GI and Nutrition - 2019 Updated! Flashcards
(Picture of gastroschisis) Which of the following anomalies is associated with this condition: a. Intestinal atresia b. Renal anomaly c. Cardiac anomaly
a. Intestinal atresia
Right of umbilicus - defect in abdominal wall (vs omphalocele which herniate abdominal contents in sac through umbilicus)
-1/10 babies have intestinal atresia (omphalocele has cardiac, renal, neural tube defects, genetic associations)
(AXR with a large bubble of stomach gas and a second bubble of gas to the left of this, no gas distally)
a. What is this XR sign called?
b. What diagnosis is this consistent with?
c. What syndrome is often associated with this diagnosis?
d. What specific heart lesion are babies with this syndrome at risk for?
a. What is this XR sign called? double bubble
b. What diagnosis is this consistent with? congenital duodenal atresia
c. What syndrome is often associated with this diagnosis? Trisomy 21
d. What specific heart lesion are babies with this syndrome at risk for? AVSD
A 16 year old 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. UGI and small bowel follow through
b. psychiatry consult
c. barium enema
a. UGI and small bowel follow through - now probably more likely to do MRE if available
- chronic anal fissures are associated with Crohn’s
- UGI can show aphthous ulcers, strictures, fistulae
Alt Q had colonoscopy as an option, which would be a better place to start.
5 yo with cough and fever. Crackles on the RLL. CXR shows either diaphragmatic eventration vs hernia. What is the best next test for diagnosis?
a. Diaphragm fluoroscopy
b. Ultrasound
c. Exploratory laparotomy
d. MRI
b. Ultrasound
U/S can help differentiate CDH from diaphragmatic eventration (weakness of diaphragm, but not a hole in diaphragm - can be acquired from phrenic nerve injury or congenital); on U/S see paradoxical movement of hemidiaphragm in eventration
13 year old with early morning throat pain. Parents comment that she has bad breath. What would you do: A) upper GI B) Abdo u/s C) CXR D) pH probe
D) pH probe
- best option of these to assess for GERD
An 8 month old child is admitted for viral gastroenteritis. The child has intermittent episodes of screaming and vomiting. On examination the child is pale and lethargic.
Which of the following examinations is most useful in diagnosis of this patient:
a. AXR
b. Serum lactate
c. Air enema
c. Air enema
- diagnostic and curative for intussusception; air preferred to saline/contrast as lower risk of perforation
A 6 year old boy tells his mother that he has swallowed a nickel. You do an abdominal XR and see a round radioopaque round object in the stomach. What is your management: a. Observation b. Upper endoscopy and removal c. Cathartics
a. Observation
- once in stomach, 95% of FBs pass spontaneously
- take the batteries and sharp objects out of trachea stat, otherwise can observe x24h for passage into stomach
Child with Foreign body in the esophagus.
List 3 indications for removal
- Respiratory symptoms
- Button Battery
- Sharp object
- Multiple magnets
- blunt object not passing into stomach in 24h
- meat not passing into stomach in 12h
- failure to visualize FB on plain film in symptomatic patient
70% esophageal FBs remain trapped
Best test of hepatic synthetic function?
a. AST
b. ALT
c. INR
d. Alk Phos
e. GGT
c. INR
assessment of liver synthetic function: increased PTT, INR that does not correct with vitamin K
Confirmation of milk intolerance
a. D-xylose
b. jejunal biopsy
c. milk RAST test
d. serum IgE
e. milk challenge
e. milk challenge - gold standard for lactose intolerance
Presumptive if: symptoms occur within a few hours of significant lactose ingestion and resolve 5-7 days after avoidance
a. D-xylose - test for malabsortion
b. jejunal biopsy - test for lactase deficiency
c. milk RAST test - aka specific IgE test - use in suspicion of IgE mediated CMPA
d. serum IgE - not useful
A child presents with watery diarrhea. Stool reducing substances will NOT be positive with which of the following:
a. glucose
b. sucrose
c. fructose
d. lactose
e. galactose
b. sucrose
- acidic stool with 2+ reducing substances suggests carbohydrate malabsorption - reducing substances include all in question plus pentose but NOT sucrose
- basic concept: you need an enzyme to convert disaccharides to monosaccharides (the small intestine can only absorb monos, not disaccharides); SO if you don’t have this enzyme you have a bunch of disacchs which end up in the colon. In the colon they get converted to methane and organic acids (reducing substances) which cause osmotic diarrhea
What 4 screening tests would you order in a child with suspected celiac disease?
