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GI HR Flashcards

1
Q 
3 month old boy has failure to thrive and chronic diarrhea. Stools are pale, foul-smelling, and greasy, and breath sounds are coarse with rhonchi. Liver has normal texture and is palpable at the right costal margin. The MOST likely diagnosis is:
A) Biliary Atresia
B) Celiac Disease
C) Congenital Lactase Deficiency
D) Cystic Fibrosis
E) Schwachman-Diamond Syndrome
A

D

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2
Q

Approach to failure to thrive?

A
  • Decreased intake (common)
  • -Social (food security)
  • -Central (satiety signaling)
  • Malabsorption
  • Hypermetabolism
  • -Inflammatory (catabolic)
  • -Neoplastic (consumptive)
  • -Chronic disease (combination)
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3
Q

Malabsorption categorized by major macronutrients and associated anatomic structure, examples of diseases?

A
  • Fat malabsorption
  • -Biliary: bile emulsifies
  • -Pancreas: lipase digests
  • -Ileum: reabsorbs bile
  • -E.g. CF, SDS, Crohn’s disease, cholestasis
  • Protein malabsoprtion
  • -Pancreas: proteases
  • -SI: AA transporters
  • -E.g. CF, Schwachman-Diamond
  • Carbohydrate malabsorption
  • -Duodenum: brush border hydrolysis
  • E.g. Primary vs. dietary causes
  • Panmalabsorption
  • -Generalized intestinal inflammation/resection
  • E.g. Celiac, IBD, lymphangiectasia, immunodeficiency, intestinal resection
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4
Q

Primary causes for carbohydrate malabsorption?

A
  • Primary causes: enzyme deficiencies - rare!
  • -e.g. Sucrase-isomaltase, trehalase, lactase congenital lactase deficiency v. rare!
  • Dietary cases: saturation of normal enzyme levels
  • -e.g. Toddler’s diarrhea (too much fructose!)
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5
Q 
Which of the following is NOT associated with an increased risk of Celiac Disease?
A) Down Syndrome
B) Turner Syndrome
C) Russell-Silver Syndrome
D) William’s Syndrome
E) Type 1 Diabetes
A

C

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6
Q

Conditions associated with Celiac Disease?

A
  • Type 1 Diabetes
  • IgA Deficiency
  • Down Syndrome
  • Turner Syndrome
  • Williams Syndrome
  • Other Autoimmune Disorders (thyroid, arthritis, liver)
  • First Degree Relative with Celiac (1:20 risk)
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7
Q

What is celiac disease?

A

An autoimmune enteropathy caused by systemically acting antibodies that are formed against gluten

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8
Q

Diagnostic path for celiac disease?

A

-Screening bloodwork +ve –> Intestinal biopsy (duodenum/jejunum): Villous atrophy –> Celiac disease

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9
Q

Treatment for celiac disease?

A

-Lifelong gluten-free diet

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10
Q

Extraintestinal manifestations of celiac disease?

A

-Dermatitis herpetiformis (papules, often shorn off, itchy elbows, knees, back and hairline)
-Dental enamel hypoplasia of permanent teeth (horizontal lines on teeth)
-Osteopenia/osteoporosis
-Short stature
-Delayed puberty
-Iron deficiency anemia
-Hepatitis
-Arthritis
-Epilepsy with occipital lobe calcifications (least common)
(listed in descending order of strength of evidence)

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11
Q

What are the dietary triggers for celiac disease?

A
  • members of hordeae
  • Wheat
  • Rye
  • Barley
  • All contain gluten protein
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12
Q

Antibody tests for celiac disease? What must you do in patients < 2 yo?

A
  • EMA-IgA (anti-endomysial antibody test)
  • -Less sensitive but more specific than TTG-IgA
  • TTG-IgA

-Quantitative serum IgA levels must be measured. Patients with low serum IgA require endoscopic biopsy for diagnosis

In children < 2 yo, must sent DGP-IgG - deamidated gliadin peptide
In over 2 y o, would have many false positives. If positive but biopsy negative NOT celiac.

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13
Q

Some reasons patients might report feeling better off gluten?

A
  • Celiac disease (need at least 8 weeks of adequate gluten intake to get reliable antibody test)
  • Non-Celiac Gluten Sensitivity (NCGS)
  • Wheat allergy
  • Difficulty digesting highly fermentable carbohydrates (FODMAPs)
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14
Q

What are FODMAPs? Best evidence in treatment of _____?

A
  • Carbohydrates that tend to be highly fermentable
  • Body does not digest these carbohydrates well–>intestinal bacteria metabolize them and produce ++gas
Fermentable
Oligosaccharides
Disaccharides
Monosaccharides
And
Polyols

-Best evidence in treatment of IBS

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15
Q 
Which of the following is NOT a unique sign of Crohn's Disease?
A) Granuloma
B) Fistula
C) Transmural inflammation
D) Hypoalbuminemia
E) Jejunal ulceration
A

D

Granulomas do occur in other conditions e.f. sarcoid, TB, leprosy

Hypoalbuminemia has much broader differential than the above..

