel sprouts, broccoli, beans, kim chee)

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37
Q

What is a controversial pharmacologic to help with IBD?

A

Tricyclic antidepressants

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38
Q

How long must symptoms be present to diagnose childhood functional abdominal pain?

A

At least once a week for past 2 months

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39
Q

What is described by episodic or continuous abdominal pain that doesn’t meet the diagnostic criteria for other GI disorders? In addition, there must be evidence of loss of daily activity and additional symptoms like headache, limb pain, or sleep disruption?

A

Childhood functional abdominal pain

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40
Q

What is the typical clinical presentation of an abdominal migraine?

A

Acute, incapacitating, periumbilical abdominal pain that lasts for more than 1 hour

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41
Q

What are some additional findings seen in abdominal migraine?

A

Pallor, anorexia, nausea, vomiting, headache, or photophobia

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42
Q

What is required to diagnose abdominal migraines (deals with when symptoms occur)?

A

There must be symptom free period lasting weeks to months between episodes.

In addition, family history of migraine headaches could be included

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43
Q

What are two non-pharmacological ways to treat abdominal migraine?

A
  1. Remove triggers like caffeine or nitrate-containing foods (smoked meats)
  2. Reduce psychological stress
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44
Q

True or False: Pharmacological treatment for abdominal migraines and regular migraines is the same?

A

True

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45
Q

What should you consider in a patient who presents with recurrent abdominal pain and urinary retention, tachycardia, blurred vision, and dry mouth?

A

Anti-cholinergic medication… this kid may have been inappropriately prescribed anticholinergics to treat recurrent abdominal pain…anticholinergics should NOT be given to kids with acute or chronic diarrhea

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46
Q

When would you order labs or imaging for a kid with suspected functional abdominal pain?

A

You wouldn’t…watch for signs or indications of psychological stressors

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47
Q

When do you use antidirrheal medications in children?

A

NEVER

If you are presented with a kid in GI distress who got anti-diarrheals, these medication are cause of symptoms

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48
Q

Where is watery diarrhea derived from?

A

Small intestine

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49
Q

How is watery diarrhea described (2)?

A
  1. High volume

2. Not bloody

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50
Q

True or False: No specific tests are needed when presented with a patient with water diarrhea?

A

TRUE

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51
Q

What are the 2 exceptions to testing for watery diarrhea?

A

Concern for C. Diff or diarrhea due to cholera

*Picture watery diarrhea with a “C” (sea) to remind you of C. Diff and Cholera needing specific studies

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52
Q

How is inflammatory diarrhea described?

A

Small and frequently contains blood, mucous, and WBCs. More toxic picture will be described.

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53
Q

True or False: Children who have diarrhea should continue to be fed age-appropriate diets?

A

True

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54
Q

What is the optimal mixture of oral rehydration solution in a child who is moderately to severely dehydrated?

A

2% glucose and 90mEq NaCl

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55
Q

True or False: Pedialyte is considered a rehydration solution

A

FALSE

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56
Q

True or False: The AAP recommends fatty foods and foods high in simple sugars (sweetened tea, juice, soft drinks) to help the diarrhea resolve faster

A

FALSE

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57
Q

What is the AAP view on the BRAT diet?

A

Contains well-tolerated foods, but too limited and doesn’t supply optimal nutrition. “Bowel rest” is considered to be unnecessary starvation.

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58
Q

Why is anything that reduces intestinal motility dangerous?

A

Results in pooling of fluids with dehydration going unnoticed

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59
Q

True or False: Oral rehydration fluids reduce ongoing stool losses?

A

False

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60
Q

Is tea part of the BRAT diet?

A

NO

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61
Q

What is more indicative of diarrhea secondary to bacteria than occult blood?

A

Neutrophils in the stool

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62
Q

What can be used to find WBCs in stool?

A

Methylene blue

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63
Q

How does viral diarrhea present (like rotavirus)?

A

Low grade fever, vomiting, and large loose watery stools

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64
Q

What is the leading and 2nd lead cause of diarrhea in infants worldwide?

A

Rotavirus, then adenovirus

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65
Q

How does bacterial diarrhea often present?

A

High fever, small frequent stools, mucous or blood

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66
Q

How does enteropathogenic E. Coli (EPEC) diarrhea present?

A

Acute and chronic diarrhea in neonates and children under 2. Stool non-bloody, but fever and vomiting commonly seen.

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67
Q

Where is EPEC more common?

A

Areas with poor sanitation

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68
Q

How does enterotoxigenic E. Coli (ETEC) diarrhea present?

A

Severe diarrhea and cramping that is self-limited

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69
Q

What is another name for ETEC?

A

Traveler’s diarrhea (Mexico)

“Entero-TACO-genetic” (enterotoxigenic) E. Coli causes traveler’s diarrhea

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70
Q

Is prophylaxis against ETEC (traveler’s diarrhea) indicated in otherwise healthy children?

A

Not typically

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71
Q

What can you use for prophylaxis against ETEC?

A

Bismuth subsalicylate or antibiotic (Bactrim)

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72
Q

When would you consider antimicrobial therapy for ETEC?

A

If diarrhea doesn’t improve after several days of supportive care and assays for Shiga toxin are negative

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73
Q

What are some treatment options for ETEC?

A

Bactrim, azithromycin, ciprofloxacin (depending on age of patient)

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74
Q

What are some other names for Shiga toxin producing E. Coli (STEC)?

A

O157:H7 serotype, enterohemorrhagic E. Coli (EHEC), verotoxin-producing E. Coli

*Important to remember that this is a Shiga-toxin producing bacterial… problems happen with this

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75
Q

How does Shiga toxin producing E. Coli present?

A

Stools usually start as watery diarrhea and become bloody after 3 or 4 days. Several abdominal pain and cramping are typical, but fever is rare.

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76
Q

What 2 complications can Shiga toxin producing E. Coli cause?

A
  1. Hemorrhagic Colitis

2. HUS

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77
Q

Why are antibiotics contraindicated in enterohemorrhagic E. Coli diarrhea?

A
  1. Can result in release of shiga toxins

2. Increase risk of HUS in kids

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78
Q

What organisms cause prolonged watery diarrhea and are common in people of all ages in industrialized as well as developing countries?

A

Enteroaggregative E. Coli (EAEC)

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79
Q

How does enteroaggregative E. Coli act (how did it get its name)?

A

Bacteria stack up on each other… bacteria aggregate and colonize intestinal mucosa, releasing enterotoxinc and cytotoxins that destroy cells lining the intestines

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80
Q

How does enteroinvasive E. Coli diarrhea present?

A

Clinical picture similar to dysentery (Shigella)… stools may be blood- and mucous-tinged, and tenesmus may be present

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81
Q

True or False: Patients with enteroinvasive E. Coli are usually afebrile

A

TRUE

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82
Q

What is protracted diarrhea defined as?

A

Diarrhea beyond 2 weeks that can’t be attributed to an acute gastroenteritis

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83
Q

What would you think for a newborn with protracted diarrhea?

A

Anatomical causes (short gut)

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84
Q

What would you think for an infant with protracted diarrhea?