- anti-tissue transglutaminase IgA antibodies (can be unreliable in < 2 y.o. because relative IgA deficiency)
- IgA level (if low, TTG can be falsely negative)
- CBC, B12, iron studies, 25-OH Vitamin D
- ? TSH
Consider:
- anti-endomesial antibodies (EMA)
- if TTG antibodies are positive but <10x the ULN, should have upper GI scope
Kid with CP presents with difficulties swallowing. She is tolerating her GT feeds but has difficulty managing her oral secretions. Of note, she got Botox injections to her legs last week. On exam, she has oral secretions and her legs feel less hypertonic. What do you do:
a. pH probe
b. do a swallow study
c. observe in hospital
ANSWER: c. observe in hospital (assuming due to botox)
b. do a swallow study (can esp if you think achalasia)
Botox can cause systemic effects beyond just local injection, including dysphagia
Newborn post repair for TEF with esophageal atresia, persistent respiratory distress. 3 possible diagnoses
- anastomotic leak
- refistulization
- post surgical stricture
- tracheomalacia
- GERD
- vocal cord paralysis
- cardiac anomaly (VACTERL)
A 1 month old has progressive non-bilious vomiting. On exam, there is a small palpable olive in the RUQ. What would be the most likely lab abnormality?
a. metabolic acidosis
b. respiratory acidosis
c. hypokalemia
d. alkalotic urine
e. hypernatremia
c. hypokalemia
Pyloric stenosis
Hypochloremic, hypokalemia metabolic alkalosis
- puke out HCl, Na and K; RAAS kicks in and preserves Na at expense of K
What is true about intussusception?
a) Meckel’s diverticulum is the most common lead point
b) 75% of cases are idiopathic
c) most patients present with red currant jelly stools
ANSWER: b) 75% of cases are idiopathic - most UTD
version of Nelson’s says 90% idiopathic
c) most patients present with red currant jelly stools - blood is usually passed in the first 12 hours, though sometimes not for 1-2 days (normal stools are often still passed in the first few hours of symptoms)
Infant has problem of vomiting with feeds and chronically wheezy.
Upper GI shows indentation of upper esophagus. What are two diagnoses you consider (2)?
Ddx of wheeze, vomiting and indentation of esophagus:
- vascular ring
- pulmonary artery sling
- esophageal duplication cyst
- tumor compression
- lymph node compression
- TEF
2 indications for fundoplication in 6 mo child with GERD.
- intractable GERD
- refractory esophagitis
- strictures
- chronic pulmonary disease
A mother of a 2 month old infant comes to you for the concern that the baby is difficult, fussy spitting up with feeds. The infant is developmentally appropriate, feeds avidly on a 6 ounce bottle without difficulty while in the exam room. The infant feeds every 4 hours. Has been gaining weight well. Mom is concerned but coping well.
What 5 non-pharmacologic recommendations would you give to the mom to help with the spitting up?
- reduce volume of feeding
- increase frequency of feeding
- feed baby in more upright position
- take breaks during feed to burp baby to allow for pacing
- keep baby upright for 30 minutes after feed, and position prone or upright when awake
- Reassurance that it does not have harmful effects
- Consider thickening feeds
Pyloric stenosis: lyte abN
a. Hyperkalemia
b. Metabolic acidosis
c. Hypochloremia
d. Hyponatremia
c. Hypochloremia
Hypochloremia, hypokalemia metabolic alkalosis
Kid vomiting recurrently, missing lots of school, mom has headaches. Most likely cause?
a. abdominal migraines
b. benign paroxysal vertigo
c. separation anxiety
a. abdominal migraines
8 month male, quadriplegic, has GER treated with ranitidine. FTT. NG placed, starting to grow, doing well with NG. Next to consider?
a) g-tube
b) J-tube
c) pH probe
d) G-tube + nissen fundoplication
a) g-tube
GT indications include FTT, severe GERD,
neurologic impairment.
