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Pediatrics- Noelle > GI > Flashcards

GI Flashcards

1
Q

Name the 3 broad causes of Failure to Thrive

A

Decreased intake
Malabsorption
Hypermetabolism (neoplasm, inflammatory, chronic diseases)

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2
Q

3 board categories (major macronutrients) of malabsorption

A 
Protein malabsorption (CF, Schwachmann diamond)
Fat malabsorption (choestasis, CF)
CHO malabsorption (enzyme deficiencies, dietary causes)
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3
Q

What are the extraintestinal manifestations of Celiac Disease

A
  1. dermatitis herpetiformis
  2. dental enamel hypoplasia of permanent teeth
  3. osteopenia/ osteoporosis
  4. short stature
  5. delayed puberty
  6. iron deficiency anemia
  7. hepatitis
  8. arthritis
  9. epilepsy with occipital lobe calcifications
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4
Q

Conditions associated with Celiac Disease

A
  1. Down syndrome
  2. Turner syndrome
  3. Williams syndrome
  4. IgA deficiency
  5. Other autoimmune disorders (thyroid, arthritis, liver)
  6. DM I
  7. first degree relative with celiac (1:20)
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5
Q

What 3 foods contain gluten protein

A

“WE REMOVE BREAD”
wheat
rye
barley

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6
Q

What is the first line screening test for celiac disease

A

TTG-IGA
must measure serum IgA as well
patients with low serum IgA require endoscopic biopsy for diagnosis
2nd line- EMA-IGA

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7
Q

In children less than 2 what test must you order to test for celiac disease

A

DGP (deamidated gliadin peptide)

TTG-IgA is poor in children <2

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8
Q

What are FODMAPS

A 
carbohydrates that tend to be highly fermentable
F- fermentable
O- oligosaccharides
D- disaccharides
M- monosaccharides
P- polyols
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9
Q

What would you see on intestinal biopsy for celiac disease?

A

villous atrophy (duodenum or jejunum)

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10
Q

What is the treatment for celiac disease

A

Life-long gluten free diet

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11
Q

How do we diagnose celiac disease

A
  1. first line screening test- TTG-IgA

2. Intestinal biopsy (jejunum, duodenum)- villous atrophy

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12
Q

Differential diagnosis of terminal ileitis (7)

A
  1. Crohn’s disease
  2. yersinia infection
  3. severe eosinophilic gastroenteropathy
  4. lymphoma
  5. tuberculosis
  6. chronic granulomatous disease
  7. lymphonodular hyperplasia (normal finding)
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13
Q 
Which of the following is not in the differential for terminal ileitis?
Crohn's disease
lymphoma
tuberculosis
yersinia infection
celiac disease
A

celiac disease is NOT on the differential for terminal ileitis

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14
Q

UC:

  • rectum
  • distribution
  • terminal ileum
  • serosa
  • bowel wall
  • mucosa
  • stricture
  • fistula
  • erythema nodosum
  • uveitis
  • PSC
A
  • rectum= YES
  • distribution= Diffuse
  • terminal ileum= NOT INVOLVED**
  • serosa- Usually normal
  • bowel wall- NORMAL
  • mucosa- Hemorrhagic
  • stricture- RARE
  • fistula- RARE
  • erythema nodosum- RARE
  • uveitis- COMMON
  • PSC- COMMON
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15
Q

Crohn’s:

  • rectum
  • distribution
  • terminal ileum
  • serosa
  • bowel wall
  • mucosa
  • stricture
  • fistula
  • erythema nodosum
  • uveitis
  • PSC
A
  • rectum- variable
  • distribution- segmental/diffuse
  • terminal ileum- YES
  • serosa- creeping fat
  • bowel wall- THICKENED
  • mucosa- cobblestone/linear
  • stricture- COMMON
  • fistula- COMMON
  • erythema nodosum- COMMON
  • uveitis- COMMON
  • PSC- RARE
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16
Q

What are the treatment options for Crohn’s/ UC to induce remission (4)

A
  1. tube feeds (common; Crohn’s only)
  2. corticosteroids (common)
  3. 5-ASA (mild)
  4. Biologics (severe)
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17
Q

What are the treatments options for Chron’s/UC to maintain remission (5)

A 
Tube feeds (Crohn's only)
5-ASA (mild, UC only)
Azathioprine (moderate)
MTX (moderate)
Biologics (severe)
** NOT STEROIDS**
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18
Q

What percentage of chronic constipation is functional? organic?

