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Cat's Questions > GI > Flashcards

GI Flashcards

1
Q

7 year old male with chronic GERD. He develops progressive distances to solids. He has lost 2.3kg as a result of his restrictive eating. Labs are normal. Best text for diagnosis ?

A. Hydrogen breath test
B. H. Pylori serology
C. Upper endoscopy and biopsy
D. Upper GI series

A

C. Upper endoscopy and biopsy

Dysphagia for solids most commonly caused by esophageal inflammation related to GERD, eosinophilia esophagitis or esophageal stricture. These patients should be evaluated by upper endoscopy with biopsies , to examine the esophageal mucosa

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2
Q

Babe crying every time she stools, mom has been to many doctors due to this. Thriving well.

A. Stop breastfeeding
B. Reassure
C. Hydrolyzed formula

A

B. Reassure

Controversial - colic vs CMPA vs normal - need age of the patient as crying when wet or after stool can be normal neonatal/infant behaviour

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3
Q

Toddler with intussuscwption, seen before and had air enema reduction. Returns with similar symptoms, but now looks sick, tachycardic, hypotensive. What to do next ?

A. Nasogastric decompression
B. Consult surgery
C. Air enema
D. Abdo ultrasound

A

A. Nasogastric decompression

Risks of pneumatic reduction
1. Perforation

RFs

  1. Age less than 6 months
  2. Long duration of symptoms ie: >3days
  3. Evidence of small bowel obstruction
  4. Use of higher pressures during the reduction

Management

  • stabilize patient
  • cessation of all feeds and enteral medications
  • nasogastric suction to decompress the abdomen
  • supportive care with fluid resuscitation and inotropic meds to correct hypotension
  • iV abx
  • surgery consult
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4
Q

8 month old with quad CP. can’t feed orally. Has been on bolus NG feeds for past few months. Improved interactions since starting. Has GERD, well controlled on ranitidine. What next ?

A. G tube
B. J tube
C. pH probe
D. G tube with fundoplication

A

A. G- tube

No fundoplication !!

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5
Q

2 y.o girl with painless bright red blood per rectum. What test will best reveal the diagnosis ?

A. Colon
B. Meckel’s scan
C. Abdo u/S

A

B. Meckel’s scan

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6
Q

3 week old has straining and is fussy 15 min before passing stools., stools are non-bloody and soft. After passing stools is well and not fussy. Gaining weight well, is breastfed and is otherwise healthy. Mom is ++ concerned and has already sought out 2 other consults with no answers. Best management ?

A. Low dose lactulose
B. Abdo X-ray
C. Reassure
D. Put mom on “bovine protein restricted” diet

A

C. Reassure

Controversial with D. But on bovine protein restricted diet

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7
Q

Baby with G-tube that looks like this (shows granuloma).

A. Reassure
B. Silver nitrate cautery
C. Topical abx
D. Fungal abx cream

A

B. Silver nitrate cautery

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8
Q

10 y.o boy refusing to eat solids since he had a bad gastroenteritis. Lost 6kg recently. Normal height/growth. Denies body image concerns. Now he is only drinking liquids and liquid nutrional supplements. (question does not mention any coughing, gagging, dysphagia, or whether he attempts to eat any solids).

A. Esophageal stricture
B. Anorexia Nervosa
C. ARFID
D. Achalasia

A

C. ARFID

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9
Q

Kid with FTT, bad eczema, 4 months, breastfeeding? CMPA

A. Hydrolyzed formula
B. Mom Elimination diet

A

B. Mom
Elimination diet

Cows milk should be eliminated first - all
Dairy should be eliminated

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10
Q

You see a teenager in your clinic with progressive dysphagia to solids and epigastric pain. He has been diagnosed with eosinophilia esophagitis, and a referral has been sent for allergy testing. In the meantime, what should you do ?

A. Elimination diet
B. Oral fluticasone by MDI
C. Proton- pump inhibitor
D. Oral prednisone

A

A. Elimination diet

Controversial other group picked PPI

Exam tip: skin test first (allergist specialist) > elimination diet > PPI > inhaled fluticasone

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11
Q

An 18 month old girl has periorbital swelling. Her albumin is 26. Her urine is negative for protein. What do you do for diagnosis ?

A. Serum trypsin
B. Stool alpha antitrypsin
C. Urine creatinine excretion
D. Echo

A

B. Stool alpha antitrypsin

Protein losing enteropathy

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12
Q

A 6 week old boy has begun having loose stools, some of them blood-tinged. Exclusively breastfed. Which is most likely ?

A. Meckel’s
B. Food-protein- induced enterocolitis
C. Infectious colitis

A

B. Food protein-induced proctocolitis

Food protein induced enterocolitis syndrome (FPIES).

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13
Q

Description of a 2 month old baby with colic. Tolerating breastfeeding well, normal exam. What is the best management ?

A. Encourage mom to continue to breastfeeding
B. Add cows milk based formula in diet
C. Add soy based formula in diet
D. Simethicone

A

A. Encourage mom to continue breastfeeding

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14
Q

2 y.o old swallows an 8mm coin battery 2h ago. Stable. On X-ray, it is found in the stomach. What is the next step in management ?

A. Consult for endoscopic removal
B. Wait for 48h, follow serially with X-rays
C. Wait for 10 days, follow serially with X rays
D. Reassess if it does not appear in the stool

A

Controversial depending on what source you use

Nelson’s
A. Endoscopic removal - within 48h to prevent gastritis

Naspaghan

Kid under 5y.o and battery <20mm and asymptomatic
- repeat x-rays at 10-14days if battery hasn’t passed. It remains then endoscopic removal. Thus answer C would be right

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15
Q

What is the utility behind a fecal calprotectin?

A. To differentiate between functional abdominal disorder and IBD
B. To differentiate between IBS and IBD
C. To determine the severity of inflammation in IBD
D. To diagnose post infectious IBS

A

Controversial
A. To differentiate between functional abdominal disorder and IBD

Can also
B. To differentiate between IBS and IBD

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16
Q

Child with 5 vomiting episodes over the last 12 months, associated with pallor, lasting 2-3h. Between episodes she is otherwise well., growing and thriving, with a normal examination. What do you want to do:

A. Reassure
B. Refer to gastroenterology
C. Neuroimaging
D. Start PPI

A

B. Refer to gastroenterology

Cyclic vomiting
Syndrome

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17
Q

7y.o boy has been complaining intermittently over the last 2 days of abdominal pain and has had non- bilious emesis. He has had several dark red mucous stools. He is tender on palpation over the RUQ. Which imaging test would reveal the diagnosis ?

A. UGI
B. Technetium 99 scam
C. Abdo U/S
D. Colonoscopy

A

C- abdo U/S

Intussuception

A- UGI - volvulus
B. Tech 99 - Meckel’s

Hmm why not a volvulus ? Is
It because of bloody stools

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18
Q

Child referred to you with suspicion of celiac disease. Had anti-TTG done, which was negative. What is your next step ?

A. Refer to GI
B. Endoscopy with biopsy
C. Anti-gliadin antibodies
D. Measure IgA

A

D. IgA - always measure when ordering TTG; IGA def will have false negative TTG

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19
Q

8 y.o girl with epigastroc discomfort for many months, progressively getting worse and now waking her up at night time. Her father has peptic ulcer disease, and she has in fact tried his antacids with some relief. What should you do ?

A. Reassure, she can use the antacids as needed
B. Treat empirically with PPI, amoxicillin, clarithromycin
C. Urea breath test
D. Esophagoduodenoscopy with biopsy

A

D. Esophagoduodenoscopy with biopsy - as per Dr. Pai

The diagnosis of H.pylori infection is made
Histologically by demonstrating the organism in the biopsy specimens.

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20
Q

You are treating a 5 year old boy for constipation. In addition to disimpaction, his mother asks you how long he will need to be treated with PEG for?

A. 3months
B. 6 months
C. Until he’s toilet trained
D. 3weeks

A

B. 6 months

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21
Q

A 3 week old baby presents with poor feeding and poor weight gain. He is jaundiced and has hepatosplenomegaly. His bilirubin is 170 with conjugated 115. Which imaging would you do next ?

A. Abdominal U/S with dopplers
B. HIDA scan
C. CT abdomen
D. MRI abdomen

A

A. Abdominal U/S with dopplers

Biliary atresia

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22
Q

A 14 year old boy has epigastric pain, dysphagia with solids and weight loss. He is scoped and diagnosed with eosinophilic esophagitis. What management would you recommend ?

A. Referral to Allergy for skin testing to identify potential allergens
B. PPI
C. Oral fluticasone
D.Oral prednisone

A

A. Referral to Allergy for skin testing to identify potential allergen

Controversial question
Vs B start PPI

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23
Q

12 y.o teen presents to your office and tells you she would like to begin a vegan diet. What is the best advice you can give her ?

A. Vit B12
B. Iron
C. Consult a dietician or nutritionist
D. Calcium supplements

A

C. Consult a dietician or nutritionist. As veganism is difficult. She will likely need all those supplements too though

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24
Q

2y.o girl, picky eater. (Long stem about how she is otherwise healthy but doesn’t like to eat certain foods). Has not gained any weight in the last few months. Has always been trending on the same percentile. What do you advise parents ?

A. Offer a variety of accepted foods and slow child to choose what to eat
B. Offer multiple snacks throughout the day
C. Let the child pick whatever they want

A

A. Offer a variety of accepted foods and allow child to choose what to eat.

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25
Q

What is the recommended vit D supplementation for a 6 month old baby living above the 55th latitude during winter months?

A. 200 IU
B. 400 IU
C. 600 IU
D. 800 IU

A

D. 800 IU

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26
Q

A 7 month old baby is switched from breast milk to formula and solids. He develops diarrhea, eczema and an erythematous rash around his orifices (moth and anus). What is the most likely nutrient he’s deficient in ?

A. Calcium
B. Zinc
C. Protein
D. Vitamin

A

B. Zinc

Acrodermatitis enteropathica - AR cannot absorb zinc. Symptoms first month of life after weaning from breast milk to cow’s milk.

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27
Q

A 7 month old boy presents with failure to thrive, diarrhea, and a severe eczematous rash around his mouth and perineum. He was previously breastfed, but was switched to an appropriate combination of formula and puréed solids. Which laboratory investigation would be most important in order to make the diagnosis ?