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16
Q 
Contrast UC vs. Crohn's MACROSCOPIC features with respect to:
Rectum
Distribution
Terminal ileum involvement
Serosa
Bowel wall
Mucosa
Stricture
Fistula
Erythema Nodosum
Uveitis
PSC
A
  • Rectum
  • -UC: Yes
  • -Crohn’s: Variable
  • Distribution
  • -UC: Diffuse
  • -Chron’s: Segmental/diffuse
  • Terminal ileum
  • -UC: Not involvedmacroscopically, look for this on scope
  • -Crohn’s: Thick/stenosed
  • Serosa
  • -UC: Usually normal
  • -Crohn’s: Creeping fat
  • Bowel wall
  • -UC: Normal
  • -Crohn’s: Thickened
  • Mucosa
  • -UC: Hemorrhagic
  • -Crohn’s: Cobblestone/Deep Ulcers
  • Stricture
  • -UC: Rare
  • -Crohn’s: Common
  • Fistula
  • -UC: Rare
  • -Crohn’s: Common
  • Erythema Nodosum
  • -UC: Rare
  • -Crohn’s: Common
  • Uveitis
  • -UC: Common
  • -Crohn’s: Common
  • PSC
  • -UC: Common
  • -Crohn’s: Rare
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17
Q

Contrast UC vs. Crohn’s MICROSCOPIC features with respect to:

  • Inflammation (distribution)
  • Lymphoid hypertrophy
  • Crypt abscess
  • Mucus depletion
  • Granuloma
  • Submucosal fibrosis
A
  • Inflammation
  • -UC: Mucosal/superficial submucosa
  • -Crohn’s: Transmural
  • Lymphoid hypertrophy
  • -UC: Infrequent
  • -Crohn’s: Common
  • Crypt Abscess
  • -UC: Extensive
  • -Crohn’s: Focal
  • Mucous depletion
  • -UC: Frequent
  • -Crohn’s: less frequent
  • Granuloma*
  • -UC: No
  • -Crohn’s Yes
  • Only in Crohn’s - this can differrentiate*
  • Submucosal fibrosis
  • -UC: Rare
  • -Crohn’s: Common
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18
Q

Major IBD Medication Classes: To INDUCE remission? To MAINTAIN remission?

A

INDUCE:

  • Tube feeds (common; Crohn’s only)
  • Corticosteroids (common)
  • 5-ASA (mild)
  • Biologics (severe)

MAINTAIN:

  • 5-ASA (mild; US only)
  • Tube feeds (Crohn’s only)
  • Azathioprine (moderate)
  • Methotrexate (moderate)
  • Biologics (severe)
  • *Not steroids**
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19
Q

Differential diagnosis of terminal ileitis?

A
  • Crohn’s
  • Lymphoma
  • Yersinia Infection
  • Tuberculosis
  • Chronic Granulomatous Disease
  • Severe Eosinophilic Gastroenteropathy
  • Lymphonodular hyperplasia (normal finding) often on MRI done for other reason. (Normal. Looks like things very thickened)
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20
Q 
Which of the following is NOT on the differential for terminal ileitis?
A) Crohn’s Disease
B) Lymphoma
C) Tuberculosis
D) Yersinia infection
E) Celiac Disease
A

E

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21
Q 
Which of the following is NOT an organic cause of constipation?
A) Hypercalcemia
B) Hypothyroidism
C) Hyperkalemia
D) Lead poisoning
E) Hirschsprung’s Disease
A

C

Hypokalemia can cause it (muscle weakness and constipation)
hyperkalemia can be an effect of constipation, but not a cause

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22
Q

What percentage of chronic constipation is functional vs organic?

A
  • 90% functional

- 10% organic

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23
Q

Natural history of chronic constipation?

A
  • Patient eventually develops megarectum

- Encopresis (“diarrhea”) due to overflow

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24
Q

General treatment strategy for functional chronic constipation?

A

-Clean out –> Maintenance x 4-6mos –> slow withdrawal

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25
Q

What to screen/test for if patient fails first-line treatment for chronic constipation (in other words, organic causes of chronic constipation)?

A
  • Hypothyroidism
  • Celiac disease
  • Lead poisoning
  • Medications
  • Cystic Fibrosis
  • CNS disorders
  • -Hirschsprung’s
  • -Cerebral palsy
  • -Neural tube defects
  • Idiopathic
  • HYPERcalcemia
  • HYPOkalemia

-Meds

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26
Q

Which are the osmotic laxatives? Special considerations?

A
  • Lactulose
  • recommended in infants*
  • PEG3350
  • Safe in all ages*
  • Magnesium citrate
  • Docusate
  • No evidence in pediatric constipation*
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27
Q

Which are the stimulant laxatives? Special considerations?

A
  • Picosalax
  • Glycerin suppository
  • Recommended in infants*
  • Bisacodyl
  • Senokot
  • Phosphate enema
  • Not recommended in <2 yo*
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28
Q

Which is a lubricant laxative? Special considerations?

A
  • Mineral oil

* Not recommended in <2 yo*

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29
Q

Which are the prokinetic stimulants?

A
  • Pucalopride

- Linaclotide

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30
Q

Which of the following is a stimulant laxative?

a) Polyethylene Glycol (PEGlyte, PEG3350)
b) Lactulose
c) Docusate sodium (Colace)
d) Dulcolax (Bisacodyl)
e) Mineral oil (Lansoyl)

A

D

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31
Q 
The most common cause of diarrhea in a 3 year old is?
A) Lactose intolerance
B) Inflammatory Bowel Disease
C) Irritable Bowel Syndrome
D) Toddler’s Diarrhea
E) Parasitic Infection
A

D

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32
Q

Broad categories for etiologies acute diarrhea?

A
  • Infectious
  • Toxic
  • Dietary intolerance
  • Neuroendocrine
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33
Q

Broad categories for etiologiies for chronic diarrhea?