A

90% functional

10% organic

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19
Q

What are the organic causes of constipation? (11)

A 
hypothyroidism
lead poisoning
celiac disease
medications
cystic fibrosis
hirshprungs
idiopathic
CP
neural tube defects
hypercalcemia
hypokalemia
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20
Q

Name 4 osmotic laxatives

A

PEG 3350
lactulose
docusate (colace)
magnesium citrate

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21
Q

Name 4 stimulant laxatives

A 
bisacodyl (docolax)
picosalax
glycerin suppository
phosphate enema
senokot
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22
Q

What is the treamtent for GER

A

8 weeks of acid blockade (H2RB or PPI)

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23
Q

What is the next step if there is no resolution of GER after 8 weeks of acid blockade or recurrence after weaning the medication (2)

A
  1. upper endoscopy to look for eosinophilic gastritis, hiatal hernia, gastritis
  2. 24 hour PH/impedance probe- physiologic, hiatal hernia, medications, dysmotility
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24
Q

Name 3 extensively hydrolyzed formulas

A
  1. Nutramigen
  2. Alimentum
  3. Progestimil
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25
Q

Name 2 amino acid based formulas

A

Neocate

Puramino

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26
Q

Treatment of BF baby with CMPA

A

remove milk protein in mothers milk

refer mother to dietician for ca supplementation (1000mg Ca2+)

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27
Q

What is the most common cause of LGI bleeding in infants?

A 
CMPA
-2-3% of formula feeders will develop
- 0.5% breastfeeders will develop
cross reactivity in 10-15% receiving soy-formula
colitis may take 2-4 weeks to resolve
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28
Q

What are Meckel’s rule of 2’s?

A 
age <2 most common age
2 feet from ileocecal valve
2:1 male:female
2% develop bleeding
2 types of mucosa in diverticulum: native + heterotypic gastric/pancreatic/colonic
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29
Q

What is first line treatment for pinworms

A

Mebendazole

albendazole

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30
Q

Name the GI infections that present with bloody diarrhea (5)

A 
salmonella
shigella
yersinia
campylobacter
e.coli
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31
Q

A patient is diagnosed with dientamoeba fragilis. Metronidazole fails to clear the infection. What is the next antibiotic choice?

A

paromomycin

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32
Q

What is the Rome IV criteria for infantile colic

A

infant <5 months of age when symptoms start and stop
recurrent and prolonged episodes of crying, fussing or irritability without obvious cause, cannot prevent or resolve
no history of FTT, fever or illness
episodes lasting >3h/day for 3 days per week for at least 1 week

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33
Q

Rome IV criteria for Functional diarrhea

A 
daily, painless, >4 large unformed stools
>4 weeks
onset 6-60 months of age (5 years)
occurs during waking hours
no FTT if caloric intake adequate
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34
Q

Infant regurgitation Rome IV criteria

A 
age 2-12 months
>2 episodes per day for > 3 weeks
Characterized by features that are NOT SEEN:
- retching
- hematemesis
- aspiration
- apnea 
- FTT
- feeding or swallowing difficulties
- abnormal posturing
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35
Q

Rome IV criteria for infant dyschezia

A

discoordination between relaxation of external anal sphincter and contraction of pelvic muscles
<9 months old
>10 minutes of straining and crying before successful passage of soft stool
otherwise healthy

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36
Q

Rome IV criteria cyclic vomiting syndrome

A

At least five attacks in any interval or a minimum of three attacks during a six-month period
Episodic attacks of intense nausea and vomiting lasting one hour to 10 days and occurring at least one week apart
Stereotypical pattern and symptoms in the individual patient
Vomiting during attacks occurs at least four times per hour for at least one hour
Return to baseline health between episodes
Not attributed to another disorder

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37
Q

Rome IV rumination syndrome

A

repeated or painless regurgitation and reviewing or expulsion of food that:
- begins soon after ingestion of a meal
- does not occur during sleep
No retching
No organic explanation
Eating disorder must be ruled out

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38
Q

Rome IV criteria for Irritable bowel syndrome

A

abdominal pain >4x per month with >1 of the following symptoms:

  1. timing related to defecation
  2. change in frequency of stool
  3. change in form of stool
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39
Q

Rome IV criteria for abdominal migraine

A 
must occur >2x:
     - paroxysmal episodes of intense acute, periumbilical pain for >= 1 hour
     -healthy for weeks to months between episodes
     -interferes with normal activities
sterotypical pattern
>= 2 of the following symptoms:
headache
pallor
nausea
vomiting
photophobia
anorexia
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40
Q

Rome IV criteria for functional constipation

A

2 or more of the following at least once per week for more than one month
not IBS
1. <=2 bowel movements/weeks in a child developmentally >= 4 yo
2. >= 1 episode of focal incontinence/week
3. retentive posturing
4. painful or hard bowel movements
5. large fecal mass in rectum
6. large diameter stools that may block the toilet
symptoms not fully explained by another medical condition

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41
Q

Nonretentive fecal incontinence

A

at least 1 month of episodes
>=1/month defecation in places inappropriate to social context
- no fecal retention
- not attributable to another condition

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42
Q

What are some red flags for organic causes of abdominal pain

A 
weight loss
hematemesis
hematochezia
nocturnal symptoms
delayed puberty
arthritis
oral ulcers
chronic diarrhea
unexplained rashes
bilious emesis
dysphagia
anemia/pallor
decreased linear growth velocity
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43
Q

What is the gold standard for diagnosing hirschsprungs disease?

A

rectal biopsy

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44
Q

what is a screening test for hirschprungs disease?

A

barium enema

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45
Q

Empty rectal vault and “blast sign” on DRE is suggestive of what?

A

Hirschprungs disease

Blast sign (explosive stool output upon
DRE)
Barium (contrast) enema: transition
zone

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46
Q

What would you see on rectal biopsy for Hirschsprungs disease (3 things)?

A

absent ganglion cells
hypertrophic nerve fibres
increased cholinesterase staining

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47
Q

Young child with 2 episodes of rectal

prolapse. What test should you do? what are you looking for?

A

sweat chloride

have to rule out CF

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48
Q

What is the definitive test for celiac disease?

A

endoscopic biopsy (small bowel biopsy)

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49
Q

List 4 causes of intestinal flat villi besides Celiac disease

A
  1. rotavirus
  2. sprue
  3. CMPA
  4. eosinophilic gastroenteritis
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50
Q

What vitamin deficiency can you have if the terminal ileum is resected?

A

Vit B12

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51
Q

What are 2 skin manifestations of Crohn’s disease?

A

erythema nodosum
pyoderma gangrenosum
metastatic Crohn’s

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52
Q

What is the differential for erythema nodosum (7)

A 
IBD
sarcoid
TB
fungal infection
strep infection
Bechett's
meds (OCP, sulpha drugs)
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53
Q

why do patients with IBD lose weight?

A

inadequate nutrient intake

they don’t feel well therefore they don’t eat

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54
Q

Ecoli UTI + jaundice=

A

galactosemia

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55
Q

What tests would you order if you suspect biliary atresia and what is the diagnostic test?

A
  1. AUS
  2. HIDA scan
  3. Cholangiogram + biopsy= diagnostic test
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56
Q

What is the treatment for biliary atresia?

A

kasai

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57
Q

What is the leading indication for liver transplant in peds?

A

biliary atresia

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58
Q

What is a key feature of biliary atresia on history?

A

pale (acholic) stools

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59
Q

What are the “BIG 5” things to investigate for hyperbilirubinemia

A
  1. biliary atresia- abdo ultrasound
  2. Thyroid- TSH/free T4
  3. Galactosemia- urine for reducing substances/ RBC GALT (The demonstration of nearly complete absence of galactose-1-phosphate uridyl transferase (GALT) activity in RBCs is the gold standard for diagnosis)
  4. Tyrosinemia- urine succinylacetone
  5. TORCH- ucx +/- other culture, TORCH w/u including urine CMV
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60
Q

what investigations would you do for autoimmune hepatitis

A

immunoglobulins, anti-SMA, anti-LKM, ANA

61
Q

what investigations would you do for Wilson’s disease (3)

A

serum copper, ceruloplasmin, 24 hour urinary cu

62
Q

what investigations would you do for acute liver failure?