A. Immunoglobulins
B. Zinc level
C. Vitamin A level
D. Electrolytes

A

B. Zinc level

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28
Q

8y.o male. Duodenal ulcer. What is treatment ? (Note none of them listed a PPI)

A. Amox + clarithromycin
B. Clindamycin + clarithromycin
C. Metronidazole + clindamycin
D. Bismuth subsalicylate + metronidazole

A

A. Amox and clarithromycin - would also need PPI

Treatment options

  1. Amox + clarithromycin + PPI
  2. Amox + metronidazole + PPI
  3. Clarithromycin + metronidazole + PPI

Abx each x 14d and PPI x 1 month

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29
Q

3 week old blood mixed with stool, has been having since 2 weeks old, normal exam, growing/thriving, formula fed

A. Anal fissure
B. Cow’s milk allergy
C. Meckel’s

A

B. Cow’s milk allergy

A. Fissure - seems kind of young and blood would be on surface of stool

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30
Q

15 y.o boy presents with severe epigastric pain that worsens after eating. He has had a few episodes of non-bilious emesis. On exam he is tachycardic and has epigastric tenderness, but is otherwise stable. Bloodwork reveals a lipase of 1650, WBC 12.5 and normal PLT, Hb, lytes, renal function and ALT. What is the next best step in management ?

A. NPO and IV fluids
B. Surgical consult
C. Ceftriaxone
D. IV pantoprazole

A

Answer A: NPO and IV fluids

Pancreatitis

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31
Q

8 y.o boy with type 1 diabetes presents with non-specific abdominal pain. He has had normal stools with no hematochezia. There has been a 1kg weight loss over the past 3 months. On exam he has a pruritic bullous lesions on his extensor surfaces of his arms and his trunk. What is the most likely diagnosis ?

A. Celiac disease
B. IBD
C. Eosinophilic gastroenteropathy
D. Parasitic infection

A

A. Celiac disease

Dermatitis herpetiformis

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32
Q

8 year old boy with gastroesophageal reflux for the last 4 years, now having dysphagia on solids. Which of the following tests would reveal the diagnosis ?

A. UGI
B. Upper scope and biopsy
C. Abdominal ultrasound
D. AXR

A

B- upper scope and biopsy

Other possibility was A looking for stricture but scope better as can dx stricture and eosinophilic esophagitis

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33
Q

In a patient with liver failure, which of the following is most concerning regarding need for transplantation ?

A. Acute onset lethargy
B. Acute liver volume loss
C. Increase in liver enzymes

A

Controversial

A- acute onset lethargy
Vs
B- acute liver volume loss - sick kids answer

Nelson’s says acute liver volume loss is a bad sign

Hepatic encephalopathy- initially minor disturbances in of consciousness or motor functio . Irritability, poor feeding and a change in sleep rhythm may be the only findings in infants. Asterisks May be demonstrable in older children. Pts can rapidly progress to deeper stages of coma

Age <1y.o, stage 4 encephalopathy, and INR >4 and the need for dialysis before transplantation are a/w increased mortality.

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34
Q

A 6 y.o boy has recurrent vomiting episodes where he needs to come to the ER and receive IV fluids. He is completely fine in between these episodes. What is the most likely diagnosis ?
A. Cyclic vomiting
B. Malrotation

A

A. Cyclic vomiting

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35
Q

A 4 year old patient presents with lethargy, bruising, hepatosplenomegaly and elevated LFTs. He has signs of acute liver failure (this is given in the question ). Which would make you most worried?

A. Sudden decrease in liver size
B. Development of asterixis

A

B. Dvlp of asterixis

Although sudden decrease in liver size is an ominous sign, signs of encephalopathy indicate severe liver failure

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36
Q

Girl with facial edema, pallor. Albumin 26. Urine negative for protein. Most likely test to reveal diagnosis ?

A. Serum trypsinogen
B. Stool alpha 1 antitrypsin
C. Echocardiogram
D. 24h creatinine clearance

A

B. Stool alpha 1 antitrypsin

Protein losing enteropathy

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37
Q

15 y.o boy with nocturnal diarrhea and diarrhea for 3 months. No pain, tried lactose free diet and didn’t help

A. UGI
B. Colonoscopy
C. Barium
D. Lower scope

A

B. Colonoscopy

Hx concerning for IBD

Nocturnal bowel movements common in UC

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38
Q

3 week old with loose stools and red blood intermixed with the stools, no FTT. What is it ?

A. Anal fissure
B. CMPA

A

B. CMPA

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39
Q

7 week old baby boy who cries 5h per day and has colic, reflux with feeds; parents try soy milk, baby gets diarrhea; what do you recommend ?

A. Try 2 weeks of hypoallergenic milk
B. Give PPI
C. Try probiotics
D. Try lactose free something

A

A. 2 weeks of hypoallergenic milk.

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40
Q

Crohn’s kid on azathioprine; present with R flank pain; stools normal. What is your dx ?

A. Renal colic
B. Cholecystitis
C. Crohn’s flare

A

A. Renal colic

Azathioprine - immunomodulatory drug used in IBD. No specific renal side effect.

Most common side effect: malaise, n/v/d, leukopenia, thrombocytopenia, black box warning for malignancy, hepatotoxicity, infection, myalgia, fever

Flank pain likely secondary to renal stone: chronic steatorrhea&raquo_space; fat binds to calcium, leaving oxalate free to be absorbed and deposited in the kidney, where it can form into stones. Patients with OBD also get Uric acid stones

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41
Q

7 y.o boy with low ferritin and low HgB. Other cell lines normal, exam normal. Has been on iron replacement for 3 months with good compliance. His ferritin and HgB are still low. What is the next step ?

A. Anti-TTG
B. Bone marrow
C. Upper GI
D. Upper endoscopy

A

A. Anti-TTG

Reasons to screen for celiac: FTT, persistent diarrhea, chronic constipation, recurrent abdominal pain, iron deficiency anemia not responsive to supplementation, ideopahtic short stature, significant pubertal delay, dermatitis herpetiformis, arthritis/arthralgia.

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42
Q

5 year old kid with abdo pain, on U/S see intussusception; has hyperpigmented macules on lips

A. Peutz- Jegher
B. Crohn’s

A

A. Peutz- Jegher

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43
Q

Teenage girl presents with hepatitis, bili 42 conjugated, 55 total. Anti- smooth muscle antibodies positive to 1:512. What is the most likely diagnosis ?

A. Alpha -1 antitrypsin disorder
B. Wilson’s disease
C. Autoimmune hepatitis

A

C. Autoimmune hepatitis

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44
Q

Kid with hepatitis, which would be an indicator of function ?

A

INR

Indications for liver function - PTT/INR, albumin, bilirubin

Progression of liver dysfunction
Decreased PLTs > INR increased > alb decreased > bilirubin increased

Pancytopenia results from hypersplenism- PLTs first then WBC then hemoglobin

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45
Q

A 3 week old patient is being worked up for cholestasis and is found to have a pointy chin, a broad forehead and butterfly vertebrae. Which of the following is most consistent with the diagnosis?

A. Chorioretinitis
B. Posterior embryo toxin
C. Cataract
D. Glaucoma

A

B. Posterior embryotoxin

Alagille syndrome

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46
Q

3 month old boy with constipation since birth, FTT, and a mildly distended abdomen (rectal exam not described). What would be the most appropriate next test ?

A. Rectal biopsy
B. TSH
C. Swear chloride
D. Follow up in 6 months

A

A. Rectal biopsy

Hirschsprung disease

Marked as controversial because can also be sweat chloride or TSH

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47
Q

A 13 y.o girl with intermittent cough and early morning throat pain. She also has shortness of breath with exertion. Parents comment that she has had bad breath. What would you do ?

A. Upper GI
B. Abdominal U/S
C. CXR
D. PH probe

A

D. pH probe

GERD

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48
Q

Cause of malnutrition in IBD

A. Low intake of nutrients
B. Malabsorption

A

A. Low intake of nutrients

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49
Q

3 month old boy with constipation since birth, FTT, mildly distended abdomen and no stool on rectal examination. What would be the most appropriate next test ?

A. Rectal biopsy
B. TSH
C. Sweat chloride
D. Follow up in 6 months

A

A. Rectal biopsy

This question was debated during review - B and C are possible answers but if they describe a rectal exam that is consistent with Hirschsprung’s than A is definitely right

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50
Q

3 month old baby boy who has been breastfeeding well, but now 3rd percentile in growth parameters. Constipated since birth.

A. TSH
B. Sweat test
C. Anal manometry

A

C. Anal manometry

Best answer would be biopsy
Hirschsprungs

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51
Q

Kid with bloody diarrhea 1 month ago which has now resolved. Now has weight loss and abdominal pain. Which was the most likely organism ?

A. Yersinia
B. Campylobacter
C. E.coli
D. Shigella

A

A. Yersinia

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52
Q

Teenager who has low grade fever, malaise, and weight loss in the last 3 weeks. It started with non-bloody diarrhea x 1 week, now resolved. What is the cause ?

A. E.coli
B. Campylobacter
C. C. Difficile
D. Yersinia

A

D. Yersinia

Great mimicker of IBD

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53
Q

Adolescent female presents with jaundice. Bloodwork findings: Bili 55, direct 40, AST 250, ALT 200. Copper, ceruloplasmin, Hep A, B, C normal. Alpha 1 antitrypsin done (2.5U). What is the cause ?

A. Alpha-1 antitrypsin
B. Autoimmune hepatitis
C. Gilbert’s

A

B. Autoimmune hepatitis

Normal alpha 1 antitrypsin level
Low is 0.8 and high 2.0 g/L

Therefore not deficient

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54
Q

Most important reason to remove a foreign body in the esophagus within 24h is to:

A. Decrease risk of GERD
B. Decrease risk of aspiration
C. Decrease risk of perforation
D. Risk of esophagitis

A

A. Decrease risk of perforation

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55
Q

2 days of fever and cough, mother concerned with yellow eyes. Indirect bili 58, direct 9, ALT 40, AST 42, normal wBC. What do you do ?

A. Do nothing
B. HIDA
C. Direct Coombs

Or

Early adolescent presenting with jaundice, indirect hyperbole (bili 56, direct 12), fever. What to do ?

A. Hep A, B, C serology
B. Blood smear
C. Do nothing

Or
Jaundiced child with elevated unconjugated bili, normal Hb, normal retics. What investigations:

A. Hep A, B, C serology
B. Blood smear

A

Answer: Do nothing vs blood smear. I feel like they are getting at Gilbert but you can’t officially rule out hemolytic anemia with the info we have

In the first question, the LFTs are normal, which would not be seen in acute viral hepatitis. Therefore, the patient may have Gilbert’s

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56
Q

2.5 year old boy in for routine check-up. Mom mentions he has had 2 episodes of rectal prolapse, reduced in the ER, in the last 6 months. You should:

A. Reassure
B. Treat for constipation
C. Check for CF

Or

Girl with rectal prolapse x 2 reduced easily in The ER. What do you do ?