A

Viral infection or protein intolerance

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85
Q

What would you think for a toddler or older kid with protracted diarrhea?

A

Lactose intolerance

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86
Q

What is a test for sugar malabsorption?

A

Clinitest (Quick Screen)… tests for reducing substances (dietary sugars except sucrose). Presence of these reducing substances in stool would correlate with sugar malabsorption.

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87
Q

What is a test for sugar malabsorption?

A

Hydrogen breath test. Normal gut flora ferments sugar, resulting in hydrogen production, which is absorbed in blood and excreted in lungs.

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88
Q

What is a test for fat malabsorption?

A

Fecal fat measurement. A single stool specimen for fat isn’t valid verification…need 3-day fecal fat determination.

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89
Q

What is a test for fat malabsorption?

A

Serum carotene and prothrombin time… indirect tests (correlate with vitamin A and vitamin K absorption.

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90
Q

What is a test for protein malabsorption?

A

Albumin level and total protein. This typically occurs along with fat malabsorption. When it occurs as an isolated clinical finding, edema and other clinical findings will be noted.

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91
Q

Does the description of loose stools suggest/confirm chronic diarrhea?

A

No.. a kid with steatorrhea might have a couple large, firm, stool daily, but still be suffering from chronic malabsorption

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92
Q

How can a neuroblastoma cause diarrhea?

A

Can produce vasoactive intestinal peptides

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93
Q

When does transient lactase deficiency occur and how long to return to normal?

A

After an acute gastoenteritis, can take up to 3-6 months to return to normal

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94
Q

What is the most common cause of chronic diarrhea in children up to age 3?

A

Toddler’s diarrhea (chronic non-specific diarrhea)

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95
Q

What is toddler’s diarrhea often due to?

A

Excessive fruit juice intake

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96
Q

How does toddler’s diarrhea present?

A

Typically in a toddler with formed stool in the AM, which becomes progressively loose as the day progresses

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97
Q

True or False: By definition, growth an development are normal in Toddler’s diarrhea?

A

True… Poor growth, fever, and melena are not seen

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98
Q

What is treatment for Toddler’s diarrhea?

A

Limiting carbohydrates in diet and increasing intake of high fiber foods (fruits and veggies)

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99
Q

What are 3 predisposing factors diarrhea can be seen with?

A
  1. Malnutrition
  2. Chronic infection
  3. Systemic disease
  4. Immunodeficiency
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100
Q

What is a common cause of vomiting in early infancy… description similar to that of a septic infant?

A

Inborn errors of metabolism

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101
Q

What should you look for if you are given an infant with a septic picture and labs as clues to point to inborn errors of metabolism?

A
  1. Metabolic acidosis with elevated anion gap
  2. Hypoglycemia
  3. Hyperammonemia
  4. No fever
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102
Q

How does duodenal atresia present?

A

Bilious vomiting during the first day of life

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103
Q

What is seen on XR for duodenal atresia?

A

Double Bubble sign

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104
Q

Why are infants with duodenal atresia frequently icteric?

A

Diminished enterohepatic circulation

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105
Q

When will you see no air distal to the site of atresia in duodenal atresia?

A

If there is complete atresia

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106
Q

What do you do for any newborn who presents with bilious vomiting?

A

Abdominal film

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107
Q

True or False: Malrotation is a surgical emergency that requires immediate intervention

A

TRUE

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108
Q

What causes malrotation?

A

Cecum’s failure to descend while being handcuffed to the posterior right abdominal wall… this compresses the duodenum, causing duodenal obstruction

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109
Q

How does malrotation typically present?

A

Bilious vomiting, abdominal tenderness, abdominal distention, crampy abdominal pain, blood via rectum

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110
Q

What presents similarly to malrotation?

A

NEC

Typically seen in preemie, but can occur in full-term infant

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111
Q

What presents in infancy as bilious vomiting and right-sided abdominal distention?

A

Volvulus

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112
Q

Which condition is associated with Ladd Bands, and what is the result of this?

A

Volvulus

Constrict the large and small bowel

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113
Q

What are the XR findings for volvulus?

A

Gastric and duodenal dilation, decreased intestinal air and corkscrew appearance of duodenum.

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114
Q

How can GE reflux present?

A

Severe emesis (sometimes out of the nose), abdominal pain, arching with feeds. Effortless regurgitation (spitting up) in infant who is well otherwise.

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115
Q

Which condition (in a severe case) can result in apnea and failure to gain weight?

A

GE reflux

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116
Q

True or False: Infant with daily episodes of spitting up at 4 months of age can be normal?

A

True

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117
Q

Which 3 things seen with suspected GERD require further workup or treatment?

A
  1. Esophagitis (posturing)
  2. Failure to thrive
  3. Apnea
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118
Q

Which test for GERD assesses for malrotation and hiatal herna?

A

UGI series

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119
Q

Which test for GERD assesses extend and duration of reflux over a 24 hour pediod?

A

pH probe study (esophageal impedence)

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120
Q

Which test for GERD looks for gastroparesis?

A

Gastric emptying scan

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121
Q

Which test for GERD measures peristalsis and esophageal sphincter pressure?

A

Esophageal motility evaluation

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122
Q

If they mention amount baby is being fed along with signs of reflux, what should you consider?

A

Reducing amount of feedings (overfeeding can cause GERD)

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123
Q

True or False: Regurgitation is often a normal finding in infants

A

True… reassurance is often correct answer

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124
Q

At what age do infants who have physiologic reflux outgrow it?

A

1

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125
Q

What are signs indicating higher risks for complications of GERD?

A
  1. Prematurity
  2. Underlying neurological impairment
  3. Family history severe GERD
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126
Q

What are 3 non-pharmacologic treatments for GERD?

A
  1. Upright when feeding
  2. Smaller more frequent feeding
  3. Thickened feeds (rarely)
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127
Q

Which 2 groups of patients is pharmacologic treatment of reflux indicated for?

A
  1. Symptomatic disease

2. Neurological impairment

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128
Q

What are 2 classes of medications for GERD?

A
  1. Antacids (ranitidine)

2. PPI (Omeprazole and lansoprazole)

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129
Q

True or False: Medications treat reflux

A

FALSE: Decrease pain from heartburn, not actual reflux

Boards want you to choose reflux precautions and reassurance

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130
Q

What should you think of with GE reflux and dystonic movements of the head and neck?

A

Sandifer Syndrome (Sandpiper blowing sand out of pipe…reflux plus twisted pipes/twisted movements)

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131
Q

What is the MOA for Zofran?

A

Serotonin receptor antagonist

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132
Q

When is surgery indicated for GERD?

A

Severe consequences (failure to grow or respiratory compromise) and medication failure

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133
Q

Does pyloric stenosis occur more frequently in males or females?

A

Males

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134
Q

Does a paternal or maternal history of pyloric stenosis increase the risk of developing pyloric stenosis more?

A

Maternal… (since it is rarer in females)

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135
Q

How is pyloric stenosis diagnosed?

A

US

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136
Q

How is pyloric stenosis treated?

A

Surgically (AFTER electrolyte imbalance is corrected)

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137
Q

What will be the description for pyloric stenosis?

