GI Flashcards
Name the 3 broad causes of Failure to Thrive
Decreased intake
Malabsorption
Hypermetabolism (neoplasm, inflammatory, chronic diseases)
3 board categories (major macronutrients) of malabsorption
Protein malabsorption (CF, Schwachmann diamond) Fat malabsorption (choestasis, CF) CHO malabsorption (enzyme deficiencies, dietary causes)
What are the extraintestinal manifestations of Celiac Disease
- dermatitis herpetiformis
- dental enamel hypoplasia of permanent teeth
- osteopenia/ osteoporosis
- short stature
- delayed puberty
- iron deficiency anemia
- hepatitis
- arthritis
- epilepsy with occipital lobe calcifications
Conditions associated with Celiac Disease
- Down syndrome
- Turner syndrome
- Williams syndrome
- IgA deficiency
- Other autoimmune disorders (thyroid, arthritis, liver)
- DM I
- first degree relative with celiac (1:20)
What 3 foods contain gluten protein
“WE REMOVE BREAD”
wheat
rye
barley
What is the first line screening test for celiac disease
TTG-IGA
must measure serum IgA as well
patients with low serum IgA require endoscopic biopsy for diagnosis
2nd line- EMA-IGA
In children less than 2 what test must you order to test for celiac disease
DGP (deamidated gliadin peptide)
TTG-IgA is poor in children <2
What are FODMAPS
carbohydrates that tend to be highly fermentable F- fermentable O- oligosaccharides D- disaccharides M- monosaccharides P- polyols
What would you see on intestinal biopsy for celiac disease?
villous atrophy (duodenum or jejunum)
What is the treatment for celiac disease
Life-long gluten free diet
How do we diagnose celiac disease
- first line screening test- TTG-IgA
2. Intestinal biopsy (jejunum, duodenum)- villous atrophy
Differential diagnosis of terminal ileitis (7)
- Crohn’s disease
- yersinia infection
- severe eosinophilic gastroenteropathy
- lymphoma
- tuberculosis
- chronic granulomatous disease
- lymphonodular hyperplasia (normal finding)
Which of the following is not in the differential for terminal ileitis? Crohn's disease lymphoma tuberculosis yersinia infection celiac disease
celiac disease is NOT on the differential for terminal ileitis
UC:
- rectum
- distribution
- terminal ileum
- serosa
- bowel wall
- mucosa
- stricture
- fistula
- erythema nodosum
- uveitis
- PSC
- 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
Crohn’s:
- rectum
- distribution
- terminal ileum
- serosa
- bowel wall
- mucosa
- stricture
- fistula
- erythema nodosum
- uveitis
- PSC
- 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
What are the treatment options for Crohn’s/ UC to induce remission (4)
- tube feeds (common; Crohn’s only)
- corticosteroids (common)
- 5-ASA (mild)
- Biologics (severe)
What are the treatments options for Chron’s/UC to maintain remission (5)
Tube feeds (Crohn's only) 5-ASA (mild, UC only) Azathioprine (moderate) MTX (moderate) Biologics (severe) ** NOT STEROIDS**
What percentage of chronic constipation is functional? organic?
90% functional
10% organic
What are the organic causes of constipation? (11)
hypothyroidism lead poisoning celiac disease medications cystic fibrosis hirshprungs idiopathic CP neural tube defects hypercalcemia hypokalemia
Name 4 osmotic laxatives
PEG 3350
lactulose
docusate (colace)
magnesium citrate
Name 4 stimulant laxatives
bisacodyl (docolax) picosalax glycerin suppository phosphate enema senokot
What is the treamtent for GER
8 weeks of acid blockade (H2RB or PPI)
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)
- upper endoscopy to look for eosinophilic gastritis, hiatal hernia, gastritis
- 24 hour PH/impedance probe- physiologic, hiatal hernia, medications, dysmotility
Name 3 extensively hydrolyzed formulas
- Nutramigen
- Alimentum
- Progestimil
Name 2 amino acid based formulas
Neocate
Puramino
Treatment of BF baby with CMPA
remove milk protein in mothers milk
refer mother to dietician for ca supplementation (1000mg Ca2+)
What is the most common cause of LGI bleeding in infants?