A. Reassure mom
B. Observe and follow in 3 months
C. Sweat chloride
D. Barium enema

A

C. Check for CF and C. Sweat chloride test

Rectal prolapse is rare if no underlying predisposing condition

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5
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57
Q

Bad breath, cobblestoning in pharynx, wheeze. What is the best test ?

A. pH probe
B. Upper GI series
C. Gastroscopy

A

A. pH probe

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58
Q

Alpha1- antitrypsin. Most likely presentation in children

A. Jaundice
B. Emphysema
C. Bronchiectasis
D. Pneumonia

A

A. Jaundice

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59
Q

Teenager with weight loss, poor appetite, anal fissure. What to do ?

A. Colonoscopy
B. Upper GI series

A

A. Colonoscopy - would need upper and lower scopes and MRE

Suggests a possible dx of Crohn’s disease given presence of peri-anal disease and constitutional sx.

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60
Q

Picture of evacuated child with FTT and muscle wasting. Best test firings diagnosis ?

A. Immunoglobulins
B. Small bowel biopsy

A

B. Small bowel biopsy

Celiac disease

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61
Q

Picture of a child with a large abdomen. This 2 year old girl has been irritable and anorexic for the past few months. Which of the following investigations would lead to the diagnosis ?

A. CT head
B. Abdo U/S

A

Answer: what??

This sounds like it could be celiac disease but proper investigations not available in answers given

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62
Q

What is the most likely cause of childhood functional abdominal pain ?

A. Mild inflammation
B. Lack of lactose digestion
C. Slow motility with increased visceral pain response

A

C. Slow motility with increased visceral pain response

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63
Q

Child who lives on a farm presents with abdominal pain and diarrhea. His small bowel follow through reveals narrowing of his distal ileum. Which of the following organisms would be important to rule out prior to getting a colonoscopy.

A. Entamoeba histolytica
B. Campylobacter
C. Yersinia

A

C. Yersinia

Things to know that cause terminal ileum thickening = salmonella, c.diff, Yersinia and histoplasmosis

Yersinia can mimic IBD

Infections a/w being on a farm: anthrax (bacillus anthracis), brucellosis, campylobacter, E.coli, influenza, leptospirosis, listeria, MRSA, coxiella, rabies, ringworm, salmonella, TB, vesicular stomatitis

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64
Q

1 month old with normal physical but total bilirubin 280 and direct 200. Hemoglobin 98, and MCV 95. Most likely cause ?

A. Breast feeding jaundice
B. Haemolytic
C. Neonatal hepatitis
D. Galactosemia

Or

Baby with bili of 280 and conjugated 200? What is the most likely cause based on incidence ?

A. Breastfeeding jaundice
B. Hemolysis ABO
C. Neonatal hepatitis
D. Galactosemia

A

Answer C. Neonatal hepatitis

A- BF jaundice presents with unconjugated hyperbilirubinemia
B.- Hemolysis also presents primarily with unconjugated hyperbili (exception: A history of severe ABO incompatibility May explain a conjugated hyperbili; in about 3% of infants, this is a benign complication which resolved on its own accord within a month.
D. Galactosemia - presents with conjugated hyperbili but is far less common than neonatal hepatitis and tend to be unwell infants.

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65
Q

Bay has inflamed, ulcerated lips and gums. (Picture shown). Which of the following conditions is this more likely to be seen in ?

A. Chronic mycoplasma infection
B. IBD
C. Eosinophilic gastritis
D. Contact dermatitis

A

B. IBD

Oral lesions are reported in at least 10% of children with Crohn’s disease; when evaluated by a dentist, oral involvement was noted in 42%

  • oral manifestations include: mucogingivitis, mucosal tags, deep ulceration, cobblestoning, lip swelling
  • no oral lesions in eosinophilic gastritis
66
Q

14 month old child with puffy eyes, albumin of 14, urine negative for protein. Looks well. On an unrestricted diet. How would you treat ? (No mention of any GI symptoms in the question)

A. Prednisone
B. High protein, high calorie diet
C. Protein hydrolysate formula
D. IV albumin

A

C. Protein hydrolysate formula

Protein losing enteropathy (unclear underlying etiology). And you trea any protein losing enteropathy with a protein hydrolysate formula

67
Q

Child with hepatitis, initially elevated ALT and AST but now resolving. What is the best thing to follow.

A. INR
B. GGT
C. ALT, AST
D. Albumin

Or

A child has resolving viral hepatitis. AST and ALT have normalized . Bilirubin is still elevated. Which of the following is best to monitor serially?

A. GGT
B. INR
C. Albumin
D. Abdo ultrasound

A

A, B: INR

68
Q

A child swallowed a coin. There is a coin in the stomach on AXR. What would you do ?

A. Observe
B. Endoscopy

A child presents after having been witnessed to swallow a nickel. X-ray confirms the coin is in the stomach. What would you do ?

A. Notify surgery for urgent laparotomy
B. Admit, repeat X-ray in 3 days
C. Notify GI for endoscopic removal
D. Observation only

A

Answer A,D observe

69
Q

A 13 month old boy has a diaper rash and diarrhea for the last few months, since his parents have been introducing new foods. Which of the following is correct?

A. Do skin testing and RAST
B. Carbohydrate intolerance is common at this age
C. He is now sensitized to cow’s milk protein

A

B. Carbohydrate intolerance is common at this age

Functional Diarrhea

  • increased intake of hyperosmolar fluids, such as fruit juices in toddlers and young children may cause diarrhea as a result of increased osmotic load
  • also called Toddler’s diarrhea
70
Q

Teen girl with weight loss, vomiting, fistula in anal area. What test to make the diagnosis ?

A. Ultrasound
B. Colonoscopy
C. Upper GI series
D. CT

Or

Teenage girl weight loss, abdominal pain and an anal fissure. Which investigation will MOST LIKELY reveal the diagnosis?

A. Abdominal U/S
B. Colonoscopy
C. Upper GI with follow - through

A

B, B colonoscopy

IBD- crohn’s

71
Q

11 year old girl with vague abdominal pain, vomiting, and jaundice. Her labs show ALT 1000, total bilirubin 100. What test will likely confirm the diagnosis ?

A. HepA IgM
B. CMV urine
C. Hep B serology
D. Monospot

A

A. Hep A IgM

HAV is the most prevalent hepatotropic virus, responsible for most forms of acute and benign hepatitis.

EBV and CMV would have other symptoms too (liver is one manifestation of multiorgan disease)

  • Hep B unlikely as no risk factors
72
Q

3 week old infant has jaundice . His His birth weight was 3250 g and he now weighs 3490g. He is breast-feeding well. Haemoglobin is 127 and total Bilirubin Is 270, conjugated billirubin is 8.Coombes test is negative. What should be done?

A.admit for phototherapy
B.referral to gastroenterology
C.reassess in one week
D.recommend switching from breast-feeding to formula

A

Answer C.reassess in one week

Breast milk jaundice
Typically presents after the first 3 to 5 days of life, peeking within two weeks after birth, and progressively declines to normal levels over 3 to 12 weeks.
The hyperbilirubinaemia is generally mild but should be monitored to ensure that it remains unconjugated and does not increase.
Breast-feeding can continue with the expectation of resolution by 12 weeks of age.
Appears to be due to a factor in human milk that promotes an increase in intestinal absorption of bilirubin

73
Q

A two-year-old is in the emergency department with bright red rectal bleeding. He is pale looking but otherwise well. He does not appear to be in any discomfort. On rectal exam, you find blood mixed with stool on your glove. Haemoglobin is normal. What is the most likely diagnosis?

A.ulcerative colitis
B.Meckel’s diverticulum
C.anal fissures

A

Answer B.Meckel’s diverticulum. The only issue with the question is bright red as it is described more as dark red in Meckel’s diverticulum.

Most common congenital anomaly of the G.I. tract. Rule of twos. Occurs in 2% of population, male to female ratio of 2 to 1, located within 2 feet of the ileocecal valve, can be 2 inches in length, two types of heterotopic mucosa presentation before two years old.

Symptoms, painless lower G.I. bleeding, intussusception which can lead to bowel obstruction, diverticulitis.

74
Q

Six-month-old baby with failure to thrive is very irritable. Was breast-fed initially solids were introduced at four months of age. What is the likely diagnosis?

A.celiac disease
B.cystic fibrosis
C.cows milk allergy

A

Answer A. Celiac disease

Clinical presentation of coeliac disease. Infants and young children with malabsorption and failure to thrive. Kids age 6 to 24 months after introduction of gluten into the diet, includes symptoms of chronic diarrhea, anorexia, abdominal distention, pain, failure to thrive, vomiting.

Older children have constipation or diarrhea.

P.cystic fibrosis. I think they would have to give you more information, like stay at to Ria or watery diarrhoea or respiratory infections.

C.cows milk allergy. If it’s IGE mediated then presents like a classic allergy with urticaria, and angioedema, Wheezing, vomiting, anaphylaxis. If it’s non-IGA median baby looks well with bloody stools

75
Q

What is the most useful intervention in treating encopresis ?

A.pharmacologic
B.behavioral
C.pharmacologic and behavioral
D.bio feedback

A

C. Pharmacologic and behavioral.

Definition: the voluntary or involuntary passage of feces Into inappropriate places at least once a month for three months consecutive once a chronological or developmental level of four years has been reached.

Treatment: clearance of impact material and short term laxatives to prevent further constipation. Behavioural modifications including change in diet, Regular post prandial toilet sitting.

CPS statement on managing functional constipation and children. Includes behavioural management should be used in conjunction with medication therapy

76
Q

What is the most common presentation of alpha-1 antitrypsin in children?

A. Jaundice
B. Emphysema
C. Bronchiectasis

A

A. Jaundice

77
Q

Two-year-old suspected of having celiac. What is a definitive test for coeliac disease?

A.Anti transglutaminase antibody
B. Jejunal biopsy
C. Gluten free diet trial
D. Antigliadin antibody

A

Answer B. Jejunal biopsy

78
Q

Seven-year-old with sore throat in the mornings, bad breath, chronic cough with abdominal pain for two weeks. Her cough is worse with activity. What test will give you the diagnosis ?

A. Throat swab
B. Pulmonary function test with methacholine challenge.
C. PH probe
D.upper G.I. series

A

Answer C. pH probe

Gerd

79
Q

Alpha-1 anti-trips in and children presents usually with

A. Cirrhosis
B.emphysema
C.pneumothorax

A

A. Cirrhosis

Steve’s group had a question like this where cirrhosis and jaundice we’re both answers. The lecture said that is not fair. And said that if we did have that question a younger (infant) would present as jaundice/cholestasis and an older kid would present as cirrhosis.

80
Q

Baby with delayed meconium passage, abdominal distension and calcifications on abdominal x-ray.