A

Progressive non-bilious vomiting

They will not likely give projectile vomiting with a palpable olive

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138
Q

When does pyloric stenosis typically occur?

A

Second month of life (could be anywhere from 2-5 months however)

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139
Q

What is the metabolic problem with pyloric stenosis?

A

Hypochloremic metabolic alkalosis with severe hypokalemia

Vomiting HCl…acid and chloride

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140
Q

When would a pre-term infant present with pyloric stenosis?

A

Later than the 2-5 month age range… but the equivalent postnatal age

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141
Q

What other lab abnormality can be seen in pyloric stenosis in up to 2.5% of cases?

A

Elevated indirect bilirubin

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142
Q

What are the diagnostic criteria for pyloric stenosis?

A

Ultrasound:

  1. Pyloric length greater than 14mm
  2. Pyloric muscle thickness greater than 4mm
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143
Q

What must be done before surgery with pyloric stenosis?

A

Correction of electrolyte imbalances

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144
Q

2 month old, Down Syndrome, projectile non-bilious vomiting with hypochloremic metabolic alkalosis….imaging study results?

A

Pyloric muscle measures over 6mm in thickness or pyloric channel 18mm in length or thickening and elongation of pyloric muscle.

-Don’t get thrown by Down Syndrome and pick double bubble…duodenal atresia presents in first day of life, not at 2 months.

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145
Q

What endocrinology problem can present as vomiting?

A

DKA

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146
Q

What cause of vomiting can have emotional overtones with a precipitating event?

A

Cyclic vomiting

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147
Q

What 2 things are children with cyclic vomiting at risk for?

A
  1. Migraines

2. Irritable bowel syndrome

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148
Q

What age is typical for cyclic vomiting?

A

Early school age

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149
Q

True or False: Cyclic vomiting episodes are separated by asymptomatic periods

A

TRUE

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150
Q

What type of diagnosis is cyclic vomiting?

A

Diagnosis of exclusion

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151
Q

Patient with intense periods of vomiting that lasts up to 48 hours. Feels well between episodes.

A

Cyclic vomiting

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152
Q

What conditions can present with severe episodic vomiting?

A
  1. Pancreatitis
  2. Metabolic defects
  3. Migraine variant cyclic vomiting
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153
Q

5 year old, vomiting episodes lasting 48 hours, end suddenly after nap, Mom with history of severe headaches, uncle going to bathroom multiple times during visit?

A

Cyclic vomiting (family history of migraine and IBS, symptoms last around 48 hours)

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154
Q

What are long-term pharmacological treatment options for cyclic vomiting?

A
  1. Cyproheptadine
  2. Propranolol
  3. TCAs
    (Similar to migraine)
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155
Q

What would be best initial treatment for kid presenting with cyclic vomiting?

A

IV hydration

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156
Q

What is rumination?

A

Frequent regurgitation of ingested food into the mouth that is re-chewed and swallowed or spit out. Appear calm during episodes.

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157
Q

What 2 groups will you typically see rumination in?

A
  1. Infants of severely disturbed caregivers

2. Older kids who are themselves disturbed or developmentally delayed

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158
Q

What disorder might be seen with kids who induce vomiting to seek attention in environments where there is a failure in reciprocal interaction between the infant and caregiver?

A

Rumination

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159
Q

What is the treatment for rumination?

A

Resolve the emotional trigger

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160
Q

What are some disorders with a presentation similar to rumination?

A
  1. Achalasia
  2. Gastric outlet obstruction
  3. GERD
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161
Q

True or False: Rumination is associated with forceful emesis

A

FALSE

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162
Q

What is associated with forceful vomiting, weight loss, dysphagia, and failure to thrive?

A

Achalasia

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163
Q

What is associated with similar symptoms to achalasia, but also abdominal pain and distention?

A

Gastric outlet obstruction

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164
Q

What kids present with nothing other than emesis, but often results in irritability (not calming)?

A

GERD (as opposed to rumination)

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165
Q

Cyst on floor of mouth described as mucocele?

A

Ranula

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166
Q

Midline mass on floor of mouth?

A

Ectopic thyroid

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167
Q

What is done for an ectopic thyroid?

A

Nothing… do not remove it

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168
Q

What is the treatment of a ranula?

A

Excision

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169
Q

What can present with underdeveloped or absent teeth?

A

Ectodermal hypoplasia (think empty dental)

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170
Q

How is ectodermal hypoplasia diagnosed?

A

Skin biopsy

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171
Q

What does skin biopsy show in ectodermal hypoplasia?

A

Lack of sweat pores

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172
Q

How is ectodermal hypoplasia inherited?

A

X-linked (picture small X’s sitting on gums)

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173
Q

What syndrome presents with underdeveloped small teeth?

A

Hallermann Streiff Syndrome

Picture large man hollering under stress…large teeth come out of mouth and only small ones left

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174
Q

How do you differentiate between ectodermal hypoplasia and Hallermann Streiff Syndrome?

A

Both have absent/underdeveloped teeth, but ectodermal hypoplasia has other signs of endocrine underfunction such as absence of sweat glands

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175
Q

Don’t mistake ectodermal hypoplasia or Hallermann Streiff Syndrome with what?

A

Physical abuse

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176
Q

What leads to portal hypertension?

A

Liver disease

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177
Q

Liver disease + bright red bloody stools, hematemesis, or tarry stools, what is the answer?

A

Esophageal varices

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178
Q

True or False: Esophageal varices can cause tarry stools

A

TRUE

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179
Q

What is the most common type of TE fistula?

A

TE fistula with a blind upper esophageal pouch

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180
Q

How does a TE fistula often present?

A

Coughing and vomiting with feeding in the newborn period

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181
Q

What film finding can you see with TE fistula?

A

Feeding tube coiled up in blind-ending esophagus

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182
Q

How is TE fistula initially managed prior to surgical correction?

A

NPO and draining the blind-ending esophagus

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183
Q

Name 4 descriptions associated with TE fistula

A
  1. Copious oral secretions
  2. Polyhydramnios
  3. Coughing and cyanosis with initial feeding
  4. Inability to pass feeding tube
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184
Q

The non-common types of TE fistulas present how?

A

Older children as respiratory symptoms (cough) associated with eating and/or drinking

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185
Q

If you have a kid with a TE fistula and are asked for further studies, what should you think?

A

Ruling out other associated findings common with VACTERL

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186
Q

What is a chronic autoimmune condition that presents as GERD unresponsive to PPI?

A

Eosinophilic esophagitis (EE)

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187
Q

How is eosinophilic esophagitis diagnosed?

A

History along with biopsy

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188
Q

What does biopsy in EE show?

A

Eosinophil-predominant inflammation in esophageal wall

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189
Q

True or False: EE can have an allergic component

A

TRUE

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190
Q

How is EE treated?

A
  1. PPI
  2. Diet changes
  3. Corticosteroid therapy
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191
Q

What is described by vomiting after eating (postprandial emesis) and epigastric pain severe enough to wake the child up at night?

A

Peptic ulcer disease

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192
Q

Can you see guaiac positive stools with PUD?