3 week old with pyloric stenosis, severe metabolic alkalosis (bicarbonate 34). What to do:
- Give hydrochloric acid IV
- OR immediately
- Give large amounts of chloride IV
- Give 5mmol/kg of KCl IV bolus
- Give ascorbic acid IV
- Give large amounts of chloride IV
Correct alkalosis pre-OR to prevent post-op apnea (compensate for metabolic alkalosis by not breathing)
Oral rehydration in kid with mod dehydration
a) 100cc/kg over 4h
b) 50cc/kg over 4h
c) NS bolus 20cc/kg
a) 100cc/kg over 4h
- Mild 50cc/kg over 4 hours or Moderate 100cc/kg over 4 hours, 5-10cc at a time
- severe- bolus then ORT
days post scoliosis surgery. Presents with bilious vx. Etiology?
a. SMA syndrome
b. Small bowel adhesions
c. Pancreatitis
a. SMA syndrome
Superior mesenteric artery syndrome
- compression of duodenum by SMA against aorta
Child with CP and GERD.
1) Name 2 tests to confirm this diagnosis.
2) Name 4 severe complications of GERD.
- Tests to confirm:
- pH monitoring and intraluminal impedence
- Endoscopy and biopsy
- 4-8 week trial of PPIs and evaluate for symptom response - Complications:
- Erosive esophagitis
- Barrett’s esophagus
- strictures
- aspiration pneumonia
- FTT
- Worsened asthma
- Apnea/stridor
- Food refusal
- laryngeal edema/granulomas
A 14 year old black male with one year history of intermittent abdominal pain and some diarrhea.
a. unlikely a primary lactase deficiency
b. if reducing substances are negative then a disaccharidase deficiency is ruled out
c. try avoiding milk
d. do a breath hydrogen test
e. do a hemoglobin electrophoresis
ANSWER: c. try avoiding milk
a. primary lactase deficiency includes congenital and non-persistence of lactase enzyme (most common cause - 85% of black adults have this)
d. could also do a breath hydrogen test, but not considered necessary for diagnosing lactose intolerance
Why do you treat Salmonella bacteremia in a 2 month old child?
a) To eliminate the carrier state
b) To decrease the duration of symptoms
c) To prevent meningitis
d) To eliminate shedding from the GI tract
c) To prevent meningitis
Salmonella gastro (not bacteremia) does not need to be treated and is poorly responsive to treatment since the infection is in the enterocytes and antibiotics cannot act on it (also abx prolong excretion/shedding, do not shorten duration of sx and can create chronic carrier state). ABx for immunocompromised and babies <3 months only
A 12 yo girl presents with >5 days of fever, unwell. Hepatomegaly. HR 85 despite the temperature of 39.5, BP normal. CBC und urine tests normal. Blood culture shows
gram negative bacilli. What is the cause?
a) pyelonephritis
b) ovarian torsion
c) typhoid fever
c) typhoid fever - salmonella enterica typhi
Salmonella bacteremia – relative bradycardia is a septic sounding patient
GNB – Salmonella typhi
A previously well 13-month-old presents with generalized puffiness and lethargy. Urine is negative for protein & blood. Albumin is 13. Initial treatment would include:
a. steroids
b. IV albumin
c. Protein hydrolysate formula
d. Lactose free formula
c. Protein hydrolysate formula
(ddx of protein losing enteropathy is milk protein allergy)
(We had answered IV albumin but I agree with this group that it wouldn’t be step one - use if severe ascites or pleural effusions, severe edema)
Shwachman-Diamond Syndrome baby. Which vitamin level would be normal?
a. Vit A
b. Vit e
c. Vit B12
d. Vit D
c. Vit B12
- abnormalities: cytopenias (esp neutropenia), exocrine pancreas dysfunction (do not absorb fat soluble vitamins DEAK), bony (short stature, metaphyseal dysostosis, dental anomalies)
A 3 mos girl BW SGA at 2200g at GA38, now wt 10th, ht 25th, HC 50 th. Which is true?