A

cbc, lytes, bun, cre, lfts, ggt
Liver function tests: albumin, inr, glucose, ammonia, albumin, bilirubin
acetaminophen, tox screen
Infectious- Hep A, B, C, EBV, CMV
alpha 1 antitrypsin
AIH- immunoglobulins, anti- SMA, anti- LKM, ANA
Wilsons- ceruloplasmin, serum copper, 24 h urinary cu
ferritin (HLH)

63
Q

what are the vitamin k dependent factors?

A 
1972
10
9
7
2
64
Q

what is the only factor that is made outside of the liver?

A

factor 8

normal if liver if the cause of coagulopathy and abnormal if DIC

65
Q

Name 2 signs of portal hypertension on physical exam in a child with liver disease

A

hepatosplenomegaly
ascites
caput medusae

66
Q

what IBD is associated with PSC

A

UC

60-80% of patients with PSC have IBD

67
Q

what would you see on MRCP with PSC

A

“beading”
(alternating
dilated and narrowed segments on MRCP, “beading”)

68
Q

what liver enzyme is particularly elevated with PSC

A

GGT

69
Q

What would you see on slit lamp for Wilsons disease?

A

kayser fleischer ring

70
Q

what is the treatment for Wilsons disease?

A

copper chelation (penicillamine)

71
Q

Wilsons disease does not usually present in children less than?

A

wilsons disease does not usually present in children less than 3

72
Q

what is acrodermatitis enteropathica

A

Autosomal recessive disorder caused by inability to absorb sufficient zinc

73
Q

where is the characteristic rash found for acrodermatitis enteropathica

A

mouth

perianal

74
Q

what is the classic finding for kwashiorkor

A

edema
enlarged abdomen
due to low protein intake
normal caloric intake

75
Q

What is the classic finding for marasmus

A

emaciation
low protein intake and low caloric intake
<70% ideal weight

76
Q

vit A deficiency results in what

A

night blindness

bitot spots

77
Q

vit D deficiency

A

ricketts (dichotic rosary)

cupping of metaphysis

78
Q

vit e deficiency

A

hemolytic anemia

neurologic deficit

79
Q

vit k deficiency

A

coagulopathy

abnormal bone matrix synthesis

80
Q

vit B1 (thiamine) deficiency

A

Beriberi

81
Q

Niacin deficiency (Pellagra)

A 
4D's
dermatitis (necklace rash) **photosensitive!
diarrhea
dementia
death
82
Q

what is the treatment for acrodermatitis enteropathica

A

zinc 1mg/kg/day for life

83
Q

what does a folate deficiency in the mother cause for a baby

A

NTD

84
Q

Vit B12 deficiency

A

megaloblastic anemia

paresthesias

85
Q

vit C deficiency

A

scurvy- bleeding gums, petechia, anemia

86
Q

if they say vegan think what vitamin deficiency

A

B12

87
Q

Cheilosis is a sign of what?

A

iron deficiency

88
Q

Glossitis is a sign of what?

A

B2 (Riboflavin) deficiency

89
Q 
Question: A child is currently on goat’s milk. What do
you recommend supplementing with?
A. Folic acid
B. Iron
C. Multivitamin
C. Vitamin B12
A

goat’s milk= deficient in folate

90
Q

perioral/bum rash + diarrhea=

A

zinc deficiency/acrodermatitis enteropathica

91
Q

Dark skin baby, bow-legged, metaphyseal cupping/flaring, rachitic rosary, Harrison groove, delayed walking

A

Ricket’s, check a 25OHD level

92
Q

Phytoestrogens in soy milk are contraindicated in what condition?

A

congenital hypothyroidism

phytoestrogens can inhibit thyroid peroxidase, potentially lowering free thyroxine concentrations

93
Q

what is the whey to casein ratio in breastmilk

A

70 whey: 30 casein

Whey fraction promotes gastric emptying, more easily absorbed

94
Q

what are the maternal contraindications to breastfeeding?

A

HIV infection
chemotherapy/cytotoxic drugs
radioactive isotopes/radiation therapy
active TB or brucellosis
Human T-cell lymphotrophic virus types I and II (HTLV type I and II)
Some drugs (eg. Primaquine, quinine, high dose metronidazole)

95
Q

what are the baby contraindications to breastfeeding?