A.Hirschsprung’s
B.cystic fibrosis
C.duodenal atresia

A

B. Cystic Fibrosis

99% of newborns will pass meconium by 48h.

  • 15-20% of newborns with CF, meconium will cause Complete obstruction of the ileum. The first 24 to 48 hours of life you get abdominal distension and no meconium and vomiting. On abdominal x-ray you see diluted loops of bowel with air fluid levels and collection of granular, ground glass material in lower abdomen. May get meconium peritonitis which is rare and you see in utero rupture of the bowel wall. On abdominal x-ray you see calcifications in the scrotum or peritoneum due to the inflammatory response to the perforated bowel that sealed off.

Meconium plug syndrome which is delayed passage of meconium and comes at 48 hours is less specific for cystic fibrosis then meconium ileus pancreatic calcifications are possible

81
Q

12 month old child who has passed three soft red stools in the past 12 hours. He is asymptomatic. The same thing happened four months ago but resolved. His haemoglobin is now 70. Investigation?

A.upper endoscopy
B. UGI series
C. Nuclear med scan for ectopic gastric tissue

A

C. Nuclear med scan for ectopic gastric tissue
Meckel’s diverticulum

Stools are red so this is lower GI process. The other two answers don’t make sense (even if you don’t know the answer).

82
Q

Work up of a child with encopresis. X-ray is done and the following is the incidental finding. What is your next step and management?. Picture given of chest x-ray and abdominal x-ray with lots of stool and round object in the right upper quadrant, on closer inspection the x-ray is totally inverted, i.e.; the heart is on the right, liver on the left. Is this a mistake? Is this total for tooth inversus? None of us knew. Consensus was that this was a coin in the stomach.

A.emergent upper endoscopy
B.elective upper endoscopy
C.consult general surgery
D.wait and do nothing
E. give prokinetic agent
A

D.wait and do nothing

83
Q

What is the most specific test for pancreatitis:

A.Amylase
B.Lipase
C.abdominal ultrasound
D.abdominal CT scan
E. Abdominal x-ray
A

B. Lipase

84
Q

A mother brings in her 13 month old child because he seems to have been getting a diaper rash and diarrhea with the introduction of new foods over the past couple months.

A.arrange for skin testing and RAST
B.it is due to sensitization cows milk protein
C.carbohydrate intolerance is a common cause
D.citrus fruit and tomatoes can cause this via an immune mediated mechanism
E.if mucus is not Present in the stool that it cannot be an immune problem

A

C. Carbohydrate intolerance is a common cause

Chronic nonspecific diarrhoea of childhood infancy. The most common form of persistent diarrhoea in the first three years after birth. Potential pathophysiologic mechanism is increased intestinal motility and osmotic affects of intraluminal solutes i.e.; carbohydrates. The rule of ingested carbohydrates has been emphasized in light of a typical toddler‘s affection for fruit juices.

A.maybe but why would Rash be in the diaper?
B. CM PA. No would have been introduced to it earlier
D.allergy
E.no

85
Q

14-year-old black boy with one year history of post prandial intermittent abdominal pain. Normal stools. No bloating. No vomiting. What test do you do?

A.hemoglobin electrophoresis
B.hydrogen breath test
C.gastroscopy with biopsy
D.upper G.I. series with small bowel follow through
E.abdominal ultrasound
A

E. Abdominal ultrasound

Differential diagnosis of postprandial abdominal pain:

  1. gastric ulcer
  2. chronic pancreatitis
  3. gallstones
  4. Abdominal ischemia
  5. Functional disorder’s for example IBS, gastroparesis, functional dyspepsia.

Cholelithiasis with right upper quadrant pain, might worsen with meals and Key evaluation is the ultrasound of gallbladder

A. To diagnose SCD
B. To diagnose H. Pylori - abdominal pain worse on empty stomach
C. Gastroscopy with biopsy - eosinophilic esophagitis
D. UGI/SBFT - difficulty swallowing

86
Q

Sexually active adolescent female with sickle cell disease and a history of previous transfusions presents with acute history of fever, jaundice and vomiting. She also developed right shoulder pain. Haemoglobin 79 and was previously 89, AST and a LT slightly elevated. Unconjugated Bilirubin is increased. What is the most likely diagnosis?

A. Fitz- Hugh- Curtis 
B. Cholecystitis 
C. Hepatitis C
D. HIV
E. Vasoocclusive disease of the liver
A

B. Cholecystitis. Debated question with Fitz- Hugh - Curtis

87
Q

What is true regarding extrehepatic portal hypertension:

A. Associated with hepatomegaly
B. Associated with splenomegaly
C. Liver transaminase will be abnormal
D. Most common cause is splenic vein thrombosis

A

B. A/w splenomegaly

A. Classically, in EHPVO cases liver is normal and the architectural pattern is preserved
B. EHPVO in child it is most often chronic and presents with features of variceal bleeding and splenomegaly, where as an adult it could be either acute or chronic.
D. Mcc is splenic vein thrombosis - no it’s obstruction in the portal vein

88
Q

Which of the following is true ?

A. The prevalence of Gerd documented by esophageal pH monitoring It’s estimated to be 10% in the first year of life
B. Regurgitation of at least one episode a day occurs in all of 10 to 12 month old
C.the natural history of Gerd is improvement in with introduction of the solid food
D. the natural history of Gerd is associated disappearance of symptoms in 98% by 15 months

A

Answer D.
The natural history of Gerd is associated disappearance of symptoms and 98% by 15 months. Yes peaks at four months and then 88% resolved by 12 months in nearly all by 24 months

A. Prevalence by PH monitoring is 10% in 1st year - likely higher
B. One episode of regurgitation a day in 10-12 months - probably not at all
C. The natural history of Gerd is improvement with introduction of the solid food. Not always, usually peaks at four months

89
Q

A 10-year-old boy has been having belly aches for about two years. They occur at night as well as during the day. Occasionally he vomits after onset of pain. Occult blood positive in his stool. His father also gets frequent stomach aches.

A.appendicitis
B.Meckel’s diverticulum
C.peptic ulcer
D.ulcerative colitis

A

Controversial question
C. peptic ulcer disease versus D. ulcerative colitis.

I don’t think this child is unwell enough to have UC, especially if it’s been going on for 2 years- they also don’t describe any extra intestinal manifestations

A. going on too long
B.Meckel’s diverticulum occurs in first or second year of life typically mechanic her in for a decade. Painless bleeding.
C.peptic ulcer’s due to H pylori
D.ulcerated colitis but it seems like blood not evident.

90
Q 
First line therapy in guard
A.antacids
B.metoclopramide
C.omeprazole
D.ranitidine
A

C. Omeprazole - PPI is first line

Used to be ranitidine. H2RAs are considered safe for use in children and are used commonly as first line therapy in infants

91
Q

15-year-old with H pie Laurie. You should treat with?

A. H2 blocker
B.amoxicillin, clarithromycin and proton pump inhibitor
C. Clarithromycin and H2 blocker
D.amoxicillin and proton pump inhibitor

A

B.Amoxicillin, clarithromycin, and proton pump inhibitor

92
Q

Fat absorption in childhood.

A. Fats are exclusively digested by pancreatic lipase
B. Medium chain triglycerides require solubilization
C. Triglycerides require tryptic pre-digestion
D.triglycerides require hydrolysis to free Friday acids
E.lipolysis is enhanced by gastric acid

A

D. TG require hydrolysis to FFA. Nonesterified FFAs are metabolically active lipids derived from lipolysis of TG stored in adipose tissue blind to albumin for circulation in the plasma

93
Q

A photograph is shown of Kayser-Fleischer rings in a 14 y.o boy. What should be evaluated in this patient ?

A. Liver function
B. Renal function
C. Blood triglyceride levels
D. Skeletal abnormalities
E. Joint abnormalities
A

A. Liver abnormalities

Wilson disease

94
Q

Which is true of children with encopresis?

A. usually in the morning
B. Most common in preschool children
C. The colon has a large caliber
D.stool softeners cure the problem

A

C. The colon has a large caliber.

A.usually in the morning. Not true can be at any time of the day, often happen throughout the day
B.most common preschool children. Not true, functional ENCOPRESIS does not begin until age 4
D.stool softeners cure the problem. Need laxatives to disimpact, the maintenance dose to clear stools and also need behavioural therapy with regular toilet sitting and high fibre diet. No laxatives are a cure

95
Q 
A child is referred for refractory ENCOPRESIS. Spine exam and deep tendon reflexes are normal. The rectal ampulla is dilated with lots of stool. How should he now be treated?
A.fecal emollient
B.peristaltic agent
C. high fibre diet
D. Bowel washouts
E. encourage regular exercise
A

D. Bowel washouts

96
Q

A mother is concerned about her six-year-old son who has been having two or three loose bowel movements per day for the past year. He usually has to change his underwear at school. He does not have abdominal pain, vomiting, or rectal bleeding. Growth is normal. When you examine the child he is shy but cooperative. Physical examination is normal except for a very dirty anus and a fecaloma on digital rectal examination. What investigations are necessary?

A.TSH
B.stool culture
C. rectal biopsy
D.psychology consult
E.no investigations
A

E. No investigations.

Constipation with overflow

97
Q

Unconjugated hyperbilirubinemia can be caused by al EXCEPT:

A. Decreased conjugation
B. Increased uptake by hepatocytes
C. Increased excretion
D: increased enterohepatic circulation 
E. Increased breakdown of hemoglobin
A

B false but also isn’t C false ?

A- decreased conjugation - true
B- increased uptake by hepatocytes - false it’s decreased hepatic bilirubin uptake
C- increased excretion - should be false because you get decreased bilirubin conjugation and this decreased excretion ?
D-increased enterohepatic circulation - true
E- increased breakdown of Hb - true

98
Q

Child with abdominal pain, Periumbilical, non-radiating. Physical exam normal. Height and weight on 25th percentile.

A.chronic constipation
B.inflammatory bowel disease
C.non-functional abdominal pain
D.lactose intolerance
E. urinary tract infection
A

A.

Chronic constipation

99
Q

Confirmation of milk intolerance

A. D-xylose 
B. Jejunal biopsy
C.milk RAST test
D. Serum IgE
E milk challenge
A

E. Milk challenge

100
Q

A child presents with watery diarrhea. Still reducing substances will not be positive with which of the following?

A. Glucose
B. Sucrose
C. Fructose
D. Lactose
E. Galactose
A

B. Sucrose

Can test stool for reducing substances and if present suggest carbohydrate malabsorption. Glucose, lactose and fructose are reducing sugars, but sucrose is not. However, malabsorbed sucrose can also be degraded by colonic bacteria to glucose and fructose, resulting in a positive test for reducing substances. Lactose breaks down into glucose and galactose.

