GI Flashcards
1
Q
Ventral wall defects - types and results
A
- Rostral fold closure –> sternal defects
- Lateral fold closure –> omphalocele, gastroschisis
- Caudal fold closure –> bladder exstrophy
2
Q
Tracheoesophageal anomalies - types (MC)
A
- Pure esophangeal atresia or stenosis
- Pure Tracheoesophageal (H-type)
- Esophangeal atresia with distal Tracheoesophageal fistula (MC-85%)
3
Q
Tracheoesophageal anomalies - clinical presentation
A
- polyhydramnios in utero
- Neonates drool, choke, and vomit with first feeding
- air in the stomach visible in CXR (in TEF, not in pure esophagus anomaly)
- cyanosis 2ry to laryngospasm (to avoid reflux-related asperation)
4
Q
Tracheoesophageal anomalies - CXR of abdomen
A
- Pure esophangeal atresia or stenosis –> gasless abdomen
- Pure Tracheoesophageal –> air in stomach
- Esophangeal atresia with distal Tracheoesophageal fistula –> air in stomach
5
Q
Intestinal atresia presents with
A
bilious vomiting (with bile) and abdominal distension within first 1-2 days of life. Proximal atresia is also presented with polyhydraminios
6
Q
MCC of gastric outlet obstruction in infants (and frequency)
A
Hypertrophic pyloric stenosis (1:600
7
Q
Hypertrophic pyloric stenosis - presentation and results
A
Palpable “olive” mass in epigastric region and nonbilious projectile vomiting at 2-6 weeks old –> hypokalemic hypochloremic alkalosis (2ry to vomitng of gastric acid and subsequent volume contraction)
OLIVE MASS –> NOT ALWAYS
8
Q
Hypertrophic pyloric stenosis - associated with
A
- exposure to macrolides
- more common in firstborn males
- formula feeding
9
Q
Annular pancreas (mechanism and presentation
A
Ventral pancreatic bud abnormally encircles 2nd part of duodenum –> forms a ring of pancreatic tissue that may cause duodenal narrowing and nonobilious vomiting
10
Q
Pancreas divisum - mechanism and symptoms
A
ventral and dorsal parts fail to fuse at 8 week –> mostly assymptomatic but may cause chronic abdominal pain and/or pancreatitis
11
Q
inguinal canal conveys
A
men –> the spermatic cord
women –> the round ligament of uterus
12
Q
site of protrusion of direct hernia
A
Inguinal (Hesselbach) triangle
13
Q
Indirect inguinal hernia - direction
A
–> follows the path of descent of the testes
enters the internal inguinal ring laterally to inferior epigastric vessels –> external inguinal ring –> into scrotum - COVERED BY ALL 3 LAYERS OF SPERMATIC FASCIA)
14
Q
Indirect inguinal hernia - occurs in (mechanism)
A
infants owing to failure to processus vaginalis to close –> can form hydrocele (MUCH MORE COMMON IN MALES)
15
Q
Direct inguinal hernia - direction
A
protrudes through the inguinal (Hesselbach triangle) –> bulges directly through abdominal wall (medially of inferior epigastric vessels) –> goes through the external superficial ring. Covered by external spermatic fascia
16
Q
inguinal (Hesselbach) triangle - borders
A
- inferior epigastric vessels
- lateral border of rectus abdominis
- inguinal ligament
17
Q
Celiac disease - lab findings
A
- IgA anti-tissue transglutaminase
- IgA anti-endomysial
- anti-deamidated gliadin peptide antobodies
- IgG also present (useful in IgA deficiency)
- biopsy –> villous atrophy, crypt hyperplasia, intraepithelial lymphocytosis
18
Q
Celiac disease - results in/symptoms
A
- malabsorption
- statorrhea
- dermatitis herpetiforms
- failure to thrive (children)
- low bone density
19
Q
Celiac disease - complications
A
increased risk of malignancy (T-cell lymphoma)
20
Q
Celiac disease - location of decreased mucosal absorption / treatment
A
distal duodenum and/or proximal jejunum
- treatment: gluten-free diet
21
Q
Appendicitis can be due to
A
- obstruction by fecalith (adults)
2. lymphoid hyperplasia (children)
22
Q
Appendicitis - signs
A
may elicit:
- psoas sign 2. obturator signs
- Rovsing sign (LLQ 4. guarding and rebound
23
Q
obturator sign?