A

YES… clincher in description

193
Q

True or False: Plain KUB is helpful when PID is suspected

A

FALSE: Plain KUB important first study when evaluating kid with abdominal pain, but not helpful when PUD suspected

194
Q

What are 4 primary meds used to treat PUD in kids?

A
  1. H2 blockers
  2. Sucralfate
  3. Prostaglandins
  4. PPIs
195
Q

Which medication blocks gastric acid secretion?

A

H2 blockers

196
Q

Which medication coats damaged gastric mucosa and protects it from further damage?

A

Sucralfate

197
Q

What enhances bicarb production and to some extent decreases gastric acid production as well?

A

Prostaglandin analogues

198
Q

What medication inhibits the gastric acid pump?

A

PPI

199
Q

What is a prostaglandin that is used for PUD, but shouldn’t be given to pregnant teens?

A

Misoprostol

200
Q

What is the best diagnostic study for PUD?

A

Upper GI endoscopy

201
Q

What should be done during UGI endoscopy with concern for PUD?

A

Biopsy… want to see histology and do culture for H. Pylori (can also rule out mild esophagitis)

202
Q

What are 2 social risk factors for H. Pylori disease?

A
  1. Lower socioeconomic status

2. Immigration from developing country

203
Q

Why do NSAIDs cause GI symptoms?

A

Interferes with prostaglandin synthesis

204
Q

True or False: Gastric ulcers are treated with diet

A

FALSE

205
Q

What do NSAID induced ulcers respond well to?

A

H2 antagonists

206
Q

True or False: There is no correlation between dyspeptic symptoms and extent of ulcer

A

TRUE

207
Q

Uncomplicated dyspepsia due to what can be managed with antacids and food?

A

NSAIDs

208
Q

12 year old with chronic periumbilical pain positive for H. Pylori on serological testin… best next step?

A

Another study like fecal antigen or urea breath tests… positive serology not enough reason to treat. You need another study is screen is positive.

209
Q

True or False: Positive serology is sufficient to make diagnosis of H. Pylori

A

FALSE… Serologic testing for H. Pylori IgG has high sensitivity with lots of false positives

210
Q

If you prove that H. Pylori is present, does that mean it is causing a patients chronic abdominal pain?

A

NO

211
Q

What is gold standard for H. Pylori diagnosis?

A

Endoscopic biopsy

212
Q

Who do you limit H. Pylori testing to?

A

At risk (not general screening)… so don’t do an endoscopic biopsy on everyone even though it’s gold standard

213
Q

Treatment for H. Pylori?

A
  1. PPI (omeprazole or lansoprazole)

2. 2 Abx (clarithromycin & amoxicillin or clarithromycin & metronidazole

214
Q

How long do you treat with H. Pylori?

A

7 days is acceptable, 14 has better eradication rate

215
Q

Abdominal distention, anorexia, diarrhea, failure to thrive, weight loss, proximal muscle wasting, non-resolving iron-deficiency anemia?

A

Celiac disease

216
Q

What is gluten found in?

A

Foods that contain wheat or rye

217
Q

Can patient with celiac eat oatmeal?

A

It’s fine in some patients and can be tested initially

218
Q

True or False: Patient with celiac disease need vitamin supplementation

A

TRUE

219
Q

What is the best way to screen for celiac disease

A
  1. Elevated levels of IgA antibodies against tissue transglutaminase (anti-tTG)
  2. IgA antibodies to endomysium
220
Q

What does a patient have to have to screen for celiac with labs?

A

Normal IgA levels (testing IgA antibody levels)

221
Q

What is diagnosis of celiac disease confirmed by?

A

Biopsy

222
Q

Small bowel resection (infant with NEC for instance) and CBC in question… what do you check?

A

B12 deficiency… look for macrocytic anemia in CBC

223
Q

Why does bowel resection cause B12 deficiency?

A

B12 absorbed at terminal ileum (with help of intrinsic factor) and resection of this part of bowel can cause B12 deficiency (AKA pernicious anemia)

224
Q

What are 2 obstacles for B12 absorption besides bowel resection?

A
  1. Parasites

2. Inflammatory bowel disease

225
Q

Which intestinal disorder has a high emotional component?

A

IBS

226
Q

Diarrhea worse in morning, no association of pain with any particular foods…?

A

IBS

227
Q

What is the best treatment for IBS?

A

High fiber diet and close attention to emotional factors contributing to problem

228
Q

What medication can be used for IBS?

A

Amitryptyline

229
Q

History of chronic diarrhea, steatorrhea, and low sodium along with fat-soluble vitamin deficiency?

A

Cystic Fibrosis

230
Q

Why does CF cause low sodium?

A

It’s lost through sweat

231
Q

Fat-soluble vitamins?

A

ADEK

232
Q

What cause fat-soluble vitamin deficiency in CF?

A

Malabsorption

233
Q

What are 4 things that can be associated with rectal prolapse?

A
  1. CF
  2. Pertussis
  3. Tenesmus
  4. Chronic constipation
  5. Meningomyelocele
  6. Parasites (recent travel, new immigrant)
    (anything causing increased intra-abdominal pressure)
234
Q

Extra teeth, pre-malignant polyps in large and small intestines, osteomas…?

A

Gardner’s Syndrome

235
Q

How is Gardner’s syndrome inherited?

A

Autosomal Dominant

236
Q

How is Gardner’s syndrome treated?

A

Surgical

237
Q

What has mucosal pigmentation of the lips and gums associated with hundreds of colonic polyps which may become malignant?

A

Peutz-Jeghers Syndrome

238
Q

What is treatment for Peutz-Jeghers Syndrome?

A

Routine colonoscopies removing any worrisome polyps

239
Q

What typically presents in a teenager with a history of chronic crampy lower abdominal pain, with or without a history of bloody stools?

A

Ulcerative Colitis

240
Q

Severe colitis can present with what 3 signs?

A
  1. Fevers
  2. Hypoalbuminemia
  3. Anemia
241
Q

Which ethnicity is at particular risk for UC?

A

Ashkenazi (European) Jews

242
Q

True or False: Severe cases of UC require initial hospitalization for rehydration and/or blood transfusion

A

TRUE

243
Q

What 3 things are required when UC is actually a medical emergency?

A
  1. Fluids
  2. Blood transfusions
  3. Steroids
244
Q

What is given when infection is suspected with UC?

A

Metronidazole

245
Q

What is first-line medical treatment for UC?

A

5-ASA

246
Q

What are 3 types of second-line medical treatment for UC?

A
  1. Corticosteroids
  2. 6-mercaptopurine or azathioprine or methotrexate
  3. Cyclosporine or tacrolimus
247
Q

Which 2 GI conditions are associated with HLA-B27 and ankylosing spondylitis?

A

Crohn’s and UC

248
Q

What eliminates the risk for cancer in kids with UC?

A

Colectomy

249
Q

What is the cancer rate per decade after first 10 years of disease with UC?

A

20%

250
Q

Name 3 extracolonic manifestations of UC

A
  1. Arthritis
  2. Mucocutaneous lesions
  3. Liver disease
251
Q

True or False: Colectomy doesn’t stop the progression of ankylosing spondylitis

A

TRUE

252
Q

What does drug therapy help prevent in UC?

