GI and Nutrition

Question 1

GERD

Answer 1

Is only significant when children have failure to thrive, positioning, sandifer syndrome (torticollis and arching related), etc.

50% resolved by 6 months of age, 95% by 12 months of age and 98% resolved by 15 months of age.

Do not treat with cisapride as it causes long QT

Diagnosis: used to be pH probe, now that is no longer necessary

Treatment: Do not smoke around the child, thickened feeds, upright after feeds for 30 minutes,
decreased abdominal pressure during feeds (do not feed in a bumbo chair).

Question 2

5th day of life Billirubin Thresholds

Answer 2

High Risk: 260; Medium Risk: 300; Low Risk 350

Question 3

Meckel’s Rule of 2’s

Answer 3

This is a remnant of the omphalomesenteric dcut (mid gut to the yolk sac). Blood is from Vitilline artery. It is made up of gastric mucosa.

Rule of 2's
2% of the population 
Occurs most commonly before the age of 2 
2:1 male to female ratio
2 ft from the ileocecal valve

Presents as painless GI bleeding, recurrent intussusseption, appy presentation with out an inflamed appendix.

Question 4

Hirschprung Disease
5 Associations
Characteristic Exam

Answer 4

Smith Lemli Opitz
Down Syndrome
Golderberg
Cartilage Hair Hypoplasia
Congenital Hypoventilation 

Exam: Tight rectum on exam, with empty rectum. An abrupt narrowing at the transition zone is noticed on barium enema.

Diagnosis is made with a rectal biopsy.

Question 5

Normal Newborn Growth

Answer 5

0-3 months: 30 g/day except for sunday
3-6 months: 15-20 g/day
6-12 months: 10-15 g/day

Double your birth weight by 6 months; triple by a year

Head circumferences
3 months 40; 9 months 45
3 years: 50; 9 years 55 cm

Height: 1/2 final adult height at 2 years of age
Should grow about 5 cm/year until puberty (<4 cm/year is pathological)

Question 6

Contraindications to Breastfeeding

Answer 6

HIV
TB (not treated yet for 2 weeks)
HTLV
Bilateral Mastitis with pus

Substance Abuse

Chloroquine if baby is G6Pd
High dose metronidazole
Radiation Treatment
Chemotherapy treatment

Galactosemia (give soy) , Urea Cycle Defect and PKU

Question 7

Chron’s

Answer 7

Diagnosis: Endoscopy, ruling out other infections, Fecal calprotectin, MRI imaging.
The amount of arthritis that is present, positively correlates with the extent of the disease.
Characteristics:
Erythema Nodosum
Growth failure and abdominal pain
Gum to bum; migratory non deforming arthritis; bloody diarrhea
ASCA antibody
Transmural, terminal ileum (B12 and bile acid problems); skip lesions
It is more common to have systemic symptoms

Treatment:
Active Disease: 5-ASA
Moderate to severe: Addition of steroids
Immunomodulators: 6MP, Azathioprine and Infliximab (remicade)

Question 8

Colitis

Answer 8

Diagnosis: Colonoscopy
Clinical characteristic:
Pyoderma gangrenosusm
Toxic Megacolon and sclerosing cholangitis
Crypt Abscesses
P ANCA +
Nocturnal bowel movements and pain; Mucous and pus present

Question 9

IPEX

Answer 9

Immune dysfunction
Polyendocrinopathy
Enteropathy
X Linked

Question 10

Intestinal Absorption of Nutrients
Dudoenum and Jejunum
Proximal Small Bowel
Mid Small Bowel
Distal Ileum

Answer 10

Calcium, Mag and Phos; Iron, Folic Acid

Proximal: Protein, CHO , Water soluble vitamins
Middle: Medium Chain Triglycerides and Micelles
Ileum: B12 and Bile salts

Question 11

Pearson Syndrome

Answer 11

Very similar to Schwacman diamond but instead of neutropenia there is macrocytic anemia
Thrombocytopenia
Pancreatic Insufficiency

Question 12

Vitamin Deficiencies

Fat Soluble Vitamins: A, D, E and K

Answer 12

Vitamin A: Night time blindness, Bitot spots on the eyes, hyperkeratosis and plaques
Vitamin D: Rickets (callous formation at the wrists, widening of joints, Cupping/splaying/fraying; Ricketic rosary, craniotabes

Vitamin E: Hemolytic Anemia, Ataxia, thrombocytopenia and edema. No upward gaze in older children. premature infants are most significantly at risk for this.

Vitamin K: Bleeding.

Question 13

Vitamin Deficiencies

Water Soluble Vitamins

Answer 13

B1 Thiamine: Wernicke’s encephalopathy and Beri Beri; peripheral neuropathy, hoarse voice
B2 Riboflavin: cheliosis, gloissitis, normocytic anemia
B3 Niacin: Pellegra: Dermaitis, Diarrhea and Dementia
B6 Pyrodoxine: Seizures, vomiting, FTT, many medications can affect B6
B12: Will be a late manifestation but there is peripheral neuropathy and ataxia.

Vitamin C: Scurvy: Collagen synthesis affected - Gum changes, leg swelling, pseudoparalysis

Question 14

Menkes vs. Wilson Diseae

Answer 14

Menkes: AR. Copper Absoprtion problem. Kinky hair

Wilson’s Disease: Kaiser Flysher rings in the eyes, cirrohsis, Copper deposits because it is not metabolized properly.

Question 15

Zinc

Answer 15

Acrodermatitis Enteropathica

Skin manifestations on the perianal area and the face

Question 16

Treatment of GERD in adolescents

Answer 16

Do not eat 3-4 hours before bed; no late meals
No caffeine
No smoking
Weight Loss
No carbonated beverages 
smaller volume meals

Question 17

Indications for Fundoplication

Answer 17

Apnea’s associated with GERD
All medications have been tried and failed
Recurrent aspirations

Question 18

TPN Risk factors for Cholestasis

Answer 18

Not a long enough cycle time
Prematurity
Intercurrent infection (NEC)
Low birth weight

Question 19

5 Features of Portal Hypertension

Answer 19

Splenomegally
Liver Failure - caput medusa, jaundice
Esophageal varices - Upper GI bleed
Ascites

Question 20

5 Causes of Villous Atrophy

Answer 20

Carbohydrate Intolerance
Allergy
Crohn's 
Celiac
Post infectious 
Congenital Abscence

Question 21

Celiac Diease Typical Presentation and Atypical

Answer 21

Recurrent Diarrhea, abdominal distension, failure to thrive, vomiting and irritability
Atypical: Dermatitis herpetiforms, arthritis, dental erosion and short stature.

Question 22

Differential Diagnosis for Protein Losing Enteropathy

Answer 22

GI: Crohns, Celiac, Allergic enteropathy, post infectious enteropathy
Lymphatic: Lymphangectasia, post fontan (due to increased pressures)

Question 23

Causes of Rectal Prolapse

Answer 23

CF, Constipation, Marfans and Ehlers Danlos, Celiac and Myelomeningocele.