A

galactosemia

96
Q

what percentage of weight loss is expected in the first week

A

lose 7-10% birth weight in first week

should be back to birth weight by 2 weeks

97
Q

what are some advantages to breastfeeding

A 
Decreases:
Bacterial meningitis
Bacteremia
Diarrhea
Respiratory tract infections
OM
UTIs
Negative effects of 2nd hand smoke
decreases SIDS

Increases:
Neurocognitive testing
Postpartum weight loss
Protection for mom from Breast cancer & Ovarian cancer
Faster gastric emptying
Less GERD
Stimulates intestinal growth, differentiation

98
Q

what is the current recommendation for breastfeeding

A

babies should be exclusively breastfeed for 6 months
Beyond 6 months = increased risk for iron def.
continue with complementary foods until ≥ 2 years
- first complementary foods should be iron rich

99
Q

what two findings are associated with Peutz–Jeghers syndrome

A

Autosomal dominant condition associated with:
benign polyps in the GI tract
hyper pigmented macules on the lips and oral mucosa
They are at increased lifetime risk of GI malignancies

100
Q

Peutz-Jeghers syndrome is associated with _________ due to small bowel polyps

A

intussusception

101
Q

A button battery in the stomach should be removed when?

A

within 48 hours

102
Q

a button battery in the esophagus should be removed when?

A

emergently!

worry about aorto-enteric fistula

103
Q

what are the electrolyte abnormalities associated with pyloric stenosis

A

hypochloremic, hypokalemic metabolic alkalosis

104
Q

gastroschesis is associated with higher rates of what 3 things?

A

malrotation, intestinal atresia and NEC

105
Q

Describe some of the findings for Alagille syndrome

A
  • pointed chin
  • paucity of bile ducts
  • posterior embrytoxin
  • butterfly vertebrae
  • deep set eyes
  • heart things (pulmonary stenosis mostly but can be TOF)
106
Q

what would you see on ultrasound for biliary atresia

A

unable to visualize the gallbladder

triangular cord sign

107
Q

what is the most common pathological lead point for intussusception?

A

meckel’s diverticulum

108
Q

what is the most specific test for pancreatitis?

A

lipase

109
Q

what is Eosinophilic esophagitis

A

esophageal dysfunction and infiltration of esophageal epithelium by >15 eosinophils per high power field

110
Q

what are the treatment options for eosinophilic esophagitis

A

PPI
elimination diet
Topically acting swallowed corticosteroids (fluticasone)

111
Q

Palpable olive in the abdomen

A

pyloric stenosis

112
Q

what is the best test of hepatic synthetic function?

A

INR

113
Q

what is an example of a non-reducing sugar?

A

sucrose

114
Q

HAV infected patients are contagious for ??

A

HAV infected patients are contagious for 2 wk before and 7 days after onset of jaundice

115
Q

how do you treat pouchitis?

A

Pouchitis commonly responds to treatment with Oral metronidazole or ciprofloxacin
Probiotics have also been shown to decrease the rate of pouchitis as well as the recurrence of pouchitis following antibiotics

116
Q

what is the worst complication of Vitamin B12 deficiency

A

neurological signs (hypotonia, irritability, regression, involuntary movements)

117
Q

Name 3 dermatological manifestations of a kid with IBD features

A 
erythema nodosum
pyoderma gangrenosum
oral ulcers
metastic crohn's
perianal skin tags
118
Q

name 2 ways to diagnose pinworms

A

direct visualization of adult worm in perianal area (usually best 2-3h after going to bed)
transparent adhesive tape to perianal area to collect eggs, look under low-power microscopy

119
Q

What is the difference radiographically between a coin in the esophagus and a coin in the trachea

A

coin in the esophagus looks front on in anterior view whereas coin in the trachea looks front on in the lateral view

120
Q

Why is it important to confirm a diagnosis of juvenile polyposis?

A

the are at increased risk of adenocarcinoma

121
Q

What is the most common cause of encopresis?

A

functional constipation with overflow incontinence

122
Q

Failure to pass stool within the first _____ hours of life should be considered pathologic until proved otherwise.

A

48

123
Q

What stool test is most useful for helping diagnose GI protein loss?