A
The examiner rotates the hip by moving the patient’s ankle away from the patient’s body while allowing the knee to move only inward.
24
Q
psoas sign
A
passively extending the thigh of a patient lying on his side with knees extended
25
MC congenital anomaly of the GI tract
Meckel diverticulum
26
Meckel diverticulum - definition/due to
True diverticulum of bowel due to persistence of vitelline duct (partial closure --> patent portion attached to ileum)
27
Meckel diverticulum can causes
1. painless melena (or hematochezia) 2. RLQ pain 3. intussusception 4. volvulus
5. obstruction near terminal ileum (mimics appendicitis)
MC asymptomatic
28
Meckel diverticulum the rule of 6 2s
```
2 times as likely in males
2 inches long
2 feet from ileocecal valce
2% of population
present in first 2 yeras of life
may have 2 types of epithelial (gastric/pancreatic)
```
29
Hirschsprung disease - definition, findings
- congenital megalcolon characterized by lack of ganglion cells/enteric nervous plexuses (both) in distal segment of colon
30
Hirschsprung disease - due to
failure of neural crest cell migration
| RET MUTATION
31
Hirschsprung disease is associated with / sex
Down syndrome
| MC in boys
32
Hirschsprung disease - diagnosis/treatment
diagnosed by rectal suction biopsy
| treatment: resection (3 stages surgery
33
Hirschsprung disease present with
bilious emesis, abdominal distention and failure to pass meconium within 48h --> chronic constipation
rectal examination: extremely tight sphincter:
inability to pass flatus
34
Malrotation - due to/mechanism / management
```
anomaly of midgut rotation during fetal development
--> improper positioning of bowel, formation of fibrous bands (Ladd bands) (esp on cecum connected with other structures)
Ladd procedure (surgery) --> reduces risk of volvulus
```
35
Malrotation can lead to
1. vovlulus
| 2. duodenal obstruction
36
Volvulus - definition / can lead to
twisting of portion of bowel around its mesentery
| can lead to obstruction and infraction
37
Intussusception - definition / age
telescoping of priximal segment bowel into distal segment commonly at ileocecal junction
- age: 6-24 months
38
Causes of Intussusception
adults --> 1. tumor or mass that acts as a lead point that is pulled into lumen
children (MC) --> 1. idiopathic (usually), 2. viral infection (adenovirus --> Payer hypertrophy --> lead pont)
3. Meckel (MC patholoci lead point)
39
Intussusception - tests
1. best initial: U/S (bull's eye or doughnut sign, or target sign)
2. most accurate: air or water enema is both DIAGNOSTIC AND THERAPEUTIC --> contraindicated if sings of peritonisis, shock, perforation
40
Intussusception - presentation / mechanism
compromised blood supply --> intermittent abdominal pain often with currant jelly stools (mixed with blood and mucus)
sausage like abd mass
41
Cringler-Najjal syndrome, type I - treatment
plasmapheresis and phototherapy
42
Cringler-Najjal syndrome, type II (vs type I)
less severe and responds to phenobarbial, which increases liver enzyme synthesis
43
Cringler-Najjal syndrome, type I - mechanism
Absent of UGT (present early in life) --> die within a few years
44
Dubin-Johnson syndrome - everything
deficiency of bilirubin canalicular transport protein (defective excretion) --> Conjugated hyperbilirubinemia
Grossly black liver (Benign)
45
Rotor syndrome - everything
similar to Dubin-Johnson but milder in presentation without black liver
DUE TO: impaired hepatic uptake (?) + excretion
46
Physiologic neonatal jaundice - mechanism
At birth, immature UDP-glucuronosyltransferase --> uncojugated hyperbilirubinemia --> jaundice/kernicterus
47
Physiologic neonatal jaundice - treatment
phototherapy (non-UV) isomerizes unconjugated bilirubin to water-soluble form
48
consider exchange transfusion if
bilirubin rises to 20-25
49
esophageal atresia - treatment
1. surgical repair in 2 STEPS
2. antibiotic coverage for anaerobes
3. FLUIDS before surgery
50
pyloric stenosis - best initial test
abdominal U/S (thickened pyloric sphincter)
51
pyloric stenosis - most accurate
upper GI series:
1. string sign: thin column of barium leaking through the tightened muscle
2. shoulder sign: filling defect in the antrum due to prolapse of the muscle inward
3. Mushroom sign: hypertrophic pylorus against the duodenum
4. Railroad tract sign: excess mucosa in the pyloric lumen resulting in 2 columns of bacteria
52
duodenal atresia treatment
- replace lost volume with IV fluids, taking special care to replace lost electrolytes. NGT to decompress the bowel.