- 2 yr for catch up growth in IUGR
- f/u in 6 mos no nutritional intervention
- need w/u for organic FTT
- increase dietary protein
- if not at 50 th %ile by 6 months then needs work up for organic FTT
- 2 yr for catch up growth in IUGR
2 year old M suspected of having Celiac disease. What is the most definitive test?
a) Jejunal Bx
b) Anti-gliadin Ab’s
c) Anti tissue transglutaminase Ab’s
d) Gluten free diet
a) Jejunal Bx
A 6 mo baby with FTT is very irritable. Was breastfed initially and solids were introduced at 4 months of age. What is the likely diagnosis?
a) Celiac disease
b) CF
c) Cow’s milk allergy
a) Celiac disease
Failure to thrive, chronic diarrhea, vomiting, abdominal distention, muscle wasting, anorexia, and irritability are present in most cases.
CMPA - would expect bloody stools, less likely FTT
Child with FTT, abd distention, wasted limbs and buttocks, irritable. Diagnosed with Celiac disease. List 4 other causes of small intestinal flat villi besides celiac dz.
Other GI conditions
- Bacterial overgrowth
- Crohn disease
- Eosinophilic gastroenteritis
- Cow’s milk enteropathy
- Small bowel ischemia
Autoimmune/immunodeficiencies
- Autoimmune enteropathy
- Primary immunodeficiency
- Graft-versus-host disease
- HIV enteropathy
- CVID
Acquired
- Tropical sprue (chronic diarrhea in the tropics, cause unknown ? frequent parasite infections)
- Chemotherapy and radiation
Food related
- Food allergies
- Malnutrition
Infectious
- HIV, giardiasis, TB, post viral, H Pylori
Name 3 atypical presentations of celiac disease. List 2 conditions that are associated with celiac disease.
- dermatitis herpetiformis
- iron deficiency anemia, unresponsive to iron supplements
- osteoporosis
- short stature
- arthritis/arthralgia
- pathologic fractures
- delayed puberty
- epilepsy
- peripheral neuropathies
- anxiety
- dental enamel hypoplasia
- ecchymosis + petechiae
- asymptomatic - T1DM
- autoimmune thyroid disease
- autoimmune hepatitis
- Addison
- Sjogren
- Rheumatoid arthritis
- Selective IgA deficiency
T21, Williams, Turners
Baby with delayed meconium passage, abdo distension and calcifications on AXR
a) Hirschprungs
b) CF
c) duodenal atresia
b) CF
- meconium peritonitis: intrauterine rupture of bowel in setting of CF or bowel atresia leads to peritoneal calcifications
A 6 year old boy presents to your office with a history of
diarrhea and periorbital edema. He is found to have an albumin of 24 (or 12). Name 4 diagnoses on your differential.
- Inflammatory bowel disease
- celiac disease
- infectious gastroenteritis
- Hypertrophic gastropathy
- liver failure
- giardiasis
- bacterial overgrowth
- SLE
- nephrotic syndrome
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.
- arrange for skin testing and RAST
- carbohydrate intolerance is a common cause
- it is due to sensitization to cow’s milk protein
- citrus fruits and tomatoes can cause this via an immune-mediated mechanism
- if mucous is not present in the stool then it cannot be an immune problem
- carbohydrate intolerance is a common cause
Toddler’s diarrhea
- Loose watery diarrhea, flatulence, abdominal distention and pain
· With onset of new foods (fruits)
12 month old child who has passed 3 soft red stools in the past 12 hours. He is asymptomatic. The same thing happened 4 months ago but resolved. His Hb is now 70.
