GI/Nutrition Flashcards
Signs/symptoms of cyclic vomiting syndrome
- MC in ages 3-7, equal in both sexes
- Diagnostic criteria: two or more periods of intense nausea and paroxysmal vomiting that last for hours to days in a 6 month period, episodes are stereotypical, episodes are separated by weeks to months with return to baseline between episodes
Treatment of cyclic vomiting syndrome
- Cyproheptadine (antihistamine) for kids 5 or younger
- Amitriptyline for kids 6 and older
- Supplementation with coenzyme Q10 and L-carnitine can be good for prophylaxis
Secondary lactose intolerance cause and diagnosis
- Cause: damage to villi in small intestine following acute gastroenteritis but also with celiac disease, IBD, autoimmune conditions, or chemo
- Symptoms: diarrhea, bloating, pain, gas, nausea
- Diagnosis: elevated stool reducing substances
Presentation of celiac disease in type 1 DM
- Recurrent hypoglycemia
- Can also have lack of weight gain and stomach aches
Vitamin E deficiency symptoms
Ataxia, hyporeflexia, limitation of eye movements, abnormal proprioception, muscle weakness
Neonatal GER gets better at what age
12 months - resolves in 95% of patients
Vitamin A name
Retinol
- Absorbed in terminal ileum, stored in liver
Vitamin E name
Tocopherol (Toke-of-E-rol)
Vitamin K name
Phylloquinone
- Absorbed in jejunum
- Newborns are deficient because insufficient intestinal bacteria
Vitamin B1 name
Thiamine
Vitamin B2 name
Riboflavin
Vitamin B3 name
Niacin
Vitamin B5 name
Pantothenic Acid
Vitamin B6 name
Pyridoxine
Vitamin B9 name
Folate
Vitamin B12 name
Cyanocobalamin
- Binds intrinsic factor, absorbed in terminal ileum, stored in liver
Vitamin C
Ascorbic acid
Most common cause worldwide of blindness in young children
Vitamin A deficiency - can also lead to dryness of the eyes
Vitamin cause of pseudotumor cerebri
Vitamin A toxicity (think of this if a teenager is on isotretinoin for acne)
Vitamin cause of macrocytic anemia, large tongue
- Vitamin B9 (folate) deficiency
- Vegetarians are at risk and if child is on goat’s milk
Vitamin cause of macrocytic anemia and pernicious anemia
- Vitamin B12 (cyanocobalamin) deficiency
- Vegans, parasitic infections, IBD, NEC are risk factors
Vitamin cause of scurvy, bleeding gums, leg tenderness, poor wound healing
Vitamin C deficiency
Vitamin cause of oxalate and cysteine nephrocalcinosis
Vitamin C intoxication
Vitamin cause of hemolytic anemia in preemies
Vitamin E deficiency
Vitamin cause of neuropathies, peripheral edema, thrombocytosis, muscle weakness
Vitamin E deficiency in older children
Vitamin cause of hemorrhagic disease in the newborn
Vitamin K deficiency
Vitamin D2 name
Ergocalciferol (2 Cs)
Vitamin D3 name
Cholecalciferol (3 Cs)
25-hydroxy vitamin D
- Gets hydroxylated in the liver and is the primary storage form
- Only one liver so only one number
- THIS IS THE ONE TO MEASURE ON A TEST!
1,25 hydroxy calciferol
- Formed in the kidney (calcitriol is another name)
- Active form!