A reducing sugar is any sugar that is capable of acting as a reducing agent because it has a free aldehyde group or a free keto group. All monosaccharides are reducing sugars along with some disaccharides, Oligosaccharides, and polysaccharides.

Monosaccharides = glucose, fructose, galactose
Disaccharides = sucrose (glucose + fructose), lactose (glucose + galactose), maltose (glucose + glucose). Sucrose is not one.

Would do this in galactosemia.

101
Q

An otherwise well 6 month old presents with a one month history of passing small hard stools once per week. She is exclusively breast-fed. Appropriate management would include:

A.careful use of laxatives
B. Enema 
C. Change to lactose-free formula
D.introduce solids
E. Change to iron free formula
A

D. Introduce to solids

For infants who have not yet begun solid foods, acute constipation can be treated by the addition of undigestible osmotically active carbohydrates to the formula titrating the dose to induce a daily bowel movement. One such option is addition of sorbitol containing juices for example Apple, prune or pear. For infants 4 months and older 2 to 4 ounces of 100% fruit juice per day is a reasonable starting dose. For infants who have just begun solid foods, sorbitol containing food Can be used. Can use glycerine suppositories if there’s hard stool and rectum. Can use laxatives like Peg if you’ve tried dietary changes. Avoid stimulants like Senna mineral oil and enemas in infants because of potential adverse side effects.

102
Q

14 year old black male with one year history of intermittent abdominal pain and some diarrhea. Unlikely a primary lactase deficiency

A. If reducing substances are negative than a disaccharides deficiency is ruled out
B. Try avoiding milk
C. Do a breath hydrogen test
D. Do a haemoglobin electrophoresis

A

B. Try avoiding milk

Confirm by eliminating milk from diet

African Americans and Asians are more likely to have decrease in lactase as they age compared to white people who are much less. So they should not do the breath test, better to do a clinical challenge. According to lecture, we basically never do breath hydrogen test. White kids can do a breath test as less likely to have lactase deficiency.

103
Q

A 16 y.o female presents with Decreased appetite and weight loss. There is a height weight discrepancy. She has an anal Fissure. What is the most appropriate investigation:

A. Upper G.I. series and small bowel follow through
B. Psychiatry consult
C. Barium enema

A

A. UGI and small bowel follow- through

Likely crohn’s but scopes would be better !!!

104
Q

13-year-old with jaundice and fatigue. Lab results: AST=222, ALT =150, Billirubin 35/20, alpha-1-antitrypsin = 2.5g/L (low <2.0), hepatitis B surface antigen negative, hepatitis C IgM negstive. The most likely diagnosis ?

A. Autoimmune hepatitis 
B. Hepatitis C
C. Wilson’s disease
D. Sclerosis cholangitis 
E. Alpha- 1 antitrypsin
A

Answer A. Autoimmune hepatitis - high transaminases, liver assosiated serum auto Ab and hypergammaglobulinemia - hepatocytes get injured

B. Not hep C
C. Wilson’s- no neurological changes, KF rings, low ceruloplasmin levels, increased free copper and urine copper
D. Sclerosing cholangitis - autoimmune process where I RTA and extra hepatic bile ducts are injured - often with IBD, asymptomatic Eli Er disease, with high ALP and GGT
E. Alpha-1- antitrypsin- Normal level of AAT. AAT is an anti-protease and the natural inhibitor of the serine proteases released by activated neutrophils. In patients with AAT liver disease, the abnormal protein accumulates within the endoplasmic reticulum, resulting in liver injury in a subset of patients by unclear mechanism. Affected individuals typically have decreased plasma ATT concentration because of impaired hepatic production.

105
Q

Boy six years old who’s dad says he stinks all the time and he has faeces in his underwear.

A. What are the two most important components of your physical exam?

B. You confirm a fecaloma. What are three management strategies for this issue?

A

A. Two most important components of your physical exam

  1. Rectal exam
  2. Abdominal exam
  3. Neurological exam

B. Confirmed fecoloma. What are 3 management strategies ?

  1. Bowel clean out with Peg 3350 or peglyte
  2. Long term maintenance therapy with PEG 3350
  3. Conservative management including increased fiber and fluid intake, avoid constipating foods including bananas, cheese; increased physical activity; bowel training
  4. Behavioural training
106
Q

A. What are x-ray findings consistent with a coin that would need an urgent removal?

B. What if it was in the esophagus. What anticipatory guidance would you provide the family and your next step (2)

A

A. X-ray findings of coin concerning

  1. Double halo sign and step off sign suggesting button battery
  2. Diameter > 25mm and length > 6cm

B. Anticipatory guidance and next step

  1. Watch for signs of drooling, dysphagia and respiratory compromise
  2. Esophageal coins should be removed within 24h in ingestion your reduce the risk of significant esophageal injury or erosion into neighbouring structures

Next steps

  1. Admit patient
  2. NPO
  3. Consult GI for endoscopic removal within 24h
107
Q

Two-year-old male with bloody diapers since yesterday. He is asymptomatic otherwise, in no pain and has normal physical exam. Mother shows you a diaper with large amounts of blood.

A. What is the diagnosis?
B. What are two other conditions it could be?
C. What investigation do you do ?

A

A. Diagnosis
- Meckel’s Diverticulum

B. Two other conditions it could be ?

  1. Anal fissure
  2. Polyps

C. Investigation
- Meckel’s scan

108
Q

A. Name 2 screening investigations for coeliac disease.

B. Name five extra intestinal manifestations of coeliac disease.

A

A. Screening investigations

  1. TTG and IgA
  2. Deamidated gliadin peptide (DPG IgA and IgG)
    - what about biopsy - I guess that is not a screening tool

B. 5 extra intestinal manifestations

  1. Abnormal liver enzymes
  2. Arthralgia/arthritis
  3. Dermatitis Herpetiformis
  4. Alopecia
  5. Fatigue
  6. Headache
  7. Anemia
  8. Stomatitis
  9. Myalgias
  10. Psychiatric disorders
  11. Rashes
  12. Seizures
  13. Neuropathy
  14. Short stature
  15. Delayed puberty
  16. Osteoporosis
  17. Infertility
109
Q

A child was at a restaurant 1.5 hours ago and had a hamburger and drink. Shortly there after, he was noted to be drooling and not tolerating his own secretions at all. You do an x-ray and find a Tooney stuck in the upper 1/3 of his esophagus. You consult G.I. and Surgery for urgent scope and removal.

A. How soon is the soonest you can safely proceed with the removal as per anaesthesia guidelines given his NPO status?

B. What are three indications for urgent removal of esophageal foreign body?

A

A. How soon for NPO ?
- 8h

A light meal or non-human milk may be ingested for up to six hours before elective procedures requiring general anesthesia, regional anaesthesia or procedural sedation and analgesia. Additional fasting time for example 8 hours or more maybe need in cases of patient intake of fried foods, fatty foods or meet. Consider both the amount and type of foods ingested when determining appropriate fasting period. Since non-human milk is similar to solids and gastric emptying time consider the amount ingested when determining appropriate fasting period.

B. 3 indications for urgent removal of an esophageal foreign body ?

  1. Sharp, long >6cm, or a super absorbent polymer and is in the esophagus or stomach
  2. High powered magnet or magnets
  3. Disk/ button battery in the esophagus
  4. Patient shows signs of airway compromise
  5. Evidence of near complete esophageal obstruction (ie; patient can’t swallow secretions )
  6. Symptoms suggesting inflammation or intestinal obstruction (fever, abdo pain, or vomiting)
110
Q

A 12 year old girl with crohn’s has a 0.8mm renal stone obstructing her ureter resulting in grade 3 hydronephrosis.
A. What is the most likely composition of the stone?
B. What are 2 indications for surgical removal of the stone ?
C. What are 3 recommendations you could give her to avoid future stone formation ?

A

A. Type of stone
- calcium oxalate

Complications of inflammatory bowel disease include kidney stones due to malabsorption of calcium and increased absorption of oxalate. When less calcium is available in the intestinal lumen to bind oxalate, oxalate absorption and therefore urinary Oxalate excretion increases.

B. 2 indications for surgical removal:

  1. Severe debilitating pain refractory to parenteral analgesic therapy
  2. Significant urinary obstruction
  3. Solitary kidney with partial or total obstruction
  4. Renal insufficiency
  5. Signs of infection
  6. Struvite stones
  7. > 5mm in diameter

C. What are 3 recommendations you could give her to avoid future stone formation ?

  1. Increase fluid intake
  2. Limiting dietary sodium (low sodium diet can enhance proximal sodium and calcium reabsorption, leading to a reduction of calcium excretion)
  3. Recommended daily allowance of calcium
  4. Avoiding excess animal protein in the diet (oxalate)
  5. Increased dietary potassium intake
  6. Moderate intake of high oxalate foods
  7. Avoidance of excess vit C
  8. Low fat diet

The greatest risk factors for calcium kidney stone formation are low fluid and high sodium intake.

111
Q

Name for autoimmune conditions associated with increased risk of developing celiac disease

A
  1. Hashimoto hypotheyroidis
  2. Type 1 DM
  3. Autoimmune hepatitis
  4. IBD

Celiac disease is associated with dermatitis herpetiformis, down syndrome, selective IGA deficiency, and other conditions which have auto immune features such as type 1 diabetes mellitus, thyroid disease, and liver disease. Patient with coeliac disease and their families may also be more likely to have atopic dermatitis compared with the general population.

112
Q

A 13-year-old girl presents to you with jaundice. She is otherwise well, and has episodes like this in the past. Bloodwork is done, which shows a mildly elevated unconjugated Bilirubin at 60 and conjugated billirubin at 12.

A. What is her most likely diagnosis?
B. What are two things that can incite jaundice in her condition?
C. How would you treat her?

A 
A. Gilbert syndrome 
B. Invites jaundice 2 things
1. Inter current illness
2. Dehydration
3. Fasting
4. Alcohol
5. Exercise

C. How would you treat her ?

  1. Reassurance - no treatment needed.
  2. Encourage hydration
113
Q

List 4 criteria for cyclic vomiting syndrome

A

NASPGHAN suggest the following diagnostic criteria all of which need to be met. These recommendations apply to children and adolescents:

  1. At least five attacks in any interval, or a minimum of three attacks during a six-month period.
  2. episodic attacks of intense nausea and vomiting lasting 1 hour to 10 days and occurring at least one week apart.
  3. Stereotypical pattern and symptoms in the individual patient
  4. Vomiting during attacks occurs at least four times per hour for at least one hour.
  5. return to baseline health between episodes
  6. Not attributed to another disorder
114
Q

A four-year-old is getting NG feeds 4 boluses a day. For the last 4 days, he has been having sweating, cramping and sometimes profuse diarrhoea one hour after feeds.