A

Relapses

253
Q

Why is a surgical consult needed for UC?

A

Risk for perforation

254
Q

What test should never be done with acute UC and why?

A

Barium enema, risk of perforation

255
Q

Why should pain meds be avoided with UC?

A

Can make it difficult to track clinical status

256
Q

What can Crohn’s disease present as even before overt GI symptoms?

A

Weight Loss

257
Q

What lab may be the only clue you get for Crohn’s?

A

ESR

258
Q

What lab should you get in a kid presenting with short statue to consider Crohn’s?

A

ESR

259
Q

What can be seen on XR for Crohn’s?

A

Skip lesions

260
Q

What can be seen on endoscopy for Crohn’s?

A

Cobblestone appearance, transmural lesions, noncaseating granulomas

261
Q

What can be mistaken for Crohn’s disease because it can result in nodularity and mucosal thickening of the terminal ileum?

A

TB

262
Q

Medical management of Crohn’s (5 things)?

A
  1. Corticosteroids
  2. Aminosalicylates
  3. Immunomodulators
  4. Antibiotics (metronidazole)
  5. Nutritional support
263
Q

What is used instead of azulfidine (sulfapyridine) for UC and Crohn’s?

A

5-ASA

264
Q

Name 7 extra-intestinal manifestations of Crohn’s disease.

A
  1. Pyoderma gangrenosum of foot
  2. Erythema nodosum (red tender nodules over shin)
  3. Ankylosing spondylitis/sacroilitis
  4. Arthritis
  5. Eyes (uveitis)
  6. Liver disease
  7. Renal stones
265
Q

Lesions are continuous (no skipped lesions), surgical excision is curative, toxic megacolon can occur, growth retardation and pubertal delay…. UC or Crohn’s?

A

UC

266
Q

Lesions aren’t continuous (yes skipped lesions), surgical excision isn’t curative, toxic megacolon can occur, growth retardation and pubertal delay…UC or Crohn’s?

A

Crohn’s (growth retardation and pubertal delay is more common in Crohn’s than UC)

267
Q

How can Crohn’s initially present?

A

As an acute abdomen (it can mimic appendicitis)

268
Q

What can oral aphthous ulcers and perianal fistulae be presenting signs of?

A

Crohn’s

269
Q

How do meds affect the long-term course of Crohn’s?

A

They don’t change the long-term course… they just decrease morbidity

270
Q

Is crohn’s managed inpatient or outpatient?

A

Mild symptoms are treated as outpatients, more severe symptoms (massive weight loss, significant systemic symptoms) are hospitalized

271
Q

For crohn’s, steroids induce remissions in what % of patients with small bowel involvement?

A

70%

272
Q

True or False: There is a high relapse rate after steroids are weaned in crohn’s

A

TRUE

273
Q

Classic presentation for intussusception?

A

Healthy child 3 months to 6 years who has sudden onset of abdominal pain with drawing up his legs and vomiting, then has a period of being perfectly fine, then pain recurs.

274
Q

What may relieve pain with intussusception?

A

Passing of a stool

275
Q

What ultimately happens to a child with intussusception?

A

They become lethargic

276
Q

What is the classic description of stool in intussusception?

A

Currant jelly

277
Q

Bloody stool with palpation of a sausage-like mass in right abdomen?

A

Intussusception

278
Q

Recurrent crampy abdominal pain in a febrile child… not as severe as in intussusception or appendicitis…?

A

Campylobacer jejuni or Yersinia infection

279
Q

In later stages, how can intussusception be described?

A

Bilious vomiting with shock-like symptoms

280
Q

Kid around 2, afebrile, symptoms mimicking sepsis, no GI symptoms…?

A

Think of intussuception (high on list in an afebrile kid that loos toxic, especially with unexplained lethargy or pallor)

281
Q

How is intussusception diagnosed and treated?

A

Air enema resulting in hydrostatic reduction

282
Q

What needs to be ruled out when a child over than 6 gets intussusception?

A

Lymphosarcoma (this could be lead point causing intussusception)

283
Q

20 month old, colicky abdominal pain and RLQ mass. Intermittent severe pain and lethargy between episodes. Best diagnostic study?

A

Air contrast enema (diagnostic and therapeutic)… don’t choose US or CT (don’t be fooled by “mass”)

284
Q

Left lower quadrant pain with palpable mass…?

A

Fecal overflow incontinence/Encopresis

285
Q

Previously stool-continent school aged child with daily soiled pants who doesn’t have weight loss, fever, or other systemic manifestations?

A

Fecal overflow incontinence/Encopresis

286
Q

3 phases of treatment for Encopresis?

A
  1. Education
  2. Emptying the colon
  3. Maintenance program
287
Q

Are soiling episodes with encopresis in the child’s control?

A

No… educate parents that episodes are out of child’s control and not purposeful behavior… punishment and blame should be avoided

288
Q

How do you cleanout for encopresis?

A

Clean out with enema, then oral cathartics and stool softeners (enemas and suppositories may traumatize child… don’t use unless there is encopresis)

289
Q

What are goals of maintenance program with encopresis?

A

Adjust doses of medications until colon regains tone and one soft stool daily is obtained

290
Q

What is congenital aganglionic megacolon?

A

Hirschprung’s Disease

291
Q

What causes hirschprung’s disease?

A

Absence of parasympathetic innervation of internal anal sphincter… affected recto-sigmoid segment is contracted, region proximal to aganglionic segment becomes distended with stool

292
Q

What is classic presentation for Hirschprung’s Disease?

A

No passage of meconium in first 48 hours

293
Q

What should you think of for any significant defecation problem in newborn, especially male/

A

Hirschprung

294
Q

What else can infants with Hirschprung’s present with besides failure to pass first stool in hospital or constipation?

A

Bilious vomiting
Poor PO intake
Abdominal distention

295
Q

What genetic condition is Hirschprung associated with?

A

Down syndrome

296
Q

How is Hirschprung diagnosed?

A

Rectal biopsy

297
Q

What is treatment for Hirschprung?

A

Surgical excision of aganglionic segment followed by colostomy and ultimately end-to-end anastomosis

298
Q

Rarely has delayed passage of meconium in newborn period, rarely has signs of obstruction, yes to soiling, no failure to thrive, present after age 2, difficulty with toilet training, and stool in rectal ampulla on PE… Functional constipation v. Hirschsprung’s?

A

Functional consipation

299
Q

Delayed passage of meconium in newborn period, signs of obstruction, rare soiling, failure to thrive, not present after age 2, no difficulty with toilet training, and no stool in rectal ampulla on PE…Functional constipation v. Hirschsprung’s?

A

Hirschsprung’s

300
Q

What is seen with anal stenosis?

A

Infant strains to pass small liquid stools and there is a tight band narrowing on anus

301
Q

True or False: Anal stenosis is self limited

A

TRUE

302
Q

When does anal stenosis remit by?

A

Age 1

303
Q

Who is functional constipation typically seen in?

A

Infants fed cereal at an early age (delayed passing of meconium will NOT be described in vignette

304
Q

Constipation, poor growth, hoarse cry, umbilical hernia, delayed closure of anterior fontanelle?