- 2 kidneys so 2 numberes
- Helps calcium absorption in the gut and releases calcium into the blood from bone
Vitamin cause of hypercalcemia and hyperphosphtamiea
Vitamin D excess
- Sx: nausea, vomiting, weakness, polyuria, polydipsia, elevated BUN, renal failure
Calculation for caloric needs
- 100 kcal/kg (1st 10 kg)
- 50 kcal/kg (next 10 kg)
- 20 kcal/kg (any more kgs)
- 1500 kcal for first 20 kg then 20kca/kg after
Caloric needs for preterm and term infants
100-120 kcal/kg/d
- Reasons for preemies to have increased caloric need: lower fat levels so spend more energy in heat production, organogenesis, developing fat stores
Protein requirements in preterm/term infants
- Preemies: 3.5 g/kg/d
- Term infants: 2-2.5 g/kg/d for the first 6 months
Cause of infant not gaining weight post op after a big GI surgery
Increased urine output due to increased renal solute load (sodium, potassium, chloride, phosphorus)
Recommended amount of iron in formula
12 mg/L
Iron supplementation in babies
- Needed early on in LBW and preemie infants
- Infants who receive more than 50% of their calories from breastmilk need iron supplementation starting around 4 months of age
- Less iron in breast milk but it’s more bioavailable
Milk protein allergy
- Milk protein allergy is IgE mediated and prevents with vomiting , rash, and irritability
- Need elemental formula
FPIES
- Food protein induced enterocolitis syndrome
- Non IgE mediated severe cow milk protein intolerance
- Presents in first 3 months with heme positive stools or hematochezia
- Switch to protein hydrolysate formula or elimination diet if breastfeeding
Scaly dermatitis, alopecia, thrombocytopenia
Essential fatty acid deficiency
Tx: IV lipids with linoleic acid
Infant with eczematous eruptions, alopecia, poor growth/diarrhea, lesions around the mouth and/or perianal area
- Zinc deficiency due to lack of absorption
- Can present when weaned from breastmilk (breast milk contains a protein which facilitates zinc absorption)
- Autosomal recessive
- Rash: acrodermatitis enteropathica (no lichenification as compared to eczema)
Menkes Kinky Hair Syndrome
- X linked disorder
- Low serum copper and low serum ceruloplasmin
- Tissue copper level is high (compared to Wilsons)
- Twisted hairs (pili torti)
Fat differences in preemies vs term babies
- Preemies have decreased amount of bile acids making it harder for them to absorb long chain trigylcerides
- Preemie formula has 50% of total fat from MCTs
- Breast milk has 12% of fat from MCTs
Phosphorus and calcium in preemies
- Calcium and phosphorus are poorly absorbed in their guts so they require large supplementation amounts
- Lack of both can lead to demineralization
- Can have normal serum calcium and phosphorus but will have elevated alkaline phosphatase
Differences in colostrum vs mature milk
- Arachidonic acid, docosahexaenoic acid, and zinc decrease in mature milk
- Vitamin d levels are lower in colostrum
- Colostrum has more protein (a lot of immunoglobulins), carotene (yellow color), less fat, a little less lactose, and less caloric content compared with mature milk
Breast milk vs cow’s milk
- Breast milk has more lactose which makes it sweeter
- Cow’s milk has more phosphorus (too much for infant kidneys to handle) so can cause hypocalcemia
Contraindications to breast milk
- Infants with galactosemia
- Mothers in the US with HIV
- Mom with active HSV lesions on the breast, TB positive (until treated for 2 weeks)
- Moms receiving chemo, flagyl, diastat, amphetamines, cocaine, PCP
Macros differences in milk vs formula
- Breast milk: 70% whey, 30% casein (breast milk is WHEY better), major carb is lactose, human milk fats
- Cow’s milk: 20% whey, 80% casein, major carb is lactose, butter fat
- Milk based cow formula: 20-100% whey, 0-80% casein, major carb is lactose, vegetable oil