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
What are Meckel’s rule of 2’s?
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
What is first line treatment for pinworms
Mebendazole
albendazole
Name the GI infections that present with bloody diarrhea (5)
salmonella shigella yersinia campylobacter e.coli
A patient is diagnosed with dientamoeba fragilis. Metronidazole fails to clear the infection. What is the next antibiotic choice?
paromomycin
What is the Rome IV criteria for infantile colic
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
Rome IV criteria for Functional diarrhea
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
Infant regurgitation Rome IV criteria
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
Rome IV criteria for infant dyschezia
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
Rome IV criteria cyclic vomiting syndrome
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
Rome IV rumination syndrome
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
Rome IV criteria for Irritable bowel syndrome
abdominal pain >4x per month with >1 of the following symptoms:
- timing related to defecation
- change in frequency of stool
- change in form of stool
Rome IV criteria for abdominal migraine
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
anorexiaRome IV criteria for functional constipation
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
Nonretentive fecal incontinence
at least 1 month of episodes
>=1/month defecation in places inappropriate to social context
- no fecal retention
- not attributable to another condition
What are some red flags for organic causes of abdominal pain
weight loss hematemesis hematochezia nocturnal symptoms delayed puberty arthritis oral ulcers chronic diarrhea unexplained rashes bilious emesis dysphagia anemia/pallor decreased linear growth velocity
What is the gold standard for diagnosing hirschsprungs disease?
rectal biopsy
what is a screening test for hirschprungs disease?
barium enema
Empty rectal vault and “blast sign” on DRE is suggestive of what?
Hirschprungs disease
Blast sign (explosive stool output upon
DRE)
Barium (contrast) enema: transition
zone
What would you see on rectal biopsy for Hirschsprungs disease (3 things)?
absent ganglion cells
hypertrophic nerve fibres
increased cholinesterase staining
Young child with 2 episodes of rectal
prolapse. What test should you do? what are you looking for?
sweat chloride
have to rule out CF
What is the definitive test for celiac disease?
endoscopic biopsy (small bowel biopsy)
List 4 causes of intestinal flat villi besides Celiac disease
- rotavirus
- sprue
- CMPA
- eosinophilic gastroenteritis
What vitamin deficiency can you have if the terminal ileum is resected?
Vit B12
What are 2 skin manifestations of Crohn’s disease?
erythema nodosum
pyoderma gangrenosum
metastatic Crohn’s
What is the differential for erythema nodosum (7)
IBD sarcoid TB fungal infection strep infection Bechett's meds (OCP, sulpha drugs)
why do patients with IBD lose weight?
inadequate nutrient intake
they don’t feel well therefore they don’t eat
Ecoli UTI + jaundice=
galactosemia
What tests would you order if you suspect biliary atresia and what is the diagnostic test?
- AUS
- HIDA scan
- Cholangiogram + biopsy= diagnostic test
What is the treatment for biliary atresia?
kasai
What is the leading indication for liver transplant in peds?
biliary atresia
What is a key feature of biliary atresia on history?
pale (acholic) stools
What are the “BIG 5” things to investigate for hyperbilirubinemia
- biliary atresia- abdo ultrasound
- Thyroid- TSH/free T4
- 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)
- Tyrosinemia- urine succinylacetone
- TORCH- ucx +/- other culture, TORCH w/u including urine CMV
what investigations would you do for autoimmune hepatitis
immunoglobulins, anti-SMA, anti-LKM, ANA
what investigations would you do for Wilson’s disease (3)
serum copper, ceruloplasmin, 24 hour urinary cu
what investigations would you do for acute liver failure?
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)
what are the vitamin k dependent factors?