A
  • Infectious
  • Inflammatory
  • Dietary intolerance
  • Neuroendocrine
  • Constipation
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34
Q

5 month old referred for poor growth and irritability. History significant for constant spitting up of formula. An upper GI series reveals normal appearance of the esophagus and stomach. Which of the following most likely explains these findings?

A) Prone positioning after feedings
B) Stress in the home
C) Hiatal hernia
D) Inappropriate relaxation of the lower esophageal sphincter
E) Pyloric stenosis
A

D

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35
Q

Causes of gastroesophageal reflux?

A
  • Physiologic (normal in infants, transient, inappropriate LES relaxation)
  • Eosinophilic esophagitis
  • Hiatal hernia (LES angle affected)
  • Medications
  • Dysmotility
  • Gastritis
  • Gastroparesis (delayed gastric emptying)
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36
Q

Treatment guidelines for gastroesophageal reflux?

A
  • H&P, check for alarm signs
  • For infant - First, counsel to avoid overfeeding, thicken feeds, continue breastfeeding
  • If not improved, consider 2-4 weeks of protein hydrolysate or AA based formula, or in breastfed infants, elimination of cow’s milk from maternal diet
  • If not improved, refer to GI

-For child - lifestyle and dietary education, if not improved, refer to GI

then:

  • Acid blockade (H2RB or PPI) x 8 weeks
  • If no resolution, OR recurrence after weaning medication
    1. Endoscopy - EOE, Hiatal hernia, Gastritis
    2. 24 hour pH/impedence probe - Physiologic, Hiatal Hernia, Medications, Dysmotility
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37
Q

Potential causes of odynophagia?

A
  • Painful swallowing
  • -Candidal infection
  • -Reflux esophagitis
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38
Q

Potential causes of dysphagia?

A
  • Difficulty swallowing
  • -Eosinophilic esophagitis
  • -Esophageal motility disorder (scleroderma)
  • -Achalasia
  • -Anatomic obstruction
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39
Q 
3 month old presents with blood stools. The most likely diagnosis is:
A) Swallowed maternal blood
B) Allergic colitis
C) Vascular ectasia
D) IBD
E) Infection
A

B

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40
Q

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

A

Cow’s Milk Protein Allergy

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41
Q

CMPA occurs in what percentage of formula feeders? In what percentage of breast feeders?

A
  • 2-3%

- 0.5%

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42
Q

Management of CMPA in breastfed infants?

A

• Goal: remove milk protein and monitor baby’s nutrition and weight gain through nursing
• Dietitian counselling for mother (1000mg Ca2+)
• Washout period for mother:
–At least 5 days (if immediate symptoms)
–14 days (if late symptoms)
• Colitis may take 2-4 weeks to resolve
• May consider soy restriction (10-15% cross reactivity)
• Do not empirically restrict other foods in diet

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43
Q

Management of CMPA in formula fed infants?

A

-Extensively hydrolyzed formula (Pregestimil, Nutramigen, Alimentum)
OR
-Amino acid-based
(Neocate, Puramino)

  • After 6 months, may start soy-based formula if tolerated
  • Not recommended before 6 months*
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44
Q 
10 year old boy has pruritis and hematemesis. Physical examination reveals ascites, and a prominent venous pattern over the abdomen. MOST likely cause for the hematemesis is:
A) Esophageal varices
B) Gastric polyp
C) Peptic ulcer disease
D) Posterior nasal bleeding
E) Thrombocytopenia
A

A

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45
Q

Causes of upper GI bleeding in infants?

A
  • Swallowed maternal blood
  • AVM
  • Gastritis
  • Trauma (e.g. NG tube)
  • Intestinal duplication
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46
Q

Causes of upper GI bleeding in Children/Adolescents?

A
  • Esophageal varices
  • Mallory-Weiss
  • Foreign body/ingestion
  • NSAIDs
  • PUD/H. pulori
  • AVM
  • Hemobilia
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47
Q

Causes of lower GI bleeding in infants?

A
  • Allergy
  • Fissure
  • Swallowed maternal blood
  • AVM
  • Meckel’s
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48
Q

Causes of lower GI bleeding in children?

A
  • Fissure
  • Infection
  • Polyp
  • Meckel’s
  • IBD
  • Rapid upper GI tract bleeding
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49
Q

Causes of lower GI bleeding in adolescents?

A
  • Fissure
  • Infection
  • IBD
  • Meckel’s
  • Rapid upper GI tract bleeding
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50
Q 
What is the first-line treatment for pinworms?
A) Mebendazole
B) Albendazole
C) Metronidazole
D) Septra
E) Fluconazole
A

A&B

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51
Q

Which GI infections cause bloody diarrhea?

A
  • Salmonella (usually)
  • Shigella
  • Yersinia (usually)
  • Campylobacter
  • E.coli

SSYCE

52
Q

Which GI infections cause non-bloody diarrhea?

A

Everything else, includingL

  • Vibrio cholerae
  • C. difficile (usually)
  • Parasites (Giardia)
53
Q

Which GI infections to treat? Which to consider treating? Which to support? Which NOT to treat?

A
  • Treat:
  • -C. difficile
  • -Parasites
  • Consider:
  • -Campylobacter
  • Support:
  • -Cholera
  • -Yersinia
  • Don’t treat:
  • -E.coli
  • -Shigella
  • -Salmonella
54
Q 
A patient is diagnosed with Dientamoeba fragilis. Metronidazole fails to clear the infection. Next antibiotic choice is?
A) Mebendazole
B) Albendazole
C) Paromomycin
D) Septra
E) Tetracycline
A

C

Way RC asks questions… in stem, has been diagnosed, already talking about treating with flagyl. so assuming treatment pathway.