Investigation?
a. Upper endoscopy
b. UGI series
c. Nuclear med scan for ectopic gastric tissue
c. Nuclear med scan for ectopic gastric tissue
- Meckels diverticulum causes 50% of lower GI bleeds in kids under 2
- presents with painless rectal bleeding
2-week old child with a 1 week history of stool mixed
with blood in an infant? Bottlefeeding well, passed stool in first 24 hours. Most likely dx?
a. anal fissure
b. cow milk protein allergy enterocolitis
c. Meckel’s diverticulum
b. cow milk protein allergy enterocolitis - would say fissure most likely, but ongoing x1 week and to have fissure start at only 1 week of life seems unusual
A 2 yo is in the ER 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. Hemoglobin is normal. What is the most likely diagnosis?
a) ulcerative colitis
b) Meckel’s diverticulum
c) Anal fissures
d) Bleed from peptic ulcer
b) Meckel’s diverticulum
2 week old girl with rectal bleeding. HR 220, BP 60/35, abdomen tense and sensitive. What is the next step in your diagnostic approach:
- Call general surgery
- Abdominal ultrasound
- IV antibiotics
- Abdominal x-ray
- Barium swallow with small bowel follow through
- Abdominal x-ray
(first step of the Diagnostic approach)
AND call Gen Surgery
1 mo old baby with blood mixed in with his stool. Cause? a . Anal fissure b. Cows milk allergy c. Colitis d. Mat blood
a . Anal fissure
Anal fissure is most common cause of rectal bleeding in kids under age 1; second most common is cow’s milk allergy
Given it is mixed in poop - CMPA might be a better answer
What are 2 surgical complications of HSP
- intussusception
- intestinal perforation
- Bowel ischemia
- Pancreatitis
- Cholecystitis
- Renal failure requiring transplant
3 month old boy comes in for routine newborn care. The mother describes symptoms of URTI and mentions 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.
- most cases are idiopathic
- onset between 1-5 years of age and resolves by 3-5 years of age
- ix: rule out CF and sacral nerve root lesions
An 8 month old baby presents with an abdominal mass, thrombocytopenia, systolic murmur and a murmur over the liver. Ultrasound shows a 3 cm mass in the liver. What would you do? a) DIC work-up b) Bone marrow c) Pulmonary imaging d) Liver function tests
a) DIC work-up
Kasabach Merritt = hemangioma with consumptive thrombocytopenia, microangiopathic hemolytic anemia, and an acute or chronic consumption coagulopathy
associated with tufted angioma and Kaposi hemangioendothelioma
Neonate, now two weeks old, with abdominal mass palpable. Has a history of umbilical catheterization. What is the cause of hepatosplenomegaly?
a. hepatic hemangioma
b. portal vein thrombosis
c. hereditary spherocytosis
d. congenital CMV
e. fungal infection
b. Portal vein thrombosis
Rate of venous thrombosis after UVC is 30%!
2 month old ex 32 weeker who was ventilated with Ua/Uv lines. Now has HSM but has an otherwise normal physical exam. What is the likely cause?
- hepatic hemangioma
- portal vein thrombosis
- hereditary spherocytosis
- congenital CMV
- fungal infection
- portal vein thrombosis
Child with abdo pain, periumbilical, nonradiating. Physical exam normal. Ht and wt on 25%ile.
a. chronic constipation
b. IBD
c. nonfunctional abdo pain
d. lactose intolerance
e. UTI
a. chronic constipation - this is most likely functional abdominal pain, but picked constipation since that’s not a choice
* note - ado pain in any location aside from periumbilical is suggestive of potential serious etiology
A 5-month-old is brought to the ER because of intermittent abdominal pain for the past 5 weeks. The pain occurs several times daily, during which he screams and extends his arms and legs up simultaneously. The episodes last only seconds, and afterwards he returns to normal. His mother also feels that he has not been himself for the past month and that he doesn’t smile as easily.
a) colic
b) constipation
c) epilepsy
d) intermittent intussusception
e) reflux esophagitis
c) epilepsy
concern for infantile spasms - flexion or extension of trunk or extremities sustained for 1-2 seconds; and developmental regression
- classic age of onset is 4 months
6 year old boy presents with severe abdominal pain and vomiting. On examination his abdomen is tender and he is tense and guarding.