- Soy formula: 100% soy, major carb is corn syrup or sucrose, vegetable oil
Breast milk immunity
Lactose derived oligosaccharides inhibit bacterial adhesions to mucosal surfaces
- IgA antibodies
Obesity complications
Depression, avascular necrosis of the hip, diabetes, hypertension, osteoarthritis
Kwashiorkor
- Protein deficiency
- Pot belly, pitting edema, rash, thin/frail hair, pallor, overall thin appearance
Marasmus
- General nutrition deficiency
- Muscle wasting without edema, underweight, hair is normal
Most common complication of NG feeding
- Diarrhea, then reflux
- Most severe complication is vomiting with aspiration
Refeeding syndrome labs
- Muscle weakness, fatigue
- Low phosphorus, low thiamine, elevated glucose (due to low insulin)
- Tx: 50% of targeted kcal/kg/d to start at and then slowly increase
Vitamin B12 anemia cause
- Leads to macrocytic anemia and neurologic changes due to degeneration of posterior and lateral spinal columns
- Intrinsic factor made in gastric parietal cells is needed for absorption of B12 –> autoimmune mediated damage to gastric parietal cells screws this up
Cholestasis definition
Conjugated bilirubin concentration greater than 2 mg/dL or greater than 20% of the total bilirubin level
Differential for neonatal conjugated hyperbilirubinemia
Urinary tract infection, Alagille syndrome, galactosemia, total parenteral nutrition–associated cholestasis, ɑ1-antitrypsin deficiency, medication side effect, biliary atresia
Clinical symptoms of Alagille Syndrome
- Heart defect (PPS)
- Short stature, vertebral anomalies
- Cholestatic liver disease (paucity of bile ducts)
- Prominent forehead, hypertelorism, deep set eyes
- Posterior embryotoxon (opaque ring around the cornea)
Genetics of Alagille Syndrome
Autosomal dominant inheritance pattern with variable penetrance because of mutations primarily in the JAG1 gene
Management of encoporesis
- Initial disimpaction (enema/suppository)
- Maintenance therapy (miralax)
- Behavioral modifications
- Family education
BMI percentiles for obese/overweight
- 85th percentile is overweight
- 95th percentile is obese
Eosinophilic esophagitis symptoms/cause
- Can be caused by food impaction
- GERD unresponsive to acid block, food refusal in infants, odynophagia
- Chronic abdominal pain in school aged kids
- Dysphagia with food impactions in adolescents/adults
- Prolonged chewing and food lubrication
- History of asthma, allergies, eczema
Eosinophilic esophagitis scope findings, complications
- Scope: longitudinal furrows, white exudates, edema, > 15 eos per HPF while on a PPI
- Complications: stricture formation, esophageal candidiasis, food impactions
Diagnostic imaging test for Hirschsprung’s disease
Barium enema –> will see zone of transition where there is no ganglionic cells
Preemie vitamin/mineral requirements
- Need iron supplementation
- Na and K: 2.5-3.5 mEq/kg/d
- Ca, phos, and Mg are related inversely to gestational age
Exam and imaging findings for appendicitis
- McBurney’s point, psoas sign (straightening legs)
- Xray with sentinel loop and absence of air in RLQ
Pain in the abdomen that is not better after BM and recent history of viral gastroenteritis
Gastroparesis
Abdominal pain improved with defecation, change in stool frequency/consistence
Irritable bowel syndrome
Acute incapacitating periumbilical abdominal pain that lasts for more than 1 hr and interferes with activities, also have migraine type symptoms
Abdominal migraines
Low grade fever, vomiting, large loose watery stools
Viral gastroenteritis
Mild, watery, non-bloody diarrhea with fever and vomiting in a neonate or child < 2 in area with poor sanitation
Enteropathogenic E. coli (EPEC)
Severe watery, non bloody diarrhea and cramping (traveler’s diarrhea)
Enterotoxigenic E. coli (ETEC)
- enteroTACOgenic
- Often self limited but if doesn’t improve and shiga toxin is negative, can treat with bactrim or azithro