Posed differently, there is lots of literature about D fragilis and B hominis that doesn’t necesarily need to be treated. If ptnt coming and already presuming this is cause, can be treated… if posed differently and asking if need to treat patient who incidentally had O&P showing this but no symptoms, then acceptable to say observe and don’t treat.

55
Q

Overall approach to management of functional GI disorders?

A
  1. Establish which FGID criteria are met (IBS, Functional Abdominal Pain, Abdominal Migraine, CVS)
  2. Consider carbohydrate intolerance (lactose, fructose, non-celiac gluten sensitivity, FODMAPs)
  3. Go diarrhea? Fiber, psyllium cookies, cholestyramine
  4. Got constipation? Osmotic laxatives, stimulant laxatives, prucalopride, linaclotide
  5. Then consider the specific disorders (CVS, Abdominal migraine, individual treatments)
56
Q

An infant boy did not pass stool during the first 36 hours of life. He has had regular passage of both watery and hard, pellet-like stools and often strains with defecation. Barium enema reveals dilation of the large bowel with narrowing immediately proximal to the rectum. The MOST appropriate management is?
A) Add prune juice to the present formula
B) Arrange for a rectal biopsy
C) Change to a soy-based formula
D) Observe
E) Order an upper gastrointestinal series

A

B
correct

key is barium enema reveals this is not an otherwise normal presentation in a child
in absence of barium enema can talk about other fucntion gi appraoches

57
Q

Rome IV Criteria for functional constipation?

A
  • > /=2 months of >/=2 of the following:
  • <3 bowel movements/week
  • Excessive stool retention
  • Painful or hard bowel movements
  • Large fecal mass in rectum
  • > /=1/wk episode of incontinence after toilet training
  • Large-diameter stools that block toilet
58
Q

Rome IV Criteria for infant regurgitation?

A
  • Occurs anywhere from 2-12 months
  • Regurgitation >2x/day for >3weeks
  • Characterized by features that are not seen:
  • retching,
  • hematemesis
  • aspiration
  • apnea
  • FTT
  • feeding or swallowing difficulties
  • abnormal posturing
59
Q

Rome IV Criteria for infantile colic?

A
  • Infant <5 months old when symptoms start and stop
  • Recurrent and prolonged periods of infant crying, fussing, or irritability without obvious cause, cannot prevent or resolve
  • No evidence of FTT, fever, or illness
  • Episodes lasting >3 hours/day for 3 days per week for >1 week
60
Q 
Infant rumination best responds to?
A) Anticholinergics
B) Soy formula
C) NG tube feedings
D) Frequent holding and social interaction
E) PPI therapy
A

D

61
Q

Rome IV Criteria for Rumination Syndrome?

A

• Repeated painless regurgitation and re-chewing or expulsion of food that…
–begins soon after ingestion of a meal
–does not occur during sleep
• No retching
• No organic explanation
• Eating disorder must be ruled out
• Responds to relaxation therapies, avoidance of behavioral reinforcement

62
Q

Rome IV Criteria for Cyclic Vomiting Syndrome?

A

• >/=2 periods of intense nausea and hyperemesis or retching lasting hours to days (in past 6mo)
–Over, and over, and over, and over (>/=4x/hr for 1hr–10d)…
• Episodes are stereotypical
• Return to usual state of health lasting weeks to months
• Symptoms not attributable to other conditions

63
Q

Rome IV Critria for Irritable Bowel Syndrome?

A

• Abdominal pain >4 times/month with >1 of the following symptoms:
–Timing related to defecation –Change in frequency of stool –Change in form of stool
• If patient experiences constipation (IBS-C), pain does not resolve with resolution of constipation

64
Q

Rome IV Criteria for Functional Abdominal Pain?

A 
• Very common
• Occurs at least 4 times per month
• Includes:
--Episodic or continuous abdominal pain 
--Insufficient criteria for other FGID’s
65
Q

Approach to hepatomegaly?

A
  1. Hepatitis (inflammation)
  2. Storage disorders
    - Glycogen (GSD)
    - Lipid (Gaucher, NASH)
    - Protein (A1AT)
    - Iron (Hemochromatosis)
  3. Infiltrative
    - Benign liver tumours
    - Malignant liver tumours
    - Disseminated tumours
  4. Biliary obstruction
  5. Posthepatic obstruction
    - Cardiac (Right Heart Failur)
    - Thrombus (Hepatic Vein, IVC)
    - Intrahepatic (Sinusoids)
66
Q

A 4 week old baby has persistent unconjugated hyperbilirubinemia. Most likely diagnosis?

A

A
correct

remember if not specified assume unconj

67
Q

Anatomic categories of hyerbilirubinemia?

A
  • Prehepatiic
  • Hepatic
  • Posthepatic
68
Q

Prehepatic causes of hyperbilirubinemia?

A
  • Hemolytic
  • -Extracellular
  • –Sepsis/DIC
  • –ABO/Rh
  • -Intracellular
  • –Membranopathy
  • –Hemoglobinopathy
  • Non-hemolytic
  • -Physiologic (50%)
  • -Hypothyroid
  • -Breast milk
  • -Gilbert’s syndrome
69
Q 
Frequency of Gilbert's syndrome?
Inheritance?
Pathophysiology?
Bili levels?
How to test?
A
  • 7% of population
  • Autosomal dominant
  • Genetic defect in glucuronyl transferase UDP1A1 promoter region
  • Fasting bili >40, <100
  • Can test parents
70
Q

Gilbert’s syndrome accounts for ____% of persistent unconjugated hyperbilirubinemia cases in infants.