What three things do you do for management (3)?
Management of acute abdominal pain and vomiting
- NPO
- NG inserted to decompress stomach/gut
- Surgical consult
- IV fluids
- Analgesia
- Monitor ABCs
- Imaging: CXR ± AUS
Child had a URTI a week ago. He now presents with bloody diarrhea, abdominal pain and a petechial rash. What is his diagnosis?
HSP: palpable purpura in context of normal platelets plus one of abdo pain, arthritis, IgA deposition on biopsy, renal involvement (hematuria, proteinuria, RBC casts)
Kid with abdominal migraine. Family history of migraines. What are two periodic syndromes
associated with migraine development as an adult.
- cyclic vomiting
- abdominal migraine
- recurrent abdominal pain
- recurrent vomiting
A 13 year old girl is seen with abdominal pain of 24 hour duration that she now rates as an 8/10. She has a fever. On examination she has a diffusely tender abdomen and
is guarding. You call general surgery to consult. In the meantime, what is your priority in management:
a. Blood C&S and antibiotics
b. IV fluids and analgesia
c. IV fluids and CT abd
b. IV fluids and analgesia
14 yo black boy with one year history of post-prandial intermittent abdominal pains. Normal stools. No bloating. No vomiting. What test do you do?
- hemoglobin electrophoresis
- Hydrogen breath test
- Gastroscopy with biopsy
- UGI/SBFT
- Abdo ultrasound
- Gastroscopy with biopsy
First line test for suspected H. pylori. This would fit with recurrent gastritis, especially if he is a new Canadian. NASPGHAN does not routinely recommend Urea breath test in children, as it has many false positives and culture and sensitivity is recommended to guide treatment.
- If there was diarrhea - then do hydrogen breath test for lactose intolerance
Sexually active adolescent female with sickle cell disease and a history of previous transfusions presents with an acute history of fever, jaundice and vomiting. She also develops right shoulder pain. Hb 79 (prev 89), AST and ALT 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
b) cholecystitis
Fitz-Hugh-Curtis: occurs in setting of PID - inflammation of liver capsule and peritoneal surfaces - minimal hepatic cell involvement.
Sickle cell girl who is obese, RUQ pain, increased liver enzymes, had been treated and recovers from the event. What do you recommend?
a. cholecystectomy
b. low-fat diet
c. ursodiol
a. cholecystectomy
1 m baby irritable, not feeding well, vomited once, distended abdomen. On exam VSS except mild tachycardia. There is a mass in the right scrotal, firm and non reducible. Does not transilluminate. What is the next step?
a. Ultrasound
b. Urgent surgical consultation
c. Nuclear scan
d. Testicular Doppler
b. Urgent surgical consultation
A 10 yo boy has headache, abdominal pain and
lethargy anytime of the day. He has missed 30 days of school in 4 months. He has:
a) migraines
b) school phobia
c) Brain tumour
school phobia or migraine
Not enough info here.
A 6 year old boy with severe abdo pain 8/10, febrile, tachycardic at 160. Abdomen is rigid. As you call surgeons, what do you do?
a) Culture and start antibiotics
b) Bolus with normal saline and give morphine for analgesia
c) Bolus with normal saline and arrange for urgent CT
b) Bolus with normal saline and give morphine for analgesia
Fluid resuscitation immediately (this patient is in shock), then culture and antibiotics
Lebanese girl with abdominal pain and fever for one day, recurrent episodes. During an episode you do some labs and find increased ESR, increased CRP and decreased albumin.