Risk factors for STEC
- unpasteurized milk and apple juice
- petting zoos
- raw/undercooked ground beef
- raw fruits and vegetables
Reason for no antibiotics with STEC
- It can release more shiga toxins and increase risk for HUS
Afebrile, stools with blood and mucous, tenesmus
Enteroinvasive E coli (EIEC)
Watery non-bloody diarrhea, abdominal pain, foul smelling stools, flatulence
Giardia
- Humans are main reservoir, infection from infected person or contaminated food/water
- Diagnosis is made by enzyme immunoassay or DFA antibody
- Microscopy: trophozites are binucleated and look like a happy face
- Tx is generally self limited but can use flagyl
Prolonged course of watery, non-bloody diarrhea
Cryptosporodium
- Intracellular parasites that are chlorine tolerant and transmitted fecal oral
- Immunocompromsied can get very very sick
- Outbreaks from contaminated drinking and recreational water, daycare, petting zoos
Diarrhea from swimming pools or municipal water
Cryptosporodium
Diarrhea from farm livestock or petting zoos
Cryptosporodium or E coli
Diarrhea in immunocompromised hosts
Cryptosporodium
Diarrhea from apple cider or undercooked ground beef
E coli
Diarrhea from pork or chitterlings
Yersinia
Diarrhea from improperly cooked poultry or dairy farms
Campylobacter
Diarrhea from unpasteurized milk
Campylobacter or E coli
Tests for sugar malabsorption
- Quick screen that tests for reducing substances in the stool
- Hydrogen breath test
Tests for fat malabsorption
- Fecal fat measurement (need a 3 day test)
- Serum carotene and prothrombin time
Tests for protein malabsorption
Albumin
Most common cause of prolonged diarrhea in kids < 3
Toddler’s diarrhea and is mostly due to excess fruit juice intake
- Formed stool in AM and progressively looser throughout the day
- Growth and development are normal
- Tx with limiting carbs, high fiber
Bilious vomiting during the first few hours of life
Duodenal atresia
- Double bubble, no air distal to the site of atresia
- A/w T21
Bilious vomiting with abdominal distension, crampy abdominal pain
Malrotation - due to duodenal obstruction by the cecum
Infant with bilious vomiting and right sided abdominal distension, associated with Ladd’s bands, xray with corkscrew appearance of small bowel
Volvulus
Child < 6yo with sudden onset abdominal pain, drawing legs up, vomiting and then improved but recurrent
Intussusception
- Bloody stool, sausage like mass in abdomen
- Later stages lead to bilious vomiting and shock
- Tx with air enema
- MC is idiopathic but need to think about Meckel’s, polyps, lymphoma, HSP vasculitis
Recurrent crampy abdominal pain in a febrile child
Campylobacter or Yersinia
Infant with reflux and dystonic movements of the head
Sandifer syndrome
Pyloric stenosis genetics
MC in white males so if a mom has a history of it, it increases risk more than if dad has it
Progressive non-bilious vomiting in the 2nd month of life
Pyloric stenosis
- Hypochloremic hypokalemic metabolic alkalosis
- Can also have elevated indirect bili
Ultrasound diagnostic criteria of pyloric stenosis
- Pyloric length greater than 14 mm
- Pyloric muscle thickness greater than 4 mm
Cyst on the floor of the mouth
Ranula - treatment is excision
X-linked, absent or underdevloped teeth
Ectodermal hypoplasia
- Diagnosed by skin biopsy showing lack of sweat pores
Portal hypertension with bright red bloody stools and hematemesis
Esophageal varices - can have tarry stools too
Coughing/vomiting with feeds in the newborn period, can also have cyanosis with initial feeding
Tracheo-esophageal fistula
- Blind pouch is the most common type
- Often will have a film with a feeding tube coiled up
Symptoms of GERD or dysphagia, can have food impaction
Eosinophilic esophagitis
- Immune/antigen mediated (commonly soy, milk, wheat, eggs, nuts or environmental)