A

50%

71
Q

Hepatic causes of hyperbilirubinemia?

A
  • Infectious
  • -Viral (TORCHES, adeno, parvo, echo)
  • -Bacterial
  • -Fungal
  • -Parasites (e.g. flukes)

-Medications, ingestions, toxins

  • Metabolic
  • -A1AT
  • -Hemochromatosis
  • -Wilson’s
  • -Carbs
  • -Fats
  • -Protein
  • -Mitochondria
  • Inflammatory
  • -Autoimmune hepatitis
  • -NAFLD/NASH
  • Neoplastic
  • -Primary
  • -Mets
  • -Hematologic
72
Q

Posthepatic causes of hyperbilirubinemia?

A

*Posthepatic = obstructive Conjugated hyperbilirubinemia

  • Biliary atresiaone to rule out first
  • Choledochal cyst
  • CF
  • Gallstones
  • Primary sclerosing cholangitis
  • Neoplastic
  • Inspissated bile syndrome
  • Genetic (PFIC)
73
Q

Causes of neonatal cholestasis?

A
  • Infectons:
  • -UTI
  • -E.coli sepsis
  • -TORCH
  • -Adenovirus
  • Biliary atresia
  • Choledochal cyst
  • A1AT deficiency
  • Hypothyroidism
  • Galactosemiaremember can be both conj and unconj
  • Mitochondrial
  • PFIC
74
Q 
The most common indication for liver transplantation in children is:
A) Acetaminophen overdose
B) Fulminant Hepatic Failure
C) Biliary Atresia
D) Autoimmune Hepatitis
E) Wilson’s Disease
A

C
vast majority will go on to need tx after, kasai as temporizing tx

keep in mind B is a description than a cause
technically reversible with correct treatment.

75
Q

Definition of acute liver failure?

A
  • Failure of vital functions of the liver occurring within days to months after the onset of clinical liver disease
  • Differentiate liver cell damage from functional impairment (ALF)
76
Q

Causes of acute liver failure and associate age group?

A
  • Indeterminate - all age groups
  • Tylenol overdose - >10y
  • Metabolic - <1yr, >10y Wilsons (90%)
  • Autoimmune - >10y
  • Viral hepatitis - <4 weeks
  • Shock/ischemia
  • Medications - >10y
  • GALD (Neonatal Hemochromatosis) - <4 weeks
  • HLH - 9 weeks-1y
  • Budd Chiari Syndrome - all age groups
  • Other
77
Q

Clinical features of acute liver failure?

A
  • CNS: Cerebral edema due to elevated intracranial pressure
  • Resp: Acute respiratory distress syndrome
  • CVS: High-output cardiac failure
  • GI: Upper GI bleeding from stress related ulcers and coagulopathy
  • GI: Pancreatitis, particularly in acetaminophen-induced acute liver failure
  • Nephro: Acute kidney injury
  • Metabolic: Hypoglycemia, lactic acidosis
  • Endo: Hypoadrenalism secondary to lack of glucocorticoid and mineralocorticoid production
  • Heme: Coagulopathy
  • ID: Infection from impaired leukocyte function
78
Q

Management principles of acute liver failure?

A
  • Close monitoring (q8h-q12h)
  • Fluid, sodium restriction
  • Monitor encephalopathy, cerebral edema
  • Follow INR (don’t give FFP because will affect ability to monitor this), manage bleeding
  • Infection prophylaxis (start antibiotics)
  • Metabolic disturbances (hypoglycemia, acid-base)
  • Early contact with transplant centre!
79
Q 
8 year old immigrant from Thailand presents with bloodwork: HBsAg -ve, HBsAb +ve. How do you interpret the bloodwork?
A) Hepatitis B Immune
B) Chronic Active Infection
C) Seroconversion
D) Cleared infection long ago
E) Mutant Hepatitis B
A

A or D
correct

for D missing impot piece - if had CORE antibody could say if at some point in past had true Hep B
alternately this is the common pattern in someone who has just gotten vaccine

80
Q

What type of virus is Hepatitis B?

A

DNA virus

81
Q

What determines indication for treatment for Hep B?

A

Transaminases

82
Q

Hep B prevention?

A
  • Hep B vaccine extremely effective

- Hep B vaccine and immunoglobulin within 12 h for at risk infant. Ig can be givin within 7 days

83
Q

Hep B serologic markers?

A
  • HepB surface antigen (HBsAG)
  • -Exposed to HepB or
  • -Presence of HepB
  • HepB surface antibody (HBsAb)
  • -Antibodies exist against HepB
  • HepB core antigen (HBcAg)
  • -Present or past chronic infection
  • HepB core antibody (HBcAb)
  • -Chronic infection (IgG)
  • Hepatitis B e Antigen (HBeAg)
  • -positive: Active viral replication
  • -negative: Seroconversion or mutant

-Hepatitis B eAb (HBeAb)
–positive: with HBeAg negative supports successful seroconversion in early phase…. as time goes on 18-24 mos, this goes away.
if recently got infection, will still be pos… but after time even this will go away

-HBV DNA: direct viral count

84
Q 
14 year old boy from Rwanda with elevated ALT. Labs below. Diagnosis?
HBsAg+ve, HbsAb +ve, HBeAg+ve, HBeAb-ve
A) Hepatitis B Immune
B) Chronic Active Infection
C) Seroconversion
D) Cleared infection long ago
E) Mutant Hepatitis B
A

B

85
Q

Same boy returns 6 month later with:

HBsAg-ve, HBsAb+ve, HBeAg-ve, ABeAb+ve, HBcAb+ve

A

C

illustrates point that if cleared, would have expected that Hep B envelope antibody should have gone away

86
Q

Hepatitis B treatments used?