1972 10 9 7 2
what is the only factor that is made outside of the liver?
factor 8
normal if liver if the cause of coagulopathy and abnormal if DIC
Name 2 signs of portal hypertension on physical exam in a child with liver disease
hepatosplenomegaly
ascites
caput medusae
what IBD is associated with PSC
UC
60-80% of patients with PSC have IBD
what would you see on MRCP with PSC
“beading”
(alternating
dilated and narrowed segments on MRCP, “beading”)
what liver enzyme is particularly elevated with PSC
GGT
What would you see on slit lamp for Wilsons disease?
kayser fleischer ring
what is the treatment for Wilsons disease?
copper chelation (penicillamine)
Wilsons disease does not usually present in children less than?
wilsons disease does not usually present in children less than 3
what is acrodermatitis enteropathica
Autosomal recessive disorder caused by inability to absorb sufficient zinc
where is the characteristic rash found for acrodermatitis enteropathica
mouth
perianal
what is the classic finding for kwashiorkor
edema
enlarged abdomen
due to low protein intake
normal caloric intake
What is the classic finding for marasmus
emaciation
low protein intake and low caloric intake
<70% ideal weight
vit A deficiency results in what
night blindness
bitot spots
vit D deficiency
ricketts (dichotic rosary)
cupping of metaphysis
vit e deficiency
hemolytic anemia
neurologic deficit
vit k deficiency
coagulopathy
abnormal bone matrix synthesis
vit B1 (thiamine) deficiency
Beriberi
Niacin deficiency (Pellagra)
4D's dermatitis (necklace rash) **photosensitive! diarrhea dementia death
what is the treatment for acrodermatitis enteropathica
zinc 1mg/kg/day for life
what does a folate deficiency in the mother cause for a baby
NTD
Vit B12 deficiency
megaloblastic anemia
paresthesias
vit C deficiency
scurvy- bleeding gums, petechia, anemia
if they say vegan think what vitamin deficiency
B12
Cheilosis is a sign of what?
iron deficiency
Glossitis is a sign of what?
B2 (Riboflavin) deficiency
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
goat’s milk= deficient in folate
perioral/bum rash + diarrhea=
zinc deficiency/acrodermatitis enteropathica
Dark skin baby, bow-legged, metaphyseal cupping/flaring, rachitic rosary, Harrison groove, delayed walking
Ricket’s, check a 25OHD level
Phytoestrogens in soy milk are contraindicated in what condition?
congenital hypothyroidism
phytoestrogens can inhibit thyroid peroxidase, potentially lowering free thyroxine concentrations
what is the whey to casein ratio in breastmilk
70 whey: 30 casein
Whey fraction promotes gastric emptying, more easily absorbed
what are the maternal contraindications to breastfeeding?
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)
what are the baby contraindications to breastfeeding?
galactosemia
what percentage of weight loss is expected in the first week
lose 7-10% birth weight in first week
should be back to birth weight by 2 weeks
what are some advantages to breastfeeding
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
what is the current recommendation for breastfeeding
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
what two findings are associated with Peutz–Jeghers syndrome
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
Peutz-Jeghers syndrome is associated with _________ due to small bowel polyps
intussusception
A button battery in the stomach should be removed when?
within 48 hours
a button battery in the esophagus should be removed when?
emergently!
worry about aorto-enteric fistula
what are the electrolyte abnormalities associated with pyloric stenosis
hypochloremic, hypokalemic metabolic alkalosis
gastroschesis is associated with higher rates of what 3 things?
malrotation, intestinal atresia and NEC
Describe some of the findings for Alagille syndrome
- pointed chin
- paucity of bile ducts
- posterior embrytoxin
- butterfly vertebrae
- deep set eyes
- heart things (pulmonary stenosis mostly but can be TOF)
what would you see on ultrasound for biliary atresia
unable to visualize the gallbladder
triangular cord sign
what is the most common pathological lead point for intussusception?
meckel’s diverticulum
what is the most specific test for pancreatitis?
lipase
what is Eosinophilic esophagitis
esophageal dysfunction and infiltration of esophageal epithelium by >15 eosinophils per high power field
what are the treatment options for eosinophilic esophagitis
PPI
elimination diet
Topically acting swallowed corticosteroids (fluticasone)
Palpable olive in the abdomen
pyloric stenosis
what is the best test of hepatic synthetic function?