- Tx with PPIs, diet changes, corticosteroids
Why do NSAIDs cause GI symptoms
Interfere with prostaglandin synthesis
Severe epigastric pain, vomiting after eating, guaiac positive stools
Peptic ulcer disease
- UGI with biopsy is diagnostic
Risk factors for H pylori
Lower socioeconomic status, poor sanitory conditions, first degree relative with gastric cancer
Testing and treatment for H pylori
- Testing with serology, fecal antigen, urea breath test (need more than one to be sure), biopsy is gold standard but not always necessary
- Tx with PPI, 2 antibiotics for 7-14 days (clarithromycin and amox)
Celiac disease symptoms and diagnosis
- Abdominal distension, anorexia, diarrhea, FTT, weight loss, proximal muscle wasting, iron deficiency anemia
- Test with IgA anti-TTG (if IgA levels are normal), confirmation with biopsy
Causes of rectal prolapse
- Cystic fibrosis
- Pertussis
- Tenesmus
- Chronic constipation
- Meningomyelocele
- Parasites
Solitary juvenile polyps
- Can be found incidentally but need to be removed
- If < 5, no further testing needs to be done
Macrocephaly, papillomatous papules, mucocutaneous lesions, acral keratosis
PTEN Hamartoma syndrome
- Skin hamartomas usually present by mid 20s
- Also have increased risk of breast, endometrial, and thyroid cancers
Familial adenomatous polyposis plus CNS tumors
Turcot syndrome
- Average age for colorectal cancer in FAP is 39 if colectomy is not done
Familial adenomatous polyposis with extra teeth and polyps in the large/small intestine
Gardner’s syndorme
- Osteomas and soft tissue tumors are also common
- Autosomal dominant
- Treat with surgery
Mucocutaneous pigmentation of lips and gums and polyps in stomach and colon
Peutz-Jeghers syndrome
- Polyps can lead to intusssusception and become malignant
- Risk of cancer in colon, pancreas, stomach, lung, testes, breast, uterus, ovary, cervix
Genetic group associated with ulcerative colitis
European jews
- Also HLA B27 (just like Crohn’s)
Treatment of ulcerative colitis
- Acute: fluids, blood transfusions, steroids
- Long term: 5-ASA
- Second line: steroids, 6-mercaptopurine, methotrexate, azathioprine, cyclosporine, tacrolimus
- Surgical consult
Risk of cancer with ulcerative colitis
- Colectomy eliminates the risk of cancer
- Risk of cancer is 20% per decade after the first 10 years of disease
Crohn’s biopsy findings
- Skip lesions, cobblestone appearance, transmural lesions, noncaseating granulomas
Crohn’s symptoms
Weight loss may be present before GI symptoms
- Can also have short stature, elevated ESR
- Oral aphthous ulcers, perianal fistula
- Extraintestinal: pyoderma gangrenosumo f the foot, erythema nodosum (red tender nodules on shin), ankylosing spondylitis, arthritis, uveitis, liver disease, renal stones
Treatment of Crohn’s
Steroids, aminosalicylates, immunomodulators, antibiotics, 5-ASA
- Steroids can induce remission but there is a high relapse rate
Cause of hirschsprung’s disease
Absence of parasympathetic innervation of internal anal sphincter, region proximal to this then becomes dilated with stool
Symptoms of hirschsprung’s
- No passage of stool in the first 48 hours of life
- Bilious vomiting, poor PO intake, abdominal distension
- Associated with Down syndrome
Infant straining to pass small liquid stools, tight band narrowing on anus
Anal stenosis - self limited, resolves by age 1
Neonate with painless effortless regurgitation of bright red blood
Swallowed maternal blood or blood from mom’s cracked nipples
- Apt test (negative means it is maternal origin)
Causes of false positive guiac test
- Recent meat ingestion
- Horseradish
- Ferrous sulfate administration
Causes of lower GI bleeding in infants/toddlers
- Hirschsprung’s with associated colitis
- Malrotation with volvulus (melena)
- NEC
- Anal fissures (usually secondary to constipation)