A

• Interferon-a (IFN-a)

  • -Cytokine
  • -Side effects: neutropenia (39%), fever, myalgia, headaches, arthralgia, anorexia with weight loss
  • -Severe mood changes

• Nucleoside analogue (e.g. lamivudine)
–Generally well tolerated, but high mutation rate leading to resistance

87
Q

Current hepatitis B treatment guidelines?

A

For children >2 yo:
• 1) HBsAg+ for >6 months, 2) ALT >2X normal, and 3) Evidence of viral replication
(HBeAg+ or HBV DNA >4 log if HBeAg-) • OR, Chronic hepatitis on liver biopsy

  • Treat with either IFN-a or lamivudine
  • 20-58% spontaneous conversion/clearance
88
Q

Surveillance recommendations for hepatitis B?

A 
• Measure ALT q6months in children >2yo
• Measure HBeAg and HBeAb yearly in
patients with normal ALT
• Liver biopsy in children >2yo with elevated ALT
• Examine for chronic liver disease
• Immunize household
• Immunize patient against Hepatitis A
• Alpha fetoprotein &amp; ultrasound annually
89
Q

Prognosis for hepatitis B?

A
  • Spontaneous seroconversion and clearance may be as high as 70-80%
  • Risk of Hepatocellular Carcinoma (HCC) is 15-35X higher
  • Lifetime risk of HCC or cirrhosis is 15-25%
90
Q

What type of virus is the Hepatitis C virus?

A

-RNA virus

91
Q

Rate of spontaneous clearance in children?

A

20% in first 3 years of life, up to 50% by age 18

92
Q

How long does cirrhosis take to develop with Hep C?

A

10-20 years, if ever

93
Q

Diagnosis of Hepatitis C?

A
  • Hepatitis C Ab (high false +ve because of maternal antibody transfer)
  • Confirm with Hepatitis C PCR and genotype
  • In at-risk infants, continue screening until at least 18 months of age with two –ve Ab’s test in a row
94
Q

Prognosis for hepatitis C?

A

Potential for 95-98% cure rates

95
Q

Longterm follow-up for liver transplant by General Pediatrician?

A
  • Neurodevelopmental care
  • -School performance
  • -Developmental assessment
  • Medication side effects
  • -Hypertension
  • -Hyperglycemia
  • -Seizure
  • Secondary graft dysfunction
  • -Liver enzymes

-Thrombosis

  • Medication adherence
  • -Adolescent care
  • -Transitioning
  • Infectious disease
  • -Common infections
  • -Opportunistic infections

-Chronic Cellular (Graft) Rejection

  • Relapse of Primary Disease
  • -Autoimmune hepatitis
  • -Primary sclerosing cholangitis
96
Q 
A 12 year old boy with chronic transaminase elevatiion and hyperechogenic liver. The most likely diagnosis is:
A) Autoimmune Hepatitis
B) Non-alcoholic Fatty Liver Disease
C) Wilson’s Disease
D) Hepatitis B infection
E) Recurrent Viral Myositis
A

B

will see NAFLD far more frequently than any of others

diffuse hyperechogenicity more commonly associated with NAFLD - rim of visceral fat that causes generaliized enhancement of liver vs. others causing focal. so if report says diffuse hyperechogen, usu nafld

97
Q

Investigations for chronic hepatitis in peds? Ddx to consider?

A
  1. Doppler U/S to look for increased portal pressures
  2. Adolescent history

Consider:

  1. Autoimmune hepatitis
  2. A1AT Deficiency
  3. Wilson’s disease
  4. Celiac disease
  5. Infectious hepatitis
98
Q

Acute management of pancreatitis?

A
  • Acute management
  • Fluids (1.5-2x maintenance)
  • Enteral nutrition early • PO/GT–>NJ–>TPN
  • Watch for complications (SIRS response)
99
Q

Causes of delayed gastric emptying?

A
  • Idiopathiic
  • Postinfectious (ileus)
  • Medications/toxins
  • Constipation (gastrocolic reflex)
  • Postsurgical (ileus)
  • Neurologic
  • Inflammatory/autoimmune
100
Q

Signs and symptoms of IgE-mediated and Non-IgE-mediated CMPA? which ones best reflect IgE vs. non-IgE?

A
  • IgE-mediated
  • -Respiratory
  • –Rhinoconjunctivitis
  • –Asthma
  • –Laryngeal edema
  • –Otitis media + effusion
  • -Cutaneous
  • –Atopic dermatitis
  • –Urticaria
  • –Angioedema
  • -Gastrointestinal
  • –Oral allergy syndrome
  • –Nausea and vomiting
  • –Colic
  • –Diarrhea
  • Non-IgE-mediated
  • -Respiratory
  • –Pulmoonary hemosiderosis
  • -Cutaneous
  • –Contact rash
  • -Gastrointestinal
  • –Reflux
  • –Transient enteropathy
  • –Protein-losing enteropathy
  • –Enterocolitis syndrome
  • –Proctocolitis
  • –Constipation
  • Unclassified
  • -Anemia
  • -Arthritis
  • -HSP
  • -Migraine
101
Q

Meckel’s rule of 2s?