A

Congenital Hypothyroidism

305
Q

What % of healthy newborns deliver their first stool within their first 24 hours?

A

99% (other 1% deliver within 48 hours)

306
Q

What should 2 considerations should there be when there is no stool production in the first 48 hours?

A
  1. Hirschprung disease

2. Cystic Fibrosis

307
Q

Why doesn’t Hirschprung’s usually present after age 2?

A

It is usually treated before age 2

308
Q

What is the first thing you should do to distinguish upper from lower GI bleeding?

A

NG lavage

309
Q

When presented with a GI bleed, what is the first consideration?

A

Immediate fluid resuscitation (if there are signs of hypovolemia)

310
Q

What is the vomiting of bright red or coffee-ground appearing blood?

A

Hemetemesis

311
Q

What reflects bleeding proximal to the Ligament of Treitz?

A

Hemetemesis

312
Q

What presents as painless effortless regurgitation of bright red blood in a newborn with no evidence of volume depletion?

A

Swallowed maternal blood

313
Q

If you are suspicious for swallowed maternal blood in an infant, what should you check?

A

Mom’s breasts for cracks that would lead to blood ingested by the infant

314
Q

What test helps to determine if swallowed blood is Mom’s or infants?

A

Apt test

315
Q

What does a negative Apt test mean?

A

Blood is of maternal origin

316
Q

In children, what is GI bleeding classified by?

A

Source of UGI bleed

317
Q

What are common causes of bleeding from esophagus?

A

Esophagitis (acid reflux or pill-ingestion) and Mallory-Weiss tears

318
Q

What are common causes of bleeding from the stomach?

A

Gastritis due to NSAIDs or stress/acid/infection

319
Q

What are common causes of bleeding from the intestine?

A

Crohn’s disease

320
Q

What can cause false-positive guaic testing?

A

Recent meat ingestion, horseradish, and ferrous sulfate administration

321
Q

What can cause false-negative guaic testing?

A

Vitamin C ingestion, outdated cards, improper specimen storage

322
Q

What is the most common cause of upper GI bleeding in all age groups?

A

Peptic or acid irritation

323
Q

What are 3 causes of GI lower GI bleeding in infants?

A
  1. Hirschprung’s disease
  2. Malrotation with an associated volvulus
  3. NEC
324
Q

Preemie infant with lower GI bleeding?

A

NEC

325
Q

What can present with bilious vomiting and melena that can cause a lower GI bleed?

A

Malrotation with associated volvulus

326
Q

What can present as lower GI bleeding in an infant with associated colitis?

A

Hirschsprung’s disease

327
Q

What has increased risk of Hirschprung disease, duodenal atresia, Meckel diverticulum, and pyloric stenosis?

A

Down Syndrome

328
Q

Name two causes of lower GI bleeding in toddlers?

A
  1. Anal fissures

2. Intussusception

329
Q

What is the most common cause of lower GI bleed in toddlers?

A

Anal fissures

330
Q

True or False: Anal fissures are benign

A

TRUE

331
Q

What are anal fissures usually secondary to?

A

Constipation

332
Q

What cause of lower GI bleeding in toddlers typically presents in a child 9 months of age or older?

A

Intussusception

333
Q

What is the passage of bright red or maroon stools?

A

Hematochezia

334
Q

What does hematochezia suggest?

A

Distal bleeding or massive proximal bleeding

335
Q

What diagnosis to consider with hematochezia?

A
  1. Allergic
  2. Infectious
  3. Intussusception
  4. Meckel’s
  5. Rectal fissures/tears
  6. Ingestions
  7. Bleeding disorders
336
Q

What is described as dark, tarry stools?

A

Melena

337
Q

What usually causes melena?

A

Upper GI bleed

338
Q

What can Melena be associated with?

A

Meckel’s diverticulum (consider this if melena is described instead of painless bleeding)

339
Q

What % of newborns is Meckel Diverticulum present in?

A

2-3%

340
Q

What manifests as painless rectal bleeding during the first 2 years of life?

A

Meckel Diverticulum

341
Q

What is done to diagnose Meckel Diverticulum?

A

Technetium 99m pertechnetate scintigraphic study (ectopic gastric mucosa takes up the material and lights up)

342
Q

What is a very common cause of lower GI bleeding?

A

Meckel Diverticulum

343
Q

What is treatment for Meckel Diverticulum?

A

Surgical

344
Q

What is the rule of 2 with Meckel Diverticulum (Meckel’s DiverTWOculum)?

A
  1. Presents around age of 2
  2. 2 types of tissue (gastric and intestinal)
  3. Found 2 feet from ileocecal valve
  4. 2 inches in length
  5. 2% of population
345
Q

What are causes of lower GI bleeding in school age children?

A
  1. Juvenile polyp
  2. Crohn’s and UC
  3. Infectious diseases
346
Q

What is typically described as painless rectal bleeding in an otherwise healthy preschool child?

A

Juvenile polyp

347
Q

True or False: Juvenile polyps are associated with an increased risk for malignany

A

FALSE

348
Q

What presents as painless rectal bleeding in a school age child?

A

Juvenile polyposis

349
Q

What 2 GI conditions can present in school age children with blood in stools?

A
  1. Crohn’s

2. UC

350
Q

What can present in school age children as fever, crampy abdominal pain, and bloody stools?

A

Infectious diseases

351
Q

What presents with elevated direct bilirubin?

A

Cholestatic jaundice

352
Q

What causes cholestatic jaundice?

A

Liver/parenchymal disease or anatomical/obstructive disease

353
Q

Why is intervention required with cholestatic jaundice

A

To prevent severe liver disease

354
Q

What is a good first step when evaluating cholestatic jaundice?

A

Hepatobiliary scintigraphy

355
Q

What happens in hepatobiliary scintigraphy with liver disease?

A

Isotope is taken up and makes its way to the biliary system

356
Q

What happens in hepatobiliary scintigraphy with obstruction?

A

Isotope has uptake in liver, but no excretion down biliary tree

357
Q

If you choose phototherapy for an infant with jaundice, what should not be present?

A

Direct hyperbilirubinemia

358
Q

What happens if you do phototherapy on a cholestatic baby?

A

Yellow babies turn into bronze babies (more green-blue and stay this color for months)

359
Q

What causes increased direct bilirubin, pale stools, and hepatomegaly?

A

Cholestatic jaundice

360
Q

When does neonatal hepatitis present?

A

Later (like months after birth)

361
Q

When does obstructive jaundice present?

A

At birth or within weeks (not months) later

362
Q

What is hyperalimentation induced cholestasis due to?

A

Protein intake

363
Q

What should protein intake be limited to with hyperalimentation cholestasis?

A

2g/kg/day

364
Q

What can be used to stimulate bile secretion and decrease serum bili levels in hyperalimentation cholestasis when limiting protein doesn’t work?

A

Phenobarbital

365
Q

What is seen with elevated direct bilirubin and acholic (clay-colored) stools in a child over 1 month of age?

A

Biliary atresia

366
Q

That can be done for biliary atresia if the infant is younger than 2 months?