A

Fecal α1-antitrypsin measurement is the most useful stool marker of protein malabsorption.
It is important to measure serum α1-antitrypsin to ensure that the patient does not have α1-antitrypsin deficiency

124
Q

How is lactose intolerance diagnosed?

A

hydrogen breath test

125
Q

What is the role of stool elastase measurement?

A

screen for pancreatic insufficiency

126
Q

What are the clinical manifestations of typhoid fever?

A

fever, abdominal pain, nausea, decreased appetite. Diarrhea begins after one week
decreased HR despite fever

127
Q

What is the most common cause of travelers’ diarrhea?

A

Enterotoxigenic E. coli

ETEC

128
Q

12 yo with chronic transaminase elevation and hyperechogenic liver. What is the likely diagnosis?

A

NAFLD

- consider when BMI >85%

129
Q

what are two things that helps improve NAFLD?

A

weight loss

exercise

130
Q

what is the acute management of pancreatitis?

A

1.5-2x maintenance
early enteral nutrition **
- if not tolerated then NJ tube feeding, if not tolerated then TPN
watch for complications (SIRS response)- due to necrotizing pancreatitis
* early nutrition is important for the intestine to rehabilitate

131
Q

AST> ALT think:

A 
ethanol
myopathies
renal syndromes
hemolysis (eg capillary blood sample)
intestinal inflammation
adenovirus infection
132
Q

If ALP is abnormally low think…

A

zinc deficiency

133
Q

If ALP is normal and other enzymes are high think…

A

Wilsons disease

134
Q

HBsAg -

HBsAb +

A

hepatitis B immune

cleared infection long ago

135
Q

HBsAg +
HBsAb +
HBeAg +
HbeAb -

A

chronic active infection

136
Q

What test is required to diagnose H. Pylori?

A

Esophagoduodenoscopy with biopsy

137
Q 
Shwachman-Diamond baby.  Which vitamin level would be normal?
Vit A
Vit E
Vit B12
Vit D
A

Vit B12

they have exocrine pancreatic insufficiency therefore affects fat soluble vitamins (ADEK)

138
Q 
Kid with Alagille syndrome. Classic eye finding:
Chorioretinitis
Posterior embryotoxin
Glaucoma
Cataract
A

Posterior embryotoxin

139
Q

What is Fitz-Hugh-Curtis syndrome

A

Fitz-Hugh-Curtis syndrome, or perihepatitis, is a chronic manifestation of pelvic inflammatory disease (PID). It is described as an inflammation of the liver capsule often due to Chlamydia

140
Q

2 life threatening complications of ulcerative colitis

A
  1. colon cancer

2. toxic megacolon

141
Q

Neonate on TPN. List four things that will increase his incidence of cholestasis.

A
  1. duration of TPN
  2. prematurity
  3. sepsis- gram neg sepsis
  4. NEC
  5. short gut syndrome
142
Q

Surveillance recommendations for Hepatitis B (7)

A 
• Measure ALT q6months in children >2yo
• Measure HBeAg and HBeAb yearly in
patients with normal ALT
• Liver biopsy in children >2yo with
elevated ALT
• Examine for chronic liver disease
• Immunize household
• Immunize patient against Hepatitis A
• Alpha fetoprotein and ultrasound annually
143
Q

what are 2 long term risks associated with hepatitis B

A
  1. hepatocellular carcinoma

2. cirrhosis

144
Q

In a patient with short gut….Of the fat soluble vitamins, which one will not be deficient and why?

A

vit k- intestinal bacteria primarily synthesize vit k

145
Q

Ddx progressive dysphagia to solids (5)

A
  1. Malignancy
  2. esophageal stricture
  3. achalasia
  4. esophageal ring/web
  5. scleroderma
146
Q

what is a common renal complication in IBD

A

nephrolithiasis (particularly oxalate stones)

147
Q

what are two indications for soy formula

A

galactosemia

religious/cultural reasons (veganism)

148
Q

what GI complication is seen post Fontan

A

protein losing enteropathy

149
Q

Name 3 complications of corrective surgery for Hischprung’s disease

A 
constipation
recurrent enterocolitis
stricture
prolapse
perianal abscesses
fecal soiling

Hirschsprung disease–associated enterocolitis can occur at any time prior to or following surgery and is the leading cause of death in these patients.

Pediatrics- Noelle (28 decks)

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