What is a likely diagnosis?
a) paroxysmal nocturnal hemoglobinuria
b) familial mediterranean fever
b) familial mediterranean fever
1-3 days every 4-8 weeks
Recurrent episodes of peritonitis, inflammation and fever
PNH.- rare, manifests as complement mediated hemolytic anemia - bone marrow failure and thrombosis (get abdo venous thrombosis with recurrent abdo pain)
What is the most specific test for pancreatitis:
- Amylase
- Lipase
- Abdo U/S
- Abdo CT scan
- AXR
- Lipase
Dx of pancreatitis (⅔):
- Acute onset persistent severe epigastric pain radiating to back
- Elevation of lipase >3x ULN or amylase
- Characteristic findings on imaging
Lipase has highest sensitivity and specificity
Kid with peptic ulcer. His treatment would likely include
a. amoxil +clarithro + PPI
b. clinda and clarithro
c. flagyl and tobra
a. amoxil +clarithro + PPI
other tx options:
▪ Amox + Metronidazole + PPI
▪ Clarithromycin + Metronidazole + PPI
A 10 month old child presents to your emergency department with a history of intermittent irritability and vomiting interspersed with periods of looking relatively well. The episodes are coming closer and closer together in time. You diagnose intussusception. What are 3 contraindications to air enema? What are 2 situations in which air enema is unlikely to work?
1. What are 3 contraindications to air enema? Refractory shock Necrosis/Perforation Peritonitis Prolonged Intussusception Pneumatosis
- What are 2 situations in which air enema is unlikely to work?
- Multiple recurrences
- Ilealileal (HSP)
- Pathologic lead points: Meckel’s, lymphoma, polyp, intestinal duplication cysts, PTLD tissue, hemangioma, neurofibroma, hamartomas, leiomyomas
Patients with inflammatory bowel disease lose weight due to:
a) inadequate nutrient intake
b) increased metabolic demands
c) malabsorption
d) drug-nutrient interactions
a) inadequate nutrient intake
- patients develop food avoidance because eating causes pain and diarrhea; also pro inflammatory cytokines cause anorexia
Teenager presents with 3 year chronic history of
intermittent abdominal pain and bloody stools and
also arthritis. His height and weight are less than the
5%.
1. What is his diagnosis?
- What are two skin
complications from his disease?
- IBD - most likely Crohn’s (more likely to present with FTT)
- Erythema nodosum, psoriasis, pyoderma gangrenosum
Teenager with weight loss and
perianal abscess.
a. ) Dx?
b. ) Child had perianal abscess. Management x2 lines.
a. IBD (more likely Crohn’s as perianal disease more common in Crohn’s than UC)
b. I+D and seton placement,
- good perianal hygiene
- Consider antibiotics (Amox-clav or clinda-gent or ancef/flagyl)
- treatment of underlying condition (steroids)
- topical tacrolimus (may be helpful in IBD)
Teenage girl with a history of ulcerative colitis, status post total colectomy. Had a “J- pouch” and an anal pull-through ostomy that was later removed. Did have an ileostomy, but that was closed following an end-to-end anastomosis.
Now she presents with a 5-day history of bloody diarrhea 8 times per day. Stool cultures are all negative.
What is the diagnosis? What 1 treatment would be the best?
- pouchitis
- treatment: oral metronidazole or ciprofloxacin
major complication of surgical repair = pouchitis, a chronic inflammatory reaction in the pouch
- presents with diarrhea, abdo pain, occasional low grade fever
more common when pouch is created in setting of UC relative to other disease processes
- mgmt: flagyl, ciprofloxacin
- probiotics may decrease rate
Kid with Crohn’s. Stomach aches in morning, gone in afternoon. Crohn’s is under control. Missed 30 days of school in past two months. 3 points to management.
- reassurance of family that CD is under control and review of symptoms that would indicate a flare
- parents should avoid reinforcing symptoms that result in secondary gain
- patient should return to school and regular activities
- cognitive behavioural therapy may be beneficial
Crohns patient who has failed prednisone management. Started on azathioprine. Comes back 2 weeks later. Abdominal pain, periumbical. Vomiting. Give 2 most likely causes.
