GI/Nutrition Flashcards
List 2 indications that paediatricians should consider recommending probiotics for.
- Prevent antibiotic-associated diarrhea
- Shorten duration of acute infectious viral diarrhea
- Prevent necrotizing enterocolitis
- Decrease symptoms of colic (decreased daily crying time)
- Decrease some symptoms of IBS
Identify 2 functions of the colonic bacteria
- Contribute to the gut’s barrier function (↑mucin secretion, ↓gut permeability, modulate immune function)
- Metabolize malabsorbed carbohydrates into SCFAs = fuel for enterocytes
- Acidify colonic content
- ↑water absorption
Name the vitamin absorption, function, deficiency and toxicities.
Vitamin A, D, E, K, B1 (thiamine), B2 (riboflavin), B3 (niacin), B5 (pyridoxine), B7 (biotin), B9 (folic acid), B12 (cyanocobalamin), C
Vitamin
Absorption
Function
Deficiency
Toxicity
Serum measure
Vitamin A
(retinol/ B-carotene)
Small bowel
Vision
Epithelium
Night blind
Keratomalacia
Bitot spots
Xerophthalmia
Hepatotoxicity
Hyperlipidemia
Alopecia
Ataxia
Cheilitis
HA/ IIH
Retinol
Retinol binding protein
Vitamin D
(cholecalciferol)
Small bowel
Skin
Regulate
Ca and PO4
Rickets
Hypocalcemia
HypoPO4
Hypercalcemia
Worsened milk-alkali syndrome
25-OH vit D
PTH
Vitamin E
Small bowel
Cell membrane antioxidant
Prolonged INR
abN bone dev
Coagulopathy
Hemorrhage
Alpha-tocopherol
Vitamin K
(phytonadione)
Small bowel
Activates clotting factors
Prolonged INR
Hemolysis
INR (for factors 2, 7, 9, 10)
Vitamin B1
(thiamine)
Jejunum
ATP synthesis
Pyruvate dehydrogenase cofactor
Refeeding and alcoholism
Wernicke enceph
Dry beriberi (dilated cardiomyopathy, Korsakoff psychosis)
none
Erythrocyte transketolase activity
Vitamin B2
(riboflavin)
Small bowel
Macronutrient metabolism
Iron absorption
Angular stomatitis
Cheilosis
Glossitis
Seb dermatitis
none
Erythrocyte glutathione reductase activity
Vitamin B3
(niacin)
Stomach
Small bowel
Precursor of NAD+/NADP+
DNA repair
Hormone synth
Pellagra (dermatitis, diarrhea, dementia, death)
Vasodilation
Pruritis
Myopathy
Headache
Urine niacin-methylated metabolites
Vitamin B6
(pyridoxine)
Jejunum
Hb synth
Nerve cell fxn
Glucose hemostasis
Dermatitis
Glossitis
Seizures
Anemia
Ataxia
Sensory neuropathy
Pyridoxal phosphate
Vitamin B7
(biotin)
Small bowel
Coenzyme
Dermatitis
Alopecia
Ataxia
Seizures
None
Biotin level
Vitamin B9
(folic acid)
Small bowel
DNA synth/repair
RBC prod
Neural tube formation
Neural tube defects
Anemia
Growth delay
Diarrhea
weakness
Rare
Folate level
Vitamin B12
(cyanocobalamin)
TI
Needs intrinsic factor
Hb synthesis
Macro anemia
Weakness
Paresthesia
(risk pernicious anemia if crohns, gastritis, bariatric surgery, TI Surg)
None
B12 levels
Methylmalonic acid
Homocysteine
Vitamin C
(ascorbic acid)
Ileum
Collagen synth
(wound healing)
Scurvy (anemia, gingival bleeding, perifollicular hemorrhage, poor wound healing)
Rare
(avoid supp if renal failure, iron overload, warfarin)
Ascorbic acid
What are causes of Protein Losing Enteropathy?
What are the symptoms?
How to diagnose?