A

Kasai procedure (joins liver to intestine)

367
Q

What is the order of tests to do when biliary atresia is suspected?

A

US, then HIDA, then ultimately biopsy

368
Q

What is the most common cause of cholestatic jaundice in a newborn?

A

TPN (especially if it’s a preemie)

369
Q

What 2 things help distinguish cholestatic jaundice from hepatocellular-caused jaundice?

A
  1. Cholestatic disease has a very high alkaline phosphatase

2. Hepatocellular has very high SGPT/SGPOT

370
Q

What is a cause of extrahepatic biliary obstruction that presents similarly to biliary atresia?

A

Choledochal cyst

371
Q

What is used to diagnose choledochal cyst?

A

Abdominal US

372
Q

What presents as neonatal jaundice, fever, acholic stools, RUQ pain, and a palpable mass?

A

Choledochal cyst

373
Q

What is Gilbert syndrome due to?

A

Glucuronyl transferase deficiency

374
Q

True or False: Gilbert syndrome is a harmless familial condition

A

TRUE

375
Q

What results in intermittently elevated unconjugated serum bilirubin, particularly with illness or other stressors?

A

Gilbert syndrome

376
Q

What will be one hint about symptoms with Gilbert syndrome?

A

Similar history in other family members

377
Q

When is Gilbert syndrome normally recognized?

A

After puberty

378
Q

What should be considered if they present you with a teenager who gets jaundiced when he has an upper respiratory infection or is fasting?

A

Gilbert Syndrome

379
Q

What labs are abnormal with Gilbert syndrome?

A

Elevated indirect bilirubin, other LFTs normal

380
Q

What is done to treat Gilbert Sydrome?

A

Nothing…no treatment is necessary

381
Q

Recent influenza-like disease or varicella during which aspirin was given?

A

Reye Syndrome

382
Q

How do kids with Reye’s Syndrom present?

A

Comatose with elevated LTFs and serum ammonia levels

383
Q

If you are presented with a second episode of a kid being comatose with elevated LFTs and serum ammonia levels what should you think?

A

Inborn error of metabolism (Reye’s Syndrome is not the right answer)

384
Q

What is Wilson’s Disease also called?

A

Hepatolenticular degeneration

385
Q

What is the inheritance of Wilson’s Disease?

A

Autosomal Recessive (you “rec”eive a copper penny)

386
Q

What is Wilson’s Disease a disorder of?

A

Copper metabolism

387
Q

Where does copper get deposited in Wilson’s Disease?

A
  1. Eyes (Kayser Fleisher Rings)
  2. Liver
  3. Brain
  4. Kidney
388
Q

What is the result of copper depositing in the kidney in Wilson’s disease?

A

Renal tubular acidosis

389
Q

How does Wilson disease present in children and teenagers?

A

Liver disease

390
Q

How does Wilson disease present in adults?

A

Neuropsychiatric disease

391
Q

How is Wilson disease diagnosed?

A

Clinically along with significantly elevated hepatic copper and decreased ceruloplasmin

392
Q

What happens to serum copper levels in Wilson’s disease?

A

They are low because most of the copper is accumulated in the tissues

393
Q

What is the copper level in the urine for Wilson’s disease?

A

Increased copper in urine

394
Q

What is treatment for Wilson disease?

A

D-penicillamine to chelate copper along with low copper diet (remember “copper penny”)

395
Q

True or False: Wilson’s disease is fatal if not treated

A

TRUE

396
Q

What can penicillamine result in?

A

Aplastic anemia (picture copper pennies clogging up the bone marrow)

397
Q

What condition besides Wilsons can you see excess copper in?

A

Chronic active hepatitis

398
Q

What is a very common presentation of A1AT deficiency?

A

Persistent jaundice in newborn period

399
Q

What 3 organ systems does A1AT deficiency affect?

A
  1. Lung
  2. Liver
  3. Skin
400
Q

What does A1AT do to the lungs?

A

COPD

401
Q

What does A1AT do to the liver?

A

Neonatal hepatitis with cholestasis

402
Q

What does A1AT do to the skin?

A

Necrotizing panniculitis and psoriasis in adults

403
Q

Recent studies suggest that A1AT may be as prevalent as what other chronic disease?

A

CF

404
Q

What are the 2 most important findings in a child with impending liver failure?

A
  1. Elevated serum ammonia level

2. Change in mental status

405
Q

If you are presented with a patient with chronic tremor and anxiety and lab findings consistent with liver disease what do you want to rule out?

A

Wilson’s Disease (measure a serum ceruloplasmin level)

406
Q

What is characterized by mid-epigastric pain radiating to the back with guarding and rebound, coupled with diminished bowel sounds and vomiting?

A

Acute pancreatitis

407
Q

What is the range of descriptions of the child you could get with acute pancreatitis?

A

Child comfortable lying on his side with knees to chest or signs of volume depletion (decreased urine output, pulmonary edema, pulmonary effusions)

Pancreatitis with Pulmonary edema and Pleural effusion

408
Q

What is the most specific test in diagnosing pancreatitis?

A

Abdominal US (NOT serum amylase)

409
Q

What test is used to follow recurrent pancreatitis, not to diagnose acute pancreatitis?

A

ERCP

410
Q

True or False: Normal amylase doesn’t rule out pancreatitis

A

TRUE

411
Q

Which lab test is more specific for pancreatic disease…amylase or lipase?

A

Lipase

412
Q

What is seen with glucose, calcium, BUN/Cr, blood counts, and coags with pancreatitis?

A
  1. Hyperglycemia
  2. Hypocalcemia
  3. Elevated BUN/Cr
  4. Anemia
  5. Coagulopathy
413
Q

Familial dyslipidemia is an important cause for recurrent what in children?

A

Pancreatitis

414
Q

What would hinting at a family member dying of premature atherosclerosis in a kid with abdominal pain be?

A

Familial dyslipidemia causing pancreatitis

415
Q

With recurrent pancreatitis in a kid with a family history of someone dying of premature atherosclerosis what is the test to order?

A

Serum lipid levels (don’t pick imaging or cardiac studies offered)

416
Q

What metabolic problem is another known cause of acute or recurrent pancreatitis?

A

Hypercalcemia

417
Q

What should you consider if you are presented with a kid who has hyperparathyroidism or kidney stones who presents with acute or recurrent abdominal pain?

A

Hypercalcemia causing pancreatitis

418
Q

Is acute sporadic or recurrent chronic pancreatitis more common?

A

Acute sporadic

419
Q

What is acute sporadic pancreatitis usually due to?

A

Blunt abdominal trauma or idiopathic

420
Q

What usually causes chronic, relapsing pancreatitis?

A

Infection, autoimmune disease, inherited conditions, or medications

421
Q

What is the most common cause of recurrent pancreatitis?

A

Hereditary pancreatitis

422
Q

What is a presenting sign in over 1/4 of kids with cholecystitis that is often not seen in adults?

A

Jaundice

423
Q

Child who is jaundiced with fatty food intolerance and has fever, pain radiating to right scapula, and palpable mass in RUQ?

A

Cholecystitis

424
Q

Abdominal pain that radiates to the shoulder is likely to be what?