A. what is the most likely reason for dumping ?
B. Name 2 pathophysiological mechanisms for why this is happening

A

A. Dumping syndrome Occurs when food, especially sugar, moves too fast from the stomach to the doudenum in the upper gastrointestinal tract. It could be happening because the patient is taking foods very high in sugar content or the NG moved to NJ.

B.

  • Early dumping syndrome = rapid emptying of food into small bowel with a sympathetic nervous system response.
  • late dumping syndrome = result of hyperglycaemia and the subsequent insulin response leading to hypoglycaemia that occurs 2-3h after a meal.

Or
According to lecturer
If this is an NG the most likely cause for dumping would be an infection.

B. The pathophysiologic mechanism would be:

1) osmotic load (rapid emptying of hyperosmolar fluid into the the small intestine)
2) high rate of administration of feed
3) dysmotility
4) small bowel bacterial overgrowth (no?)
5) late dumping due to hypoglycaemia following postprandial insulin peak

But if question was not remembered correctly and the child had a G-tube then:

A. Most likely reason for dumping would be either post-op for recent G-tube insertion or migration of G-tube to GJ tube.
B. Possible pathophysiological mechanisms include:
1). Osmotic load
2) post op ileus
3) small bowel bacterial overgrowth

For NJ tube - can get dumping shortly after insertion.
If NG has migrated to NJ, more likely to cause vomiting than the above symptoms

115
Q

13 y.o, previously healthy adolescent male presents with retrosternal chest pain. He has had 3 months or progressive dysphagia with solids.

A. What are the 2 most likely causes ?
B. What are 3 additional possible causes ?

A

A. 2 most likely causes of dysphagia

  1. Eosinophilic esophagitis
  2. GERD Esophagitis

B. 3 additional possible causes of dysphagia

  1. GERD
  2. Achalasia
  3. Esophageal spasm
  4. Scleroderma
  5. Intrinsic lesions
  6. Foreign bodies including pills
  7. Esophagitis: GERD, eosinophilic esophagitis
  8. Stricture: corrosive injury, pill induced, peptic
  9. Esophageal webs
  10. Esophageal rings
  11. Esophageal diverticula
  12. Neoplasm
  13. Extrinsic lesions
  14. Vascular compression
  15. Mediastinal lesion
  16. Cervical osteochondritis
  17. Vertebral abnormalities
116
Q

Aside from micronutrient deficiency and malabsorption, name 3 sequels of short gut syndrome.

A

3 sequelae of short gut syndrome

  1. Sepsis or line infection
  2. Hepatic cholestasis (due to parenteral nutrition ) + cirrhosis
  3. Renal stones
  4. Thrombosis
  5. Gallstones
117
Q

Child with CP and G-tube for 2 years, who has been growing well with it, now comes with acute abdominal pain. Name 4 “complications” (they used this wording) of indwelling enteral tubes that could explain this presentation.

A

4 complications of indwelling enteral tubes

  1. Gastric outlet obstruction
  2. Infection at site - local ostomy site infection/irritation
  3. Dislodged G-tube
  4. G-tube malfunction ie; clogged, leaky, rupture balloon
  5. Disruption of ostomy tract
  6. Peritonitis and Septicemia
  7. Pneumoperitoneum
118
Q

Child with restricted eating.
A. List 2 risk factors for refeeding syndrome
B. List 2 electrolyte abnormalities in refeeding syndrome

A

A. 2 risk factors for refeeding syndrome

  1. Quick refeeding
  2. Rapid weight loss with weight less than 70% ideal body weight
  3. Low baseline PO4, Mg, K

B. List 2 electrolyte abnormalities

  1. Hypophosphatemia
  2. Hypokalemia
  3. Hypomagnesemia
119
Q

A 4 year old boy has had pain and non-bilious vomiting today. And ultrasound shows an intussusception (ileo-colic). As the emergency physician, you recommend an air enema reduction. Before going ahead with the procedure, the parents want to know more about the risks of air enema reduction:

A. What are the chances of successful reduction with air enema ?
B. What are the chances of a perforation with air enema?
C. What are the chances of recurrence after an air enema?
D. What are 2 contraindications to suing an air enema ?

A

A. Chances of successful reduction ?
- 80-95% as per Nelson’s

B. Chances of perforation?
- 0.1-0.2%

C. Chances of recurrence ?
- 10% (2-5% after surgical correction)

D. Two contraindications

  1. Prolonged intussusception
  2. Signs of shock, peritoneal irritation, intestinal perforation or pneumatosis intestinalis
120
Q

A 1 month old baby has total bilirubin of 180, conjugated bilirubin of 85. What are 5 conditions that could cause this and name the 1 diagnostic test for each condition.

A

5 conditions of neonatal cholestasis and diagnostic tests

  1. Biliary atresia - biopsy
  2. Neonatal hepatitis - serologies
  3. Alagille syndrome - genetic testing
  4. Alpha-1- antitrypsin deficiency - a1 level
  5. Choledochal cyst - U/S
121
Q

A one-month-old baby girl presents to the emergency department because she has been fussy over the last two days. She is afebrile, thriving, and otherwise well. On examination, you discover an abdominal mass. Name three non-Renal causes for this abdominal mass.

A

3 non-renal cause of abdominal mass

  1. Constipation
  2. Neuroblastoma
  3. Intussusception
122
Q

Name 4 dermatologic manifestations of inflammatory bowel disease

A
  1. Erythema nodosum; painful raised red lesions 1 to 3 cm in diameter, seen most commonly on the shins
  2. pyoderma gangrenosum; a severe ulcerating rash that responds to immunosuppression, is rare in children and is seen more often in patients with long-standing ulcerated colitis and patients with Crohn’s disease.
  3. cutaneous vasculitis; cutaneous small vessel vasculitis and cutaneous polyarteritis nodosa
  4. Metastatic Crohn’s disease; metastatic Crohn’s disease is characterized by cutaneous ulcerating nodules and violaceous plaques that demonstrate histologic similarity to the underlying Crohn’s disease and have noncaseating granulomas on biopsy.
  5. epidermolysis bullosa acquisita; epidermolysis bullosa acquisita is a rare subepithelial blistering disorder that has been associated with Crohn’s disease.
  6. Sweet syndrome; sweet syndrome is an acute inflammatory dermatitis characterized by tender papules, plates, and nodules distributed on the face, arms and trunk.
  7. psoriasis
123
Q

A. Name 5 vitamins/ micronutrients that can be deficient in a 4 year old who is strictly vegan.

B. Why does a vegan kid need to take 1.5x protein as a normal kid ?
C. What is the risk of taking in so much more fiber ?

A

A. 5 vitamins/micronutrients that could be deficient

  1. Vit B12
  2. Vit D
  3. Calcium
  4. Iron
  5. Zinc

B. Why do they need more protein ?

  • because the amino acid composition and digestibility is less from non animal sources
  • Animal foods are considered complete or high quality proteins because they contain all nine essential amino acids. Plant-based foods are usually incomplete, meaning they are deficient in one or more of the essential amino acids.

C. Risk of so much fiber ?
- can compromise dietary energy intake and reduce the bioavailability of minerals such as iron, calcium, zinc.

124
Q

A boy with previous liver transplant presents with a systemic illness including fever, lymphadenopathy, large red mass behind left tonsil, and lymphadenopathy.

A. What infectious organisms are you concerned about?
B. What are three non-infectious complications that can be seen post liver transplant?

A

A. EBV
Most common transplant related infections are CMV and EBV

B. What are three non-infectious complications that can be seen post liver transplant?

  1. Primary non-function of the graft (rare and Peds)
  2. Hepatic artery thrombosis (most frequent and early vascular complication; can have devastating consequences on the graft and may require transplantation
  3. Portal vein or hepatic vein strictures/occlusions (rare and usually later finding)
  4. Biliary strictures (most frequent surgical complication around 10 to 30%)
  5. Rejection - usually after the first two weeks after transplant and peaks within the first 90 days; abnormal liver function
  6. Chronic rejection rejection (progressive damage presenting as cholestasis)
  7. PTLD (post transplant lymphoproliferative disease)
125
Q

7 month old has nonbilious vomiting that was previously diagnosed as GERD. What are 5 signs that this is not GERD?

A

Warning signals of underlying pathology: the presence of warning signals suggest that an infant’s reflux may be related to an underlying gastrointestinal systemic disease that may be associated with regurgitation of vomiting. These findings should prompt for the evaluation. Warning signals include:

Symptoms of gastrointestinal obstruction or disease

  1. Bilious vomiting
  2. Gastrointestinal bleeding: hematemesis, hematochezia*
  3. Consistently forceful vomiting
  4. Onset of vomiting after six months of life *
  5. Constipation
  6. Diarrhea
  7. Abdominal tenderness, distention
  8. Recurrent pneumonia raises possibility of tracheoesophageal fistula

Symptoms or signs suggesting systemic or neurologic disease

  1. Hepatosplenomegaly
  2. Bulging fontanelle
  3. Microcephaly or microcephaly
  4. Seizures
  5. Hypotonia or hypertonia for example cerebral palsy
  6. Stigmata of genetic disorders for example trisomy 21
  7. Chronic infections for example HIV

Nonspecific symptoms

  1. Fever
  2. Pneumonia*
  3. Lethargy
  4. Failure to thrive*
    * May also be a consequence of Gerd
126
Q

15-year-old female adolescent with left lower quadrant pain and vomiting who states she is not sexually active. What are the three most concerning causes that you need to rule out.

A 
Ovarian torsion
Ectopic pregnancy
Incarcerated inguinal hernia
Pelvic inflammatory disease
Ruptured ovarian cyst
Appendicitis
Nephrolithiasis
127
Q

AXR of bird’s beak. What is the condition ?

A

Achalasia

128
Q

Teen with dysphagia, odynophagia with solids, name 3 differentials

A

Eosinophilic esophagitis
Esophagitis from Gerd
Esophageal webs rings
Achalasia

Dysphasia and Odynodysphagia

  1. GERD
  2. Eosinophilic esophagitis
  3. Crohn’s disease with esophageal involvement
  4. Infectious pharyngitis (ie; due to GAS, EBV)
  5. Retropharyngeal abscess
  6. Infectious epiglottitis
  7. Stomatitis (ie; enterovirus auch as cox’s a lie A; herpetic gingivostomatitis)
  8. Medication- induced esophagitis (ie; tetracycline: but this is not with solids )

Dysphagia (but no odynophagia)

  1. Neuromuscular disorders: cerebral palsy, brain tumor, CVA, MS, dermatomyositis, myasthenia gravis, muscular dystrophies
  2. Hypothyroidism, goiter
  3. Achalasia
  4. Scleroderma
  5. Esophageal webs, esophageal rings, esophageal diverticula
  6. Esophageal neoplasm
129
Q

A 14-year-old girl with steroid resistant Crohn’s disease is started on azathioprine. Three weeks later she starts complaining of epigastric pain, particularly after meals. What are two possible diagnosis?