- Surgical duodenostomy is the MC surgical procedure
53
volvulus - treatment
```
best initial: endoscopic decompression
most effective (and if endoscopy fails): surgical decompression
```
54
choanal atresia
infant born with a membrane between the nostrils and pharyngeal space that prevents breathing during feeding
55
choanal atresia is associated with
Charge syndrome
56
Charge syndrome
```
Coloboma of the eye
Heart defects
Atresia of choanae
Retardation of growth and/or development
Genital and/or urinary defects (hypogonadism)
Ear anomalies and/or deafness
```
57
choanal atresia presentation
turn blue when feeding and then pick with crying
58
choanal atresia - diagnostic tests
best iniital: pass NG tube
| confirmed with CT scan
59
choanal atresia - treatment
initially: oropharyngeal airway and orogastric tube feeding
definitive: surgical intervention to perforate the membrane
60
imperforate anus is associated with
Down syndrome
61
VACTERL syndrome
```
Vertebral anomalies
Anal atresia
Cardiovascular
Tracheoesophageal fistula
Esophageal atresia
Renal anomalies
Limb anomalies
```
62
imperforate anus - presentation / diagnostic tests / treatment
failure to pass meconium
| surgery
63
current jelly - seen in
- pneumonia with Klebsiella as sputum
| - Intussesception in the stools
64
Intussusception - treatment
- fluids and electrolytes correction are the most important initial tests --> NGT decompression
- Barium enema is also curative --> if not --> emergent surgical intervention
10% occur within 24 hours
65
Meckel diverticulum - most accurate test
Meckel scan (99mTc)
66
causes of bilious vomiting - onset / initial test / treatment
1. duondenal atreasia --> 1st day --> AXR --> fluids + surgery
2. vovlulus --> 1st year --> AXR --> fluids + surgery
3. intussesception --> 1st year --? U/S --> fluids + surgery
67
2nd MCC of infants death worldwide
acute diarrhea
68
acute diarrhea - the most important next step
rehydration
mild: oral fluids
severe: IV
antidiarrheal such as loperamide are always wrong
69
Viral infectious diarrhea - ddx (MC?) seasons? / duration
- Rotavirus (MC) --> winter, less than 7d
- Adenovirus (endemic) --> less tan 7d
- Norwalk (epidemic) --> 1-2d
70
Viral infectious diarrhea - symptoms
- Rotavirus: fever, emesis, NO BLOOD / viral prodrome
- Adenovirus: fever, emesis, NO BLOOD / viral prodrome
- Norwalk: explosive, cramping, pain
71
Necrotizing enterocoitis - definition / presentation
- premature infants, bowel undergoes necrosis and bacteria invade the wall (30% mortality)
- vomiting, abd distention
-FEVER
HYPOTHERMIA
72
Necrotizing enterocoitis - diagnostic tests
- abd x-ray: pneuatosis intestinalis
- CT: air in portal vein, dilated bowel loops, pneumoperitoneum (if perforation)
- frank or occult blood can be seen in stool
73
Necrotizing enterocoitis - treatment
- stop feeding
- IV fluids
- NGT
antibiotics: vano, gentamicin, metronidazole
if medical management fail --> surgery
74
how to estimate fluid loss of a baby after diarrhea
by the weight AND:
1. mild dehydr (3-5%): history of decreased intake or loss with minimal or no symptoms
2. Moderate (6-9%): decreased skin tugor, dry mucus membbranes, tachycardia, irritability, 2-3 sec capillary refill, low urinary output
3. Severe (10-15%), cool, clammy skin, more than 3 sec capil refill, cracked lips, dry mucus, sinken eyes, hypotension and signs of shock
75
IV fluids resuscitation - fluids?