A
  • 2% of population
  • 2:1 male:female distribution
  • 2ft from ileocecal valve
  • 2% develop bleeding
  • <2 y o most common age
  • 2 types of mucosa in diverticulum: native + heterotopic gastric/pancreatic/colonic
102
Q

What is infant dyschezia? Rome IV? Treatment?

A
  • Discoordination between relaxation of external anal sphincter and contraction of pelvic muscles
  • < 9 moonths old
  • > 10 minutes of straining and crying before successful passage of soft stool
  • Otherwise healthy

-Treatment is reassurance. Don’t use rectal stim. No need for laxatives

103
Q

Rome IV criteria Functional Diarrhea? Treatment?

A
  • Daily painless, >4 large unformed stools
  • > 4 weeks
  • Onset 6-60 months of age
  • Occurs during waking hours
  • No FTT if calorie intake adequate
  • Treatment is parental education and reassurance. Not harmful and self-limiting.
  • Recommend evaluate fruit juice and fructose intake, dietary advice.
104
Q

Rome IV criteria Abdominal Migraine? Treatment?

A
  • Must occur >2x:
  • -Paroxysmal epiisodes of intense, acute, periumbilical pain for >/= 1 hour
  • -Healthy for weeks to months between episodes
  • -Interferes with normal activities

-Stereotypical pattern

  • > /=2 of the following symptoms:
  • -anorexia
  • -nausea
  • -vomiting
  • -headache
  • -photophobia
  • -pallor
  • Treatment determined by the frequency, severity, and impact of the abdominal migraine episodes on the child and family life
  • DBPC trial founds benefit of pizotifen (anti-serotonin and antihistamine)
  • Ppx with amitriptyine, propranolo and cyproheptadine have been successful
105
Q

Rome IV criteria functional dyspepsia? Treatment?

A
  • > 1 of the following with symptoms at least 4 days per month for > 2 months:
  • -Post prandial fullness
  • -Early saatiety
  • -Epigastric or burning pain not associated with defecation (gastrocolic reflex)
  • -Not attributable to another condition
  • Treatment:
  • Avoid aggravating foods (e.g. caffeine, spicy, fatty) and NSAIDs
  • Address potential contributing psych factors
  • Can offer H2RB or PPI for pain predominant symptoms
  • Difficult cases - amitriptyline and mimipramine
  • For nausea, bloating, early satiety - prokinetics e.g. cisapride and domperidone
  • Cyproheptadine safe and effective
106
Q

Rome IV criteria functional constipation?

A
  • Occurs at least once per week for at least 2 months
  • Not IBS
  • > /= 2 symptoms in a child developmentally >/= 4 yo:
  • -= 2 BMs/week
  • ->/=1 episode of fecal inconotinence/week
  • -Retentive posturing
  • -Painful or hard BMs
  • -Large fecal mass in rectum
  • -Large diameter stols that may block toilet
107
Q

Rome IV criteria for Nonretentive Fecal Incontinence? Treatment?

A
  • At least 1 month of episodes
  • > /= 1 month of defecation in places inappropriate to social context
  • -No fecal retention
  • -Not attributable to another condition
  • Treatment
  • Educate re: psych disturbances, learning difficulties, behavioural problems usually significant contributors
  • Victims of sexual abuse must be identified
  • Most successful approach to management involved behavioural therapy
  • Regular toilet training use with rewards
108
Q

Complications of acute liver failure?

A
  • Encephalopathy
  • Cerebral edema
  • Coagulopathy and hemorrhage
  • Bone marrow failure
  • Hypoglycemia
  • Electrolyte/Acid-Base disturbance
  • Renal dysfunction
  • Pancreatitis
  • Ascites
  • CVS and pulmonary effects
  • Secondary bacterial and fungal infections
109
Q

Hepatitis B disease states?

A
  1. Acute infection
  2. Chronic infection
    - HBeAg +ve
    - HBeAab -ve
  3. Seroconversion with spontaneous clearance OR development of mutant
110
Q

If AST> ALT, DDx?

A
  • EtOH
  • Myopathies
  • Renal syndromes
  • Hemolysis (e.g. capillary blood sample)
  • Intestinal inflammation
  • Adenovirus infection
111
Q

If ALP is abnormally low? If ALP normal and other enzymes high?

A
  • ALP abnormally low: zinc deficiency

- ALP normal and other enzymes high: Wilson’s disease

112
Q

Vitamin K dependent factors?

A

-II, VII, IX, X, Protein C, Protein S

113
Q

Which is the only coagulation factor not produced in the liver? How to distinguish liver disease from DIC based on this?

A
  • Factor VIII
  • Factor VIII levels will be normal to increased in liver disease because factor VIII is produced in endothelial cells rather than the liver
  • Factor VIII levels are generally low in DIC
114
Q

CPS Constipation recommendations?

A
  • Education important
  • -Stool frequency can vary for breastfed infants qfeed to q1-days
  • Criteria for dx
  • Fecal disimpaction needed to initiate treatment (PEG, enemas, mineral oil, hospitalization)
  • Investigations rarely necessary
  • PEG3350 recommended for long-term Rx
  • Stool diary, fibre intake
  • Regular follow-up needed
  • Referral to Ped GI for refractory or organic pathology
115
Q

CPS Energy and sports drinks?

A
  • Not recommended: contributes to obesity, mixing with EtOH
  • Health Canada: No immediate safety concerns related to caffeinated energy drinks, but more research needed and children may be uniquely susceptible to effects
  • Higher risk in CVD, renal, liver disease, seizure d/o, diabetes, mood d/o, hyperthyroidism
116
Q

Health Canada recommended maximum daily intakes for caffeine?