A

Gallbladder pain

425
Q

What causes shoulder pain with gallbladder issues?

A

Diaphragm irritation (diaphragm and shoulder share common pain pathways)

426
Q

Name 5 conditions that leave children predisposed to cholecystitis.

A
  1. Hemolytic disease
  2. Prolonged use of TPN
  3. Small intestinal disease
  4. Obesity
  5. Pregnancy
427
Q

15 year old male presents with right shoulder pain, nausea, vomiting, lethargy…. diagnosis, how to diagnose, treatment?

A
  1. Cholecystitis
  2. Abdominal US
  3. Surgery
428
Q

What refers to stones in the gallbladder?

A

Cholelithiasis

429
Q

What refers to stones within the hepatic or common bile duct?

A

Choledocholithiasis

430
Q

What 3 things can choledocholithiasis result in?

A
  1. Cholangitis
  2. Obstructive jaundice
  3. Pancreatitis
431
Q

Name 4 risk factors for gallstones.

A
  1. Cystic Fibrosis
  2. Ileal resection
  3. Treatment with ceftriaxone
  4. TPN
432
Q

15 year old icteric female presents with abdominal pain and hepatosplenomegaly…diagnosis and test?

A

Cholelithiasis, abdominal US (NOT hepatitis)

433
Q

How are cholelithiasis and cholecystitis diagnosed?

A

US

434
Q

What are common symptoms between cholecystitis and cholelithiasis?

A
  1. Abdominal pain
  2. Nausea
  3. Vomiting
    * Both diagnosed by US*
435
Q

What are symptoms unique to cholecystitis (not cholelithiasis)?

A
  1. Shoulder pain

2. Lethargy

436
Q

What are symptoms unique to cholelithiasis (not cholecystitis)?

A
  1. Hepatosplenomegaly

2. Icteric

437
Q

When is IgM-specific antibody positive?

A

Only acutely (then it resolves)

IgM is iMMediate

438
Q

When is IgG antibody positive?

A

For life (once it turns positive, it is always positive)

IgG is for Good

439
Q

What is the presentation for HAV?

A

Flu-like symptoms, elevated LFTs, recent trip to place where Hep A is endemic

440
Q

How is Hepatitis A transmitted?

A

Fecal-Oral

441
Q

Where is Hep A prevalent?

A

Where there is poor hygiene and poor sanitation

442
Q

How is Hep A contracted?

A

From household contacts and daycare centers by drinking contaminated water or by ingesting contaminated foods (raw or undercooked shellfish from contaminated waters)

443
Q

What % of kids younger than 5 have asymptomatic infection with Hep A and won’t be jaundiced?

A

90% (most kids with hepatitis A infection will be asymptomatic)

444
Q

Which ethnic groups is Hepatitis A prevalent among?

A
  1. Native American

2. Alaskan Natives (Eskimo)

445
Q

Which ethnic group is Hep A not commonly seen in?

A

Asians

446
Q

Which groups of children and adults with HAV should be excluded from work and for how long?

A

People who work in food service or child care centers, one week after onset of symptoms

447
Q

How is Hep A diagnosed acutely?

A

IgM for hepatitis A

448
Q

How long can an IgM level remain elevated in Hep A?

A

6 months

449
Q

What does elevated IgG confirm with regard to Hepatitis A infection?

A

Previous infection and immunity against the disease

450
Q

How is hepatitis A treated?

A

Supportive…this is self-limited and doesn’t lead to chronic disease

451
Q

What can be given for pre- and post- exposure prophylaxis for HAV?

A

Immune globulin

452
Q

What are the 3 main modes of transmission for Hepatitis B?

A
  1. Blood transfusions
  2. Sexual contact
  3. Perinatal transmission
    (it is spread via contact with bodily fluids)
453
Q

What 3 serological tests for HBV can be done in acute phase?

A
  1. HBsAg
  2. HBeAg
  3. HBV-DNA
454
Q

What is HBsAg mean?

A

Hepatitis B surface antigen (marker of active infection)

455
Q

What does HBeAg mean?

A

High viral load, infectivity, and replication

456
Q

What does HBV-DNA tell you?

A

Sensitive marker indicating viral replication

457
Q

What 2 things happen to serological tests with recovery of HBV?

A
  1. HBV-DNA and HBsAg disappear

2. Anti-HBs, Anti-HBc, and Anti-HBe appear (antibodies to Hep B surface antigen, core antigen, and HBe)

458
Q

When does HBV-DNA and HBsAg disappear after Hep B infection?

A

Around 6 months after its appearance

459
Q

What indicates chronic infection with Hep B?

A

Persistence of surface antigen (HBsAg) beyond 6 months

460
Q

How long is HBsAg detected in serum of patients with chronic Hep B?

A

Lifelong

461
Q

What is seen with serological testing in a patient with no hepatitis B disease, but who had the hepatitis B vaccine?

A

Positive HBsAb (Hepatitis B surface antibody), but every other antigen and antibody will be negative

462
Q

Which Hep B marker is present during active infection, but doesn’t differentiate between acute and chronic infection?

A

HBsAg

463
Q

Which Hep B marker is consistent with previous infection or positive response to immunization?

A

HBsAb

464
Q

Which Hep B marker tells you there was a previous infection which has now resolved?

A

HBcAb

465
Q

Which Hep B marker correlates with a high rate of replication, and its presence correlates with a high rate of infectivity?

A

HBeAg

Think of E as evil or very infectious… E antigen as Excess because it can spread to Everyone

466
Q

True or False: Almost ALL kids born to mothers with HBeAg positivity will develop chronic Hep B?

A

TRUE: When HBeAg is positive, the mother is highly infectious

467
Q

The earlier the age of infection with Hep B, the ___ the incidence of chronic HBV?

A

Higher (90% for infants, 10% for adults)

468
Q

What are the 2 most feared complications of chronic HBV infection?

A
  1. Fulminant hepatic failure

2. Hepatocellular cancer

469
Q

Which type of hepatitis can result in liver disease, cirrhosis, and is associated with an increased incidence of hepatocellular carcinoma?

A

Hepatitis C

HepC is associated with liver Cancer and Cirrhosis

470
Q

What is the most common bloodborne infection in the US?

A

Hep C

471
Q

What is the most common cause of chronic viral hepatitis?

A

Hep C

472
Q

How is hepatitis C transmitted?

A
  1. Blood transfusions
  2. Sexual contact
  3. Perinatal transmission

Via contact with bodily fluids- Same as Hep B

473
Q

True or False: Most infections with Hep C in children are asymptomatic

A

True

474
Q

What should Delta antigen make you think of?

A

HDV

475
Q

What is unique about Hepatitis D?

A

It cannot replicate by itself- Requires the presence of HBsAg to provide its outer coat

D is Dependent or Deficient

476
Q

How is Hepatitis E transmitted?

A

Fecal-Oral route

477
Q

Where is Hep E most common in?

A

Parts of Asia, Africa, and Mexico

478
Q

What exposure if Hepatitis E associated with?

A

Contaminated water

479
Q

True or False: Hepatitis E can lead to chronic hepatitis

A

FALSE

Peds (35 decks)

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