- PLE = Abnormal protein loss from GI tract
- Causes:
- Abnormal protein leakage across the gut
- Ie. mucosal erosion, gut inflammation
- Decreased protein uptake by lymphatic system
- Ie. Post-Fontan
- Lymphatic obstruction
- Ie. Intestinal lymphangiectasia
- Metabolic
- Ex. congenital disorders of glycosylation
- Abnormal protein leakage across the gut
- Causes:
- Symptoms:
- Diarrhea: fat and/or carbohydrate malabsorption
- Edema: dependent, extremity, facial
- Pleural or pericardial effusion
- Diagnosis:
- Labs
- Low serum proteins (albumin, A1AT, ceruloplasmin, transferrin)
- Malabsorption of fat-soluble vitamins (ADEK)
- Hypogammaglobulinemia (IgA, IgG, IgM)
- Lymphocytopenia
- Normal UA (no urine protein loss)
- Normal liver function (ie. not low production b/c liver disease)
- Diagnostic:
- 24hr collection = elevated stool a1-antitrypsin or fecal calprotectin
- Small bowel contrast study
- “Stacked coins”—thickened or edematous folds
- Endoscopy for mucosal inflammation
- Labs
What is the presentation and management of H pylori?
- Most common cause of gastritis (50% of population)
- Risk factors:
- Developing countries, crowded living, no running water, low SES
- Colonizes stomach and has T cell response with bacteria that release urease
- Leads to epithelial damage and inflam
- Presentation
- Peptic ulcer disease, iron deficiency anemia, reflux
- Diagnosis:
- Gold standard = endoscopy with biopsy
- Nodularity in stomach with cobblestone appearance
- Urea breath test
- Stool antigen
- Gold standard = endoscopy with biopsy
- Treatment:
- Triple therapy = amoxicillin + clarithromycin + PPI x 14 days
(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? AV canal defects
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
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
Battery Sharp object blunt object not passing into stomach in 24h meat not passing into stomach in 12h 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 CMPI 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 CMPI 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-TTG 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 Consider: - IgG anti-deamidated gliadin peptide antibodies (useful if IgA deficient) - if TTG antibodies are positive but <10x the ULN, should have upper GI scope - if >10x ULN should have anti-endomesial antibody testing (EMA)
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
- tracheomalacia (almost always associated with TEF) - refistulization - GERD - 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
2 indications for fundoplication in 6 mo child with GERD.
- refractory esophagitis - strictures - chronic pulmonary disease
Mother has two month old child who is fed 6-8 0z of formula every 6 to 8 hours. The baby spits up with feeding and is irritable. What are four recommendations to help alleviate this problem without medication?
- reduce volume of feeding 2. increase frequency of feeding 3. feed baby in more upright position 4. take breaks during feed to burp baby to allow for pacing 5. keep baby upright for 30 minutes after feed, and position prone or upright when awake
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: 1. Give hydrochloric acid IV 2. OR immediately 3. Give large amounts of chloride IV 4. Give 5mmol/kg of KCl IV bolus 5. 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. Name 2 tests to confirm this diagnosis. Name 4 severe complications of GERD.
- Tests to confirm: pH monitoring - intraluminal impedence - ?trial of PPIs and evaluate for symptom response 2. Complications: - Barrett’s esophagus - strictures - aspiration pneumonia - 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). ABC 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
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)
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), 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? 1. 2 yr for catch up growth in IUGR 2. f/u in 6 mos no nutritional intervention 3. need w/u for organic FTT 4. increase dietary protein 5. 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
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.
- giardiasis - bacterial overgrowth - crohn’s - HIV enteropathy - lymphoma
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 2. T1DM hypothyroidism 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 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.
- IBD - CMPA/FPIES - giardiasis - celiac disease
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. 1. arrange for skin testing and RAST 2. carbohydrate intolerance is a common cause 3. it is due to sensitization to cow’s milk protein 4. citrus fruits and tomatoes can cause this via an immune-mediated mechanism 5. if mucous is not present in the stool then it cannot be an immune problem
- carbohydrate intolerance is a common cause - 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: 1. Call general surgery 2. Abdominal ultrasound 3. IV antibiotics 4. Abdominal x-ray 5. Barium swallow with small bowel follow through
- Abdominal x-ray
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
What are 2 surgical complications of HSP
- intussusception 2. intestinal perforation
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 - in Kasabach Merritt get rapidly enlarging hemangioma, TCP, hypofibrinogen/coagulopathy - clotting cascade gets activated within vasculature of hemangioma
Neonate, now two weeks old, with abdominal mass palpable. Has a history of umbilical catheterization. What is the cause of hepatosplenomegaly? a) Portal vein thrombosis b) Infection
a) Portal vein thrombosis
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? 1. hepatic hemangioma 2. portal vein thrombosis 3. hereditary spherocytosis 4. congenital CMV 5. 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
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)