A

Two diagnosis ?

  1. Pancreatitis - from azathioprine toxicity
  2. Cholelithiasis - complication from Crohn’s
  3. Dyspepsia or gastric ulcer
  4. Crohn’s exacerbation or flare
  5. Crohn’s disease involving the esophagus

Other side effects of azathioprine

  1. Bone marrow suppression
  2. Liver dysfunction/hepatotoxicity
  3. Drug fever
  4. Arthritis, rash
  5. Nausea
  6. Pneumonitis
  7. Increased risk of lymphoma

Regular monitoring recommended: CBC, serum aminotransferases , bilirubin, amylase

130
Q

Indications to investigate abdominal pain (3) ?

A

Indications to investigate abdominal pain

  1. Weight loss
  2. Decreased growth velocity
  3. Nocturnal symptoms
  4. Severe chronic diarrhea
  5. Bloody stool
  6. Hematemesis/bilious emesis
  7. Jaundice/stigmata of liver disease/HSM
131
Q

Child diagnosed with Crohn’s disease. Was off school for 2-3 weeks, and now upon return to school, complains of abdominal pain the first hour of school, and improves after going home. His Crohn’s disease is well controlled (hx of depression anxiety). What counselling methods do you offer this family.

A

Counselling methods:
1. Relaxation techniques (deep breathing exercises, progressive muscle relaxation)
2. Cognitive behavioural therapy
3. Guided imagery/hypnotherapy, distraction technique through which child enters a state of engagement and imagery and relaxation, which distracts attention from painful stimuli
4. Biofeedback - Technique that provides a visual or auditory despite other physiologic response to pain/anxiety (for example heart rate,
Skin temperature, so the effects of relaxation techniques can be externally validated)
5. For separation anxiety parent child interaction therapy (PCIT) = therapists teach caregivers to reinforce desired behaviours and extinguish unwanted behaviours and coach them to apply them while interacting with her child

I do wonder though if the question really was how do you manage counsel the family?

  1. Therapeutic relationship between clinician and patient and the family is important. The family and patient should believe their concerns are taken seriously.
  2. Reassurance and education; reassurance that there is no evidence of a serious underlying disorder
  3. Acknowledge that the pain is real and has affected important activities in a child’s life. Functional abdominal pain thought to be caused by heightened sensitivity to the normal function of the stomach and bowel; it can be triggered and exasperated by environmental and psychosocial factors including
    stress, anxiety, and social reinforcement.
  4. The pain is not life-threatening and does not require activity restriction. Thus treatment should focus on return to normal activity despite discomfort. A plan to return to school is crucial. Plan ahead for pain episodes at school, provide parents with guidelines about when the child is too sick to go to school, identifying and addressing school related sources of stress for example bullying. If the child also has IBS with diarrhoea provide a note to school requesting that child be allowed to use the bathroom whenever necessary.
  5. Management of pain should include avoiding triggers and improving coping skills.
  6. Reinforcement of well behaviours - praising/rewarding the child for attending school or extracurricular activities (for example sticker chart)
  7. Improve coping through relaxation techniques, distraction, guided imagery and hypnotherapy, cognitive behavioural therapy and bio feedback
  8. Screen for coexisting anxiety disorder
  9. Medical interventions: probiotics, increased water soluble fiber, peppermint oil none of these are well-established but they have low risk of harm so short term trial is reasonable.
132
Q

Three month old boy comes in for routine newborn care. The mother describes symptoms of upper respiratory tract infection and mentioned that when he has coughed on two recent occasions, she has noticed a swelling protruding from his anus. Picture of rectal prolapse. List the most likely underlying etiology.

A

Rectal prolapse underlying etiology .
According to lecturer idiopathic is most likely but probably the question asks what is the most important thing to rule out? Answer would be cystic fibrosis. According to lecture with rectal prolapse need to rule out chronic constipation, cystic fibrosis, inflammatory bowel disease, and repaired Hirschsprung’s.

133
Q

A 1 week old breast-fed baby comes into your office for newborn care. There is bright red blood mixed in with the stool. The baby did not have any bleeding or bruising with vitamin K injection at birth or with a newborn screen. The Anus appears normal and there’s no evidence of a fissure. List the most likely cause of the blood in the stool.

A

Answer: swallows maternal blood. We confirmed this with the lecturer and confirmed that the blood would be red.

The rectal blood should be tested to determine whether it comes from the infant or whether it represents maternal blood which may have been swallowed doing delivery or ingested during breast-feeding from cracked nipples. APT test for brown yellow colour looking for adult Hb, pink colour = fetal Hb

Neonatal period. The most common diagnosis to consider in newborns with LGIB are:

  1. Swallowed maternal Blood
  2. Anorectal fissures
  3. Necrotizing enterocolitis
  4. Malrotation with midgut volvulus
  5. Hirschsprung’s disease with enterocolitis
  6. Coagulopathy
  7. Brisk upper G.I. bleeding
  8. Vascular malformations
  9. Gastric or duodenal ulcer
  10. Gastrointestinal duplication cyst

** FPIAP/CMPA - usually starts at 2 weeks **

Infants and toddlers, the most common causes bleeding in infants and toddlers one month to two years includes:

  1. Anal fissures especially around the introduction of solid food or cows milk
  2. Milk or soy protein induced colitis (allergic colitis)
  3. Intussusception,
  4. Infectious colitis
  5. Meckel’s diverticulum
  6. Lymphonodular hyperplasia
  7. Gastrointestinal duplication cyst
  8. Coagulopathy
134
Q

A teenage boy comes to your office with recurrent episodes of yellow sclera often following an upper respiratory tract infection. Liver enzymes are normal. Direct Bilirubin is low, but indirect Bilirubin is 47. There is no evidence of hemolysis on a blood smear. List the most likely cause.

A

Gilbert syndrome

135
Q

A nine-year-old boy comes into your ER with severe abdominal pain and Bilious vomiting. He has presented in a similar manner on 3 previous occasions in the past two years. List the most likely underlying diagnosis (1 point)and one investigation you would do in about one week when he is feeling well (1point).

A
  1. Intestinal malrotation with volvulus
  2. Upper GI contrast series

Intestinal malrotation in older children most common symptom is abdominal pain and vomiting which may or may not be Bilious. Intestinal malrotation can lead to volvulus. Evaluation begins with plain radiographs to exclude obvious perforation for example a pneumoperitoneum. Then do an upper G.I. contrast series which shows clearly misplaced duodenum with the ligament of Treitz on the right side of the abdomen. They duodenum appears as a corkscrew appearance. With your duodenal obstruction you may have a “beak” appearance of volvulus is present. Treatment is the LADD procedure to minimize future risk of volvulus by widening the base of the mesentery and placing the bowel in a position of non-rotation.

136
Q

A teenage girl comes to your office. She has a known history of all Ulcerative colitis. One year ago she had a total colectomy with a J pouch Creation. She had an ileostomy until about six months ago, when it was closed. Now, she presents with a two week history of bloody diarrhea up to 10 times a day and abdominal pain. Still cultures are negative.

A. What’s the most likely diagnosis?
B. What is the best treatment?

A

A. Pouchitis - inflammation of the ileal pouch (an artificial rectum surgically created of ileal gut tissue in patients who have undergone a colectomy)

B. Treatment:
Pouchitis =PO ciprofloxacin (other option: metronidazole)

Vs
Cuffitis is a mild presentation with some blood loss but is not a/w pain or significant bloody diarrhea. This occurs if colonic mucosa has been left behind. This presentation sounds more like pouchitis which is also more common to see. Also in the text they say total colectomy (not subtotal) which may be another hint.

Cuffitis - treatment is steroid/mesalamine

Based on uTD, I think pouchitis but based on Nelson’s, I think pouchitis

UTD
Pouchitis
- among patients who have undergone an ileal PICU- anal anastomosis, reported incidence of pouchitis ranges from 23-59%
- ulcerative colitis is the most important risk factor for pouchitis
-clinical presentation: increased stool frequency, urgency, abdominal cramps, tenesmus, Night time fecal seepage, incontinence

Vs
Cuffitis
- symptoms of hematochezia are rare in patients with pouchitis and are suggestive of inflammation of the rectal cuff (cuffitis)
- cuffitis typically presents with urgency and hematochezia
- cuffitis is considered a recurrence of ulcerative colitis in the residual cuff of rectal mucosa
- pouchitis and cuffitis can co-exist
- Treated with steroids/mesalamine

Nelson’s
The ileostomy is usually closed within several months, restoring bowel continuity. At that time, stool frequency is often increased but may be improved with loperamide. The major complication of this operation is pouchitis, which is a chronic inflammatory reaction in the pouch, leading to bloody diarrhea, abdominal pain, and, occasionally, low grade fever. The cause of this complication is unknown, although it is more common when the ileal pouch has been constructed for ulcerative colitis than for other indications. It 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 abx therapy.

137
Q

Baby with GERD on formula feeds. What are 4 non-pharmacological management strategies?

A

4 strategies for GERD in baby. Non pharmacological

  1. Prone when awake, avoid supine/side positions
  2. Upright x 20 min after feeds
  3. Thickened feeds
  4. Can try hypoallergenic diet - exclude milk or soy protein
  5. Normalize feeding volumes - smaller volumes more frequently
  6. Avoid exposure to tobacco smoke
138
Q

An 8 y.o boy presents with a two year history of severe constipation and encopresis. On exam he has significant amounts of stool in his rectal vault. What are 4 steps in this patients’ management ?

A

4 steps in management

  1. Disempaction
    - daily enemas x 6days or PEG 1.0-1.5g/kg/daily divided TID (max 100g/day)
    - if severe, admit to hospital and give NG PEG until rectal effluent clear
  2. Maintenance therapy with PEG 3350
    - start at 0.4-0.8g/kg/day as single daily dose or twice daily and can tailor dose
  3. Behaviour modification. - toileting regime
    - routine, scheduled toilet sitting for 3-10min 1-2x a day
    - make sure they have a foot stool to make valsalva more effective
    - praise for stooling and sitting
    - no punishment for not stooling
  4. Dietary modification
    - balanced diet
    - diet with prunes, Apple or pear juice is good for retaining water in stool
    - adequate fiber (AAP: 0.5 mg/kg/day to max of 35g/day). - no evidence for giving more than this
    - no real evidence for milk elimination, but can try this if constipation Is not improve with medical and behavioural management as intolerance to cows milk in atopic children has been associate with chronic constipation.
    - No evidence of probiotic
139
Q

An 18-month-old boy presents with acute fulminant hepatitis without neurological symptoms. What are four steps you would do for support of management?