20 ml / kg NORMAL saline IV
76
Hirschsprung vs Mecocium ileus
Hirschsprung --> Down, obstraction on Rectosygmoid, Normal Meconium consistency, (+) Squirt sign (explosion of gas and stools in rectal examination)
Meconium ileus --> CF, obstraction on ileum, inspissated meconum consistency, (-) Squirt sign
77
biliary atresia - presentation
jaundice and pale stools by the 2nd month
| well initially
78
Reye syndrome - biopsy / treatment
MICROVESICULAR fatty infiltration
| supportive
79
DDX of crying infant
1. Colic: more than 3h / day (usually evening, more than 3 times / wk, for 3 or more weeks
2. GERD: back pain during or after food (Sandifer syndrome), Frequent spits up or vomiting, poor weight gain
3. Corenal abrasion: (+) fluorescein examin)
4. Hair tourniquet: tied hair around extremity
5. Mild protein allergy: blood-steaked mucousy, loose stools, severe constipation
6. Normal infant crying: less than 2 h / day, resolves with consoling methds
80
CF - infertility ?
100% males
| 20% females
81
milk protein allergy present with
nonbillous voimiting and bloody stools or constipation
82
Diagnostic criteria of cyclic vomiting syndrome
1. 3 or more episodes in 6 months
2. easily recognisable to family (stereotypical)
3. lasts 1-10 days
4. vomiting 4 or more times/hr at peak
5. no symptoms in between episodes
6. no underling condition can be identified
83
cyclic vomiting syndrome - family history? / treatment
- family history of migraines often presents
| - antiemetics + antimigraine are often beneficial
84
advantages of human milk over formula
1. human decreases reflex + colic
2. contain lactoferin, lysozyme, and IgA
3. less Ca2+ and P+, but better absorbed
4. improves gastric emptying
5. contains proteins that are absorbed better (WHEY)
NO VIT D
85
necrotizing enterocolitis - RF
```
prematurity
LOW WIEGHT
enteral feeding (esp with formula - due to exposure to bacteria)
congenital heart disease
hypotension
```
86
malrotation - presentation - tests
bilious vomiting + abd distention
can progress oto ischemia, bloody stools, perforation
upper GI contrast study is te gold standard (croskscrew pattern)
x-ray: gasless
87
evaluation of bilious emesis in neonates
stop feeding, NG, IV fluids --> X-rays
1. double sign --> duodenal atresia
2. Free air, hematemesis, unstable vital --> sirgery
3. Dilated loops --> contrast enema --> microcolon (meconium eleus), transition zone (Hirschsprung)
4. NG tube in misplaced duodenum --> UPPER GI series --> Ligament of Treitz on the Right side --> malrotation
88
pediatric constipation - RF
1. initiation of solid food + cow milk
2. toilet training
3. school entry
89
pediatric complciations - treatment
dietery fibers + water
limit cow's milk
laxatives
90
direct hyperbilirubinemia means
CBD more than 2 or more than 20% of bilirubin
91
Biliary cysts - pathogenesis / diagnosis
```
type 1 (MC): extrahepatic, sinlge cystic dilation of biliary duct
- U/S / ERCP
```
92
biliary cyst - clinical manifestation
triad: pain, jaundice, palpable mass
| - usually before 10 years old
93
biliary cyst - treatment
surgical resection to relieve obstruction + prevent malignant transformation
94
Biliary atresia - diagnosis
U/S: absent or abnoarmal gallbladder
Hepatobiliaty scintigraphy
Liver biopsy
Intraoperative cholangiogram (glod standard): biliary obstruction
95
biliary atresia - treatment
Kasai procedure: hepatoportoenterostomy
| liver transplant
96
risk for iron def anemia in infants
prematurity
iron def mother
cow's milk before 1 year
97
intussusception - indications for laparotoy
1. perforation signs
2. enema inefective
3. pathologic lead point is identified
98
DDX of regurgitation + vomiting in infants
1. GERD
2. Milk protein allergy
3. Pyloric stenosis
99
GERD - types
physiologic: asymptomatic, happy spitter
pathologic: failure to thrive, signif irritability, Sandifer syndrome
100
GERD - management
physiol: reassurance, positional therapy