A

-4-6 years: 45mg/day
-7-9 years: 62.5mg/day
-10-12 years: 85mg/day
Adolescents 13 and older: 2.5mg/kg of body weight/day

117
Q

CPS probiotics? Definitions of pro- and pre-biotics? Proven benefits?

A
  • Probiotics: live micro-organisms which confer health effect on host
  • Prebiotics: non-viable food components with confer health effect on host by affecting existing microorganisms
  • Proven benefits:
    1. Preventing antibiotic associated diarrhea (2018 data disproves)
    2. Preventing recurrence of C.diff
    3. Reducing duration of acute infectious diarrhea
    4. Preventing infectious diarrhea
    5. Decreasing colic symptoms
    6. Improving IBS
    7. Preventinig NEC >1000g babies
  • Small risk in immunocompromised patients
118
Q

CPS Baby-Friendly Initiative? Benefits of BF? Contraindications?

A
  • Benefits of breastfeeding:
    1. Decreases infections in infancy
    2. Reduced SIDS
    3. Enhanced neurocognitive testing
    4. Decreased maternal breast and ovarian cancer
    5. Economical

-BF should be gold standard

  • Pasteurized donor milk recommended if no BM available
  • Delay introduction of pacifiers until BF established

-Contraindications: HIV+, cytotoxic or radioactive treatment in mother, galactosemia

119
Q

CPS Human Milk banking?

A

• Donor milk prioritized for hospitalised newborns
• Statistics in this position statement are outdated (2010);
cross-reference against other data
• Description of testing, collection, and processing techniques
• Pasteurization inactivates pathogens and partially reduces beneficial immune cells
• Canadian Pediatric Society does not endorse unprocessed human milk

120
Q

CPS Promoting optimal cmonitoring of chilid growth in Canada?

A

• All infants (birth-5 years): WHO Child Growth Standards
-All school-aged children: WHO Growth Reference 2007
• Recumbent length (birth-2 years)
• Standing height (2 years or older)
• Head circumference (birth-2 years)
• Corrected age until 24-36 months of age
• BMI (2 years or older)
• Weight for Length (<2 years)
• Consider: percentile, relationship between weight/length/BMI, cut-off values, parental heights, trend
• Tables provided of recommended cut-off
definitions

121
Q

CPS Fluoride?

A
  • Pathophysiology of fluorosis and dental caries
  • Fluoride should be added to water supplies if <0.3ppm
  • Pea-sized portion of toothpaste in children only
  • Supplement fluoride >6mo if:
  • Drinking water has <0.3ppm
  • The child does not brush their teeth BID
  • High risk for caries (family history, community prevalence)
  • Supplements should be given as mouthwash, lozenge or drops
  • Table of recommended fluoride concentrations for children
122
Q

CPS Nutrition for healthy term infants, six to 24 months?

A
  • Breastfeeding exclusively for 6 months, with support along with complementary feeding for 2+ years
  • Vitamin D 400IU PO for breastfed children
  • Complementary foods for older infants, iron-rich foods as first foods, lumpy textures <9 months, full textures <12 months
  • Feed based on child’s hunger cues, self-feeding, open cup
  • Iron rich fods, cow’s milk >12 months limited to 750ml/day for 9-12mos
  • Supervised meals, choking hazards, safe food preparationi and storage, no honey < 12months
  • > 12 months regular scheduled meals, variety of foods, limit sugar and salt, higher-fat foods are nutritious, 500ml/day homogenized miilk/breastfeeding continiue, water for thirst (not SSBs)
  • Advocacy for breast feeding
  • Formula until 9-12 months, homogenized milk 12-24mo, no formula >12 mo, alternative “milks” not appropriate alternative to cow’s milk, avoid prolonged bottle feeding and at night
123
Q

CPS nutrition for health term inifants, birth to sex months?

A
  • Recommend exclusive breast feeding x 6 months
  • Implement policies of Baby-Friendly Initiative for Hospitals and Community Health Services
  • Vitamin D 400IU PO OD for breastfed infants
  • Iron-rich complementary first foods
  • Routine growth monitorng needed
124
Q

CPS Picky Eater?

A

-Most picky eaters are healthy and have an appropriate appetite
• Review food diary and parental expectations
• Definitions of normal growth (study these)
–1st year: 7 kg in weight and 21 cm in length
–2nd year: growth is about 2.3 kg and 12 cm; most toddlers reach average weight of 12.3 kg and height of 87 cm at two years of age
–Between 2 &5 y: weight gain slows down. Most children gain 1 kg to 2 kg and 6 cm to 8 cm per year
• Review of reasons for picky eating
• Detailed history and physical examination necessary
• Nutritional supplements, vitamins, appetite stimulants, formulas have no role in well- growing children

COUNSELLING:

  1. appetites decrease 2-5yo
  2. focus on growth
  3. estimate 1tbsp/food/year
  4. snack between meals
  5. no juice
  6. no grazing throughout day
  7. make eating enjoyable
  8. no distractions
  9. avoid meals when overtired or overstimulated
  10. teach by imitation
125
Q

CPS Toddler falling off the growth chart?

A
  • First 2-3yrs growth deviations are common
  • Regular monitoring of growth at each visit
  • Mid-parental height calculations important (study)
  • Complete nutritional history
  • Complete history and physical with attention to top causes
  • Basic workup indicated: Bloodwork, Additional Testing, Referral
  • Exceptional cases only require appetite stimulants
  • Tube feedings in exceptional cases

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