A

4 steps for supportive management in acute fulminant hepatitis

  1. Transferred to Centre with ICU and that can do a liver transplant if required
  2. Intubation to prevent aspiration, reduce cerebral edema by hyperventilation
  3. Glucose containing fluids to maintain normal serum glucose
  4. Treat for coagulopathy with vitamin K times one
  5. If actively bleeding can give FFP, cryoprecipitate, platelets
  6. IV PPI due to high-risk of G.I. bleeding
  7. Volume to correct and avoid hypovolemia
  8. Frequent monitoring of electrolytes
  9. Protein restriction or elimination based on encephalopathy
  10. Regular neural vitals and can use lactulose if encephalopathy
  11. Dialysis fluid overload acute renal failure
  12. Administer antibiotics/acyclovir if unclear etiology
140
Q

Name to life-threatening complications of ulcerative colitis

A
  1. Toxic megacolon
  2. Bowel perforation

Other colon cancer

Toxic megacolon happens in 5% of people with severe ulcerative colitis. It can be triggered by hypokalaemia or opiate use. Think about this in patients with severe abdominal pain and distention. Symptoms may be masked in patients on steroids. Transverse colon > 4 cm in diameter, if age less than 10, (if age <10), may see loss of Haustral folds. Be worried about fever abdominal pain, distension not associated with bowel movements.

141
Q

Name the Two most important factors in increasing risk of colonic adenocarcinoma in a patient with ulcerated colitis (be specific).

A
  1. Disease extent
  2. Disease duration

The risk for development of colorectal cancer and patience with ulcerated colitis increases with Disease extent and duration

142
Q

Name two signs of portal hypertension on physical exam and a child with some liver problem.

A

2 signs of ports HTN

  1. Splenomegaly
  2. Caput Medusa (distended periumbilical veins)
  3. Hemorrhoids
  4. Ascites
  5. Varices (but not visible on exam)
143
Q

Child with chronic diarrhoea and weight loss. Name 4 possible diagnosis of hypoalbbuminemia.

A

Causes of hypoalbuminemia

  1. Decreased production
    - protein malnutrition
    - defective synthesis
  2. Increased loss
    - protein-losing enteropathy
    - nephrotic syndrome
    - excessive burns
  3. Redistribution
    - inflammation of vasculature (ie; sepsis)
    - hemodilution
144
Q

Neonate on TPN. List 4 things that will increase his incidence of cholestasis.

A

4 things that increase neonates incidence of cholestasis on TPN

  1. Low birthweight < 1000g
  2. Duration of TPN = usually after >2weeks
    3.+ 4Complicated medical courses, including those affected by respiratory distress , hypoxia, acidosis,
    NEC, sepsis, and short bowel syndrome
145
Q

What 4 screening tests would you order in a child with suspected celiac disease ?

A

4 screening tests

  1. IgA endomyseal antibodies (EMA)
  2. IgA tissue transglutaminase (TTG)
  3. Total IgA level of (1 and 2 are negative but IgA level is low, then celiac disease strongly suspected)
  4. Intestinal biopsy
146
Q

Child presents with bloody diarrhea, anemia and thrombocytopenia. What is the diagnosis ?

A

HUS

147
Q

Teenager presents with Three-year chronic history of intermittent abdominal pain and bloody stools and also arthritis. His height and weight are less than the 5th percentile.

A. What is his diagnosis?
B. What are 2 skin complications from his disease ?

A

A. IBD

Crohn’s disease
-generally don’t have abdo pain in UC and height isn’t affected

B. 2 skin manifestations

  1. Erythema nodosum
  2. Pyoderma gangrenosum
  3. Aphorism ulcers
  4. Vesiculopustular eruption
  5. Necrotizing vasculitis
  6. Metastatic Crohn’s disease
148
Q

Infant has problem of vomiting with feeds and chronically Weezy. Upper G.I. shows indentation of upper esophagus. What are two diagnosis you consider?

A

2 dx

  1. Vascular ring
  2. Esophageal stricture
  3. Esophageal web
  4. Eosinophilic esophagitis
149
Q

Child with FTT, abdominal distention, wasted limbs and buttocks, irritable. Diagnosed with coeliac disease. List 4 other causes of small intestinal flat villi besides coeliac disease.

A

4 other cause of flat villi

  1. Tropical sprue
  2. Giardiasis
  3. Crohn’s disease
  4. HIV enteropathy
  5. Bacterial overgrowth
  6. Autoimmune enteropathy
  7. Eosinophilic gastroenteritis
  8. Cow’s milk enteropathy
  9. Soy protein enteropathy
  10. Primary immunodeficiency
  11. GVHD
  12. Chemo and radiation
  13. Lymphoma
  14. Protein energy malnutrition
  15. Non-gluten food intolerance
150
Q

A. Name 3 atypical presentations of celiac disease.

B. List 2 conditions that are associated with celiac disease

A

A. Atypical form:

  1. Absence or few gastrointestinal symptoms
  2. Presence of atypical symptoms, such as anemia due to iron deficiency, osteoporosis or osteopenia, infertility, low stature

B. List 2 conditions that are a/w celiac disease

  1. Thyroid disease - hashimoto’s
  2. Type 1 DM
  3. Multiple sclerosis
  4. Autoimmune hepatitis
  5. Addison disease
  6. Arthritis
  7. Snogged ‘s syndrome
  8. Idiopathic dilated cardiomyopathy
  9. IgA nephropathy
151
Q

14 year old boy with RLQ abdominal pain, weight loss and diarrhea. RLQ mass palpable and anal fissure noted.
A. What is the most likely diagnosis ?
B. List 2 diagnostic tests to confirm the diagnosis ?
C. List 3 acute complications of this disease?

A

A. Crohn’s disease

RLQ mass = inflamed terminal ileum.

B. List 2 diagnostic tests to confirm diagnosis

  1. Upper and lower endoscopy with biopsy
  2. Abdominal MRI- enterography (to see terminal ileum which you can’t really see on scope)

C. List 3 acute complications of this disease

  1. Toxic megacolon
  2. Bowel perforation
  3. Abscess
  4. Fistulas
  5. Bowel obstruction
152
Q

Young child with periorbital edema and diarrhea. His albumin is 12. What is your differential diagnosis ?

A
  1. Protein losing enteropathy
  2. Nephrotic syndrome
  3. Celiac disease
  4. Eosinophilic enteropathy
  5. Hypertrophic gastritis (Menetrier’s disease)
  6. Milk protein allergy
  7. IBD
  8. Giardiasis
  9. Intestinal lymphangiectasia
  10. Structural heart disease
153
Q

Teenager with weight loss and perianal abscess.

A. Dx
B. Child with perianal abscess. Management x 2 lines

A

A. IBD, likely Crohn’s
B. Conservative management (observation) with sitz bath. May need I &D under local anesthesia if very painful. Pain management. Abx are generally not useful.

From Nelson’s: common in children and usually manifests in the first year of life of unknown etiology. Links to congenitally abnormal crypts of Morgagni have been proposed, suggesting that Deeper crypts lead to trapped debris and cryptitis. Strong male predominance in those affected younger than two years of age. Imbalance corrects in older patients where the etiology shifts to associated conditions such as inflammatory bowel disease, leukaemia or Immunocompromised states

154
Q

2 indications for fundoplication in 6 month old child with GERD

A

Fundoplication is effective therapy for intractable GERD in children, particularly those with refactory esophagitis or strictures and those at risk for significant morbidity from chronic pulmonary disease. It may be combined with a gastrostomy for feeding or venting.

Peas and review: fundoplication may be considered in patients with confirmed GERD who experience severe refractory or recurrent symptoms or life-threatening complications of GERD.

155
Q

2019 Q: a 4 y.o girl presents to you with progressive abdominal pain. She has a history of pulling out her hair. An upper GI is done as is shown below (picture of mass). What is definitive management ?

A. Endoscopy
B. Laparoscopy
C. Observe
D. Laparotomy

A

A. Endoscopy

Gastric bezoar - trichollimania.
Need endcosopic removal

156
Q

2019 Q: 1 week old infant presents with an umbilical granuloma. What is the treatment ?

A. Excise
B. Silver nitrate
C. Observe/reassure

A

B. Silver nitrate

157
Q

2019Q: 7 y.o kid with history of GERD, and new onset abdominal pain. How do you diagnose ?

A. Esophagoduodenoscopy and biopsy
B. Scope
C. Urea breath test
D. Stool for H.pylori

A

A. Esophagoduodenoscopy and biopsy

158
Q

2019 Q: A 9 y.o boy has a BMI of 95%. His weight has been steadily increasing since 5 y.o. He watches tv. 5h a day and has a sedentary lifestyle. His father died (or had) an MI at the age of 32. His blood work showed a high total cholesterol, high LDL, normal HDL, and normal TG. His TSH is on the upper limit of normal. What is the most likely diagnosis ?

A. Familial hypercholesterolemia
B. Obesity related dyslipidemia
C. Familial combined dyslipidemia
D. Subclinical hypothyroidism

A

Answer A. Familial hypercholesterolemia - increased total cholesterol + increased LDL with Normal TG + family Hx of early CVD death

C. Familial combined dyslipidemia = FCH - increased total cholesterol and increased TG

159
Q

2019Q: Adolescent girl with intermittent epigastric pain for months. Normal weight and diet. Father has history of peptic ulcer disease. Tried his dad’s antacids and experienced some relief. What would be the best management ?

A. Amox + clarithromycin and PPI
B. Scope and biopsy
C. Urea breath test
D. Stool antigen test

A

B. Scope and biopsy

160
Q

2019Q: Boy with hard infrequent stools, some overflow stool, dad asks about management.

A. What two medications can you use intially
B. What 2 non- pharmacological treatments would you suggest ?

A

A. 2 meds

  1. Peg 3350
  2. Enemas

B. 2 non-pharmacological treatments you would suggest

  1. Behaviour modifcation
  2. Dietary modification
161
Q

2019Q: 14 y.o female found to have gallstones. Name 3 conditions that predispose you to gallstones in this age range.

A

Name three conditions that predispose you to gallstones in this age range.

  1. Obesity
  2. Female gender only after puberty
  3. Hemolytic disease such as sickle cell disease, hereditary spherocytosis, thalassemias, Wilson’s disease.
  4. Reduced bile salt pool for example history of ileal resection, small bowel Crohn’s disease, cystic fibrosis with pancreatic insufficiency
  5. TPN
  6. Medications such as ceftriaxone, furosemide, octreotide, cyclosporine
  7. T21
  8. Hypertriglyceridemia
  9. Pregnancy
  10. Some Native American tribes

Cat's Questions (13 decks)

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