- Intussusception
Meckel’s diverticulum “rules”
- Painless rectal bleeding
- Presents in first 2 years of life, 2 types of tissue (gastric/intestinal), 2 feet from ileocecal valve, 2 inches in length, 2% of population
- Diagnose with 99m technetium scan
Testing for cholestatic jaundice
- Elevated direct bilirubin
- Hepatobiliary scintigraphy –> with liver disease with isotope is taken up and makes its way to biliary tree, with obstruction there will be uptake in the liver but no drainage down the biliary tree
Symptoms of biliary atresia
- Elevated direct bili with clay colored stools in a child over 1 month of age
- Tx with Kasai
- Dx with ultrasound then HIDA scan
Neonatal jaundice, fever, acholic stools, RUQ pain, palpable mass
Choledochal cyst
Intermittently ele ated unconjugated bili with fasting illness or other stressors
Gilbert syndrome
- Genetic deficiency of glucuronyl transferase
- Normally presents in teenagers
- Have normal LFTs, no hemolysis, no treatment
Elevated LFTs and serum ammonia after a viral illness in which aspirin was given
Reye’s syndrome
Liver disease in children and teenagers, neuropsychaitric disease in adults
Wilson’s disease
- Autosomal recessive abnormal copper metabolism
- Elevated hepatic copper, decreased ceruloplasmin, serum copper levels are low because it’s all in the tissues, increased copper in urine
- Kayser fleischer rings in eyes
- Tx: d-penicillamine to chealte the copper, low copper diet
Persistent jaundice in the newborn period, neonatal hepatitis with cholestasis, necrotizing panniculitis and psoriasis, COPD
Alpha 1 antitrypsin deficiency
Definition of portal hypertension
- Portal venous pressure > 5
- Portal to hepatic vein gradient of > 10
- Diagnose with abdominal US with doppler
Risks for portal hypertension
- Hx of UVC causing portal vein thrombosis
- Kids with chronic liver disease
- Splenomegaly is the most sensitive indicator of portal hypertension and varices
Symptoms and transmission of hepatitis A
- Flu like symptoms plus jaundice and elevated LFTs
- Recent travel
- Fecal oral transmission
- Poor hygiene, poor sanitation, drinking contaminated water or eating shellfish from contaminated waters
- People who are positive need to be out of work for 1 week after onset of symptoms
Transmission of hepatitis B
- Blood transfusions, bodily fluids, sexual contact, perinatal transmission
Serologies in acute hepatitis B
- HBsAg positive (tells active infection but not acute/chornic)
- HBeAg (high viral load)
- HBV-DNA (indicates viral replication)
Serologies in recovery hepatitis B
- Disappearance of HBV-DNA and HBsAg
- Appearance of HBsAb, HBcAb, HBeAb - antibodies to surface antigen, core antigen, and e antigen
Serologies in chronic hepatitis B
Persistance of surface antigen HBsAg beyond 6 months
Most common bloodborn infection in the US
Hepatitis C - also most common cause of chronic viral hepatitis
- Increased risk of HCC
Hepatitis E virus transmission
- Fecal oral route from contaminated water in Asia, Africa, Mexico
- Does not lead to chronic hepatitis
Most specific test to diagnose pancreatitis
Abdominal ultrasound (not serum amylase)
- ERCP can be used to follow recurrent pancreatitis not diagnose acute
- Lipase is more specific than amylase
- Additional labs: hyperglycemia, hypocalcemia, elevated creatinine, anemia, coagulopathy
Causes of pancreatitis
- Familial dyslipidemia
- Hypercalcemia
- Trauma
- Idiopathic
- Hereditary pancreatitis
- Autoimmune
Fever, abdominal pain, pain to right shoulder, jaundice
Cholecystitis –> diagnose with ultrasound
Risks for cholecystitis
- TPN, hemolytic disease, small intestinal disease, obesity, pregnancy
Definition of cholelithiasis
- Stones in gallbladder
- Choledocholithiasis is stones in hepatic or common bile duct
Risk factors for gallstones
- CF
- Ileal resection
- Tx with rocephin
- TPN