Medication related:
- N/V are known side effects of this medication (especially if fast initiation)
- hepatitis
- pancreatitis
Crohn’s related:
- stricture
- intra-abdominal abscess
Boy has had inflamed, ulcerated lips and gums. (Picture shown). Which of the following conditions is this more likely to be seen with?
a. Chronic mycoplasma infection
b. IBD
c. Eosinophilic gastritis
d. Contact dermatitis
b. IBD
Crohns (Gum to Bum)
5 yo with bloody stools. Hyperpigmented lesions on lip and mucosa. Diagnosed with intussusception. What is underlying cause?
a. HSP
b. Peutz-Jehgers
c. Langerhans histiocytosis
b. Peutz-Jehgers
- Type of Inherited Colorectal Cancer Syndrome (Autosomal dominant but rare)
- Key: mucocutaneous pigmentation + extensive GI hamartomas polyposis
Kid with crohn’s on sulfasalazine and has hairless patch with slight scale.
a. alopecia areata
b. trichotillomania
c. tinea capitus
a. alopecia areata
- AI disorder, seen in IBD; treated with steroids, methotrexate or sulfasalazine
14 yo boy with R lower quadrant abdo pain, wt loss and diarrhea. RLQ mass palpable and anal fissure noted. 1. What is the most likely diagnosis? 2. List 2 diagnostic tests to confirm diagnosis. 3. List 3 acute complications of this disease.
- Dx: Crohn’s
- Ix: Upper endoscopy and colonoscopy with biopsy + UGI with SBFT or Magnetic Resonance Enterography
- thrombosis/stroke, perianal fissure and fistula, bowel perforation, bowel obstruction, intra-abdominal and retroperitoneal abscess, pelvic osteomyelitis, pancreatitis
A 16 year old boy with a known diagnosis of ulcerative colitis comes to see you in your office with his mother. He and his mother have been doing some research and are
concerned about the risk of adenocarcinoma in UC.
Name 2 risk factors for adenocarcinoma in the setting of a diagnosis of UC.
- Duration of disease (increases after 8-10 years)
- Pancolitis
- Primary sclerosing cholangitis
- Family history
- Mucosal dysplasia
2 life threatening complications of ulcerative colitis
- toxic megacolon
- bowel perforation
- colorectal cancer
1 year old with rectal abscess. Mgmt?
a. Systemic abx
b. Excision by surgery
c. I and D
c. I and D (note: can just do nothing)
- healthy infant - can just watch and wait; sitz baths, pain management
Which is most characteristic of encopresis:
a. usually in morning
b. dilated bowel
c. mostly in preschool children
d. stool softeners often cure the problem
b. dilated bowel
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. rectal biopsy
True constipation in the neonatal period is most likely secondary to Hirschsprung disease, intestinal pseudoobstruction, or hypothyroidism
A child is referred for refractory encopresis. Spine exam and DTR’s 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
d) bowel washouts
fecal emollient (laxatives that incorporate more water and fat into the stool and make it pass through easier - examples include docusate) b) peristaltic agent (act on the intestinal mucosa or nerve plexus and stimulate peristalsis - examples include senna and bisacodyl)
False negatives for sweat chloride
a. hypoalbuminemia
b. hyponatremia
c. hypercalcemia
a. hypoalbuminemia
they are edematous
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
c. sweat chloride
What is most useful intervention in treating encopresis?
a) pharmacologic
b) behavioural
c) pharmacologic and behavioural
d) biofeedback
c) pharmacologic and behavioural
A 3-week-old infant has jaundice. BW 3250g, now 3490g. Breastfeeding well. Hemoglobin 127, bilirubin 270, Coombs negative. What should be done:
a. stop breastfeeding and start formula feeding
b. come back in 1 week for reassessment
c. do further tests including liver enzymes
d. refer to a gastroenterologist
b. come back in 1 week for reassessment
Breast milk jaundice
Consider:
c. do further tests including liver enzymes
Ham Review - Breast milk jaundice max Tbili 220
(depends on what the “further testing” included)