pathol: Thickened feeds, antiacids, if severe: PPI
101
Breastfeeding failure jaundice vs breast milk jaundice regarding timing and clinical features
1. Breastfeeding failure: 1 week, suboptimal breatfeeding, signs of dehydration
2. Breast milk jaundice: start on day 3, peaks on 2nd week. adequate breast feeding, normal examination
102
Breastfeeding failure jaundice vs breast milk jaundice regarding pathophysiology
1. Breastfeeding failure: lactation failure --> decreased bilirubin elimination, increaed enterohepatic circulation
2. breast milk jaundice: high levels of β-glucuronidase --> decongestate intestinal CB
BOTH UCB
103
how many breastfeeding the 1st month
8-12 times / day 10-20 mins per breast
104
how many stools per day the 1st week
the same as days of life
105
Milk- or soy-protein induced colitis - RF / prognosis
family history of allegies, eczema, asthma
| spontaneous resolution by age 1
106
milk- or soy-protein induced colitis - clinical features
```
age: 2-8 weeks
regurgiation or vomiting
+/- eczema
+/- painless bloody stools
NON IGE MEDIATED
```
107
milk- or soy-protein induced colitis - treatment
elimiantion of milk + soy from maternal diet of exclusively breastfed infants
initiation of hydrolyzed formula in formula fed infants
108
all patients with CF will develop
chronic rhinosinusitis
109
suspect eosinophilic esophagitis - next step
2 months trial of PPI --> if not improvement --> endoscopy (furrows + circular rings) and biopsy (at least 15 eosinoph)
(dietary modification)
110
triple bubble? / RF
jejunal atresia
| - RF: cocaine and other vasoconstrictors
111
swallowing of a coin
esophagus: if asymptomatic can be observed up to 24 hous --> if symptomatic or the time of ingestion is unknown --> remove by FLEXIBLE endoscopy
- stomach --> observation for 24 h
112
cow milk vs cow mild based formula - the same?
not the same --> the 2nd is the appropriate if no breast feeding
113
congenital umbilical hernia - clinical features / pathophysiology
1. soft nontender bulge at umbilicus
2. protrudes with increased abd pressure
3. typically reducible
- incomplete closure of abd muscles
114
congenital umb hernia - management
observe (for spontaneous closure)
| elective surgery at age 5
115
pediatric GI - down is associated with
1. hirsburg
2. duodenal atresia
3. imperforate anus
4. umbilical hernia
5. celiac
116
Beckwith-Wiedemann syndrome - phyisical examination
1. fetal macrosomia, rapid growth until late childhood
2. omphalocele or umbilical hernia
3. macroglossia
4. hemihyperplasia
117
Beckwith-Wiedemann syndrome - complications
1. Wilms tumor
| 2. hepatoblastoma
118
Beckwith-Wiedemann - surveillance
1. serum α-fetoprotein
2. abd/renal U/S
3. monitor for hypoglycemia
119
crying due to colics - next step
soothing and feeding techniques should be reviewed and parents should be emotionally supported and reassured
120
x-ray - coffee bean sign
U-shaped apperance of the distended sigmoid loop in volvulus
121
CF - typical level of obstruction in intestine
ileum
122
CF - hearing loss
in 20% due to frequent treatment with aminoglycosides from gram (-) infection)
123
Hirs vs CF regarding squirt sign
(+) only in hirschspung: forceful explusion of stool after rectal examination
124
mechanism of physiologic jaundice
1. high HCT
2. low activity of UGT
3. enterohepatic recycling is increased as the sterile newborn gut cannot break down bilirubin to urobilinogen
125
GERD is common in infants due to
shorter esophagus, incomplete closure of the LES, greater time spent in the supine position
126
Raye syndrome - jaundice?
usually no
127
Batteries in GI
esophagus --> remove immedeiately under endoscopic guidance
| distal to the esophagus- --> observe / stool examination and/or follow up x-rays to confirm excretion
128
CF in neonata - management
hyperosmolar enema to break up the inspissated meconium and disolve the obstruction --> if unsuccessul --> surgery