INR
what is an example of a non-reducing sugar?
sucrose
HAV infected patients are contagious for ??
HAV infected patients are contagious for 2 wk before and 7 days after onset of jaundice
how do you treat pouchitis?
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
what is the worst complication of Vitamin B12 deficiency
neurological signs (hypotonia, irritability, regression, involuntary movements)
Name 3 dermatological manifestations of a kid with IBD features
erythema nodosum pyoderma gangrenosum oral ulcers metastic crohn's perianal skin tags
name 2 ways to diagnose pinworms
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
What is the difference radiographically between a coin in the esophagus and a coin in the trachea
coin in the esophagus looks front on in anterior view whereas coin in the trachea looks front on in the lateral view
Why is it important to confirm a diagnosis of juvenile polyposis?
the are at increased risk of adenocarcinoma
What is the most common cause of encopresis?
functional constipation with overflow incontinence
Failure to pass stool within the first _____ hours of life should be considered pathologic until proved otherwise.
48
What stool test is most useful for helping diagnose GI protein loss?
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
How is lactose intolerance diagnosed?
hydrogen breath test
What is the role of stool elastase measurement?
screen for pancreatic insufficiency
What are the clinical manifestations of typhoid fever?
fever, abdominal pain, nausea, decreased appetite. Diarrhea begins after one week
decreased HR despite fever
What is the most common cause of travelers’ diarrhea?
Enterotoxigenic E. coli
ETEC
12 yo with chronic transaminase elevation and hyperechogenic liver. What is the likely diagnosis?
NAFLD
- consider when BMI >85%
what are two things that helps improve NAFLD?
weight loss
exercise
what is the acute management of pancreatitis?
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
AST> ALT think:
ethanol myopathies renal syndromes hemolysis (eg capillary blood sample) intestinal inflammation adenovirus infection
If ALP is abnormally low think…
zinc deficiency
If ALP is normal and other enzymes are high think…
Wilsons disease
HBsAg -
HBsAb +
hepatitis B immune
cleared infection long ago
HBsAg +
HBsAb +
HBeAg +
HbeAb -
chronic active infection
What test is required to diagnose H. Pylori?
Esophagoduodenoscopy with biopsy
Shwachman-Diamond baby. Which vitamin level would be normal? Vit A Vit E Vit B12 Vit D
Vit B12
they have exocrine pancreatic insufficiency therefore affects fat soluble vitamins (ADEK)
Kid with Alagille syndrome. Classic eye finding: Chorioretinitis Posterior embryotoxin Glaucoma Cataract
Posterior embryotoxin
What is Fitz-Hugh-Curtis syndrome
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
2 life threatening complications of ulcerative colitis
- colon cancer
2. toxic megacolon
Neonate on TPN. List four things that will increase his incidence of cholestasis.
- duration of TPN
- prematurity
- sepsis- gram neg sepsis
- NEC
- short gut syndrome
Surveillance recommendations for Hepatitis B (7)
• 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
what are 2 long term risks associated with hepatitis B
- hepatocellular carcinoma
2. cirrhosis
In a patient with short gut….Of the fat soluble vitamins, which one will not be deficient and why?
vit k- intestinal bacteria primarily synthesize vit k
Ddx progressive dysphagia to solids (5)
- Malignancy
- esophageal stricture
- achalasia
- esophageal ring/web
- scleroderma
what is a common renal complication in IBD
nephrolithiasis (particularly oxalate stones)
what are two indications for soy formula
galactosemia
religious/cultural reasons (veganism)
what GI complication is seen post Fontan
protein losing enteropathy
Name 3 complications of corrective surgery for Hischprung’s disease
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.
