GI / Nutritional Flashcards
Most common causes of appendicitis
- Fecalith (MC)
- Inflammation
- Malignancy
- Foreign Body
Vomiting usually occurs ________ pain in appendicitis
After
RLQ with LLQ palpation
Rovsing Sign
Appendicitis
RLQ pain with internal and external hip rotation with flexed knee
Obturator Sign
Appendicitis
RLQ pain with right hip flexion/extension (right leg against resistance)
Psoas Sign
Appendicitis
Diagnosis for appendicitis
- CT scan
- Ultrasound
- Leukocytosis
Otherwise healthy infant aged 2-3 months seems to be in pain, cries for more than 3 hours a day for more than 3 days a week, for more than 3 weeks
Colic
Severe paroxysmal crying that occurs mainly in late afternoon
Colic
Transient relaxation of LES leading to esophageal mucosal injury
GERD
Complications of GERD (4)
- Esophagitis
- Stricture
- Barrett’s esophagus
- Esophageal carcinoma
Sign/symptoms of GERD
- Heartburn (hallmark) - sometimes retrosternal and postprandial
- Regurgitation (acidic taste)
- Dysphagia, cough at night
Alarm symptoms of GERD
- Dysphagia
- Odynophagia
- Weight loss
- Bleeding (suspect malignancy)
Diagnosis of GERD
Clinical diagnosis
- Endoscopy often first
- Esophageal manometry
- 24 hour ambulatory pH monitoring - gold standard
Lifestyle modifications for GERD
Elevation of head of bed by six inches Avoid recumbency for three hours after eating Eat small meals Avoid certain foods Decrease fat and EtOH intake Weight loss smoking cessation
Pharmacological therapy for GERD
- Antacids and OTC H2 receptor antagonists
- PPI and prokinetic agents (cisapride)
- Nissen fundoplication if refractory
Dyssynergic defecation, slow transit, and IBS-constipation type
Primary causes of constipation
DM, hypothyroid, hypercalcemia, intestinal mass, Parkinson’s disease, anal stricture, and medications
Secondary causes of constipation
Alarm symptoms of constipation
- Hematochezia
- Weight loss
- Fam hx of colon CA
- Anemia
- Heme positive stools
- Severe persistent constipation
Diagnosis of constipation
- Rectal exam - r/o masses, fissures, sphincter tone
2. Colonoscopy if alarm sx
Treatment of constipation
- Increase fluids, exercise, develop bowel pattern
- Fiber of 25 g daily
- Bulk/osmotic laxatives
- Prunes are an alternative
Hypertrophy and hyperplasia of the muscular layers of the pylorus
Pyloric Stenosis
Most common cause of intestinal obstructioni n infancy
Pyloric stenosis
95% of pyloric stenosis present in the first ___________ of life, and the condition rarely presents after ____________
3-12 weeks
> 6 months
Physical exam signs of pyloric stenosis
Signs of dehydration/malnutrition
Hypochloremic metabolic acidosis
Jaundice
Olive-shaped, nontender, mobile, hard pyloric
Diagnosis of pyloric stenosis
- Ultrasound - first line
2. Upper GI contrast (string sign)
Treatment of pyloric stenosis
- Rehydration
2. PYloromyotomy
Intestinal segment invaginates/telescopes into adjoining intestinal lumen, leading to bowel obstruction
Intussusception
Most patients with intussusception are between ______________ of age
6-18 months
Intussusception most commonly occurs at the:
Ileocolic junction
Intussusception often occurs after:
Viral infection
Lead points for intussusception
- Meckel diverticulum
- Enlarged mesenteric lymph node
- Hyperplasia of peyer’s patches
- Benign/malignant tumor
- Henoch-schonlein purpura
- Foreign body
Classic triad of intussusception
- Vomiting
- Abdominal pain
- Passage of blood per rectum “currant jelly stool”
Physical exam of intussusception
“Dance’s Sign”
Sausage-shaped mass in RUQ or hypochondrium and emptiness in RLQ
Diagnosis of intussusception
Barium contrast enema (often diagnostic and therapeutic)
Radiographs - lack of gas in the bowels
Management of intussusception
Barium or air insufflation
Hydration (IV fluids)
Surgical resection if refractory
Congenital absence of ganglion cells leading to functional obstruction
Hirschsprung disease
Hirschsprung disease occurs most commonly in the:
Distal colon and rectum (75%)
Increased incidence of hirschsprung disease in:
Males and down syndrome
Pathophysiology behind hirschsprung disease
- Absence of enteric ganglion cells: failure of complete neural crest migration
- Functional obstruction due to failure of relaxation of aganglionic segment.
- Enterocolitis - vomiting, diarrhea signs of toxic megacolon
Signs/symptoms of hirschsprung disease
- Neonatal intestinal obstruction - failure of meconium passage > 48 hours
- Bilious vomiting, abdominal distention, failure to thrive
- Enterocolitis - vomiting, diarrhea, signs of toxic megacolon
- Chronic constipation
Diagnosis of hirschsprung disease
- Anorectal manometry - lack of relaxation of internal sphincter with balloon rectal distention. Often used as initial screening test
- Contrast enema
- Abdominal radiographs
- Rectal biopsy - definitive - shows absence of ganglion cells
Management of hirschsprung disease
Surgical resection of the affected bowel
Repeated passage of stool into inappropriate places by child chronologically or developmentally > 4 years
Encopresis
> 90% of cases of encopresis result from
Constipation
Diagnosis of encopresis
Rectal exam
Abdominal XR
Treatment of encopresis
Oral laxatives or enema
Treatment can be monitored by abdominal XRs
Establish bowel regimen
Inflammation of the liver caused by 5 different viruses
Viral hepatitis
Hepatitis __, __, and __ are transmitted through bodily fluids, while __ and __ are transmitted through the fecal-oral route
BCD
AE
Hepatitis __ requires co-infection with hepatitis __
D
B
Signs/symptoms of viral hepatitis
- Fever, fatigue
- N/V
- Abd pain
- Dark discolored urine (secondary to conjugated hyperbilirubinemia)
- Jaundice
Hepatitis __ and __ will usually be asymptomatic
B and C
Diagnosis of hepatitis
- Elevated LFTs
- Elevated PT (if developed cirrhosis)
- Antibody testing (IgM and IgG)
In hepatitis testing, __ is for acute infection and __ is for chronic infection
IgM
IgG
This does not apply to Hep B and Hep C
Test for check for active Hepatitis C infection
Hep C virus RNA
If there is positive Hep C antibody, but negative RNA
Pt has cleared Hep C infection
If there is positive Hep C antibody and positive Hep C RNA
Pt has active Hep C infection
Hepatitis B screening:
- HbsAg (-)
- anti-HBc (-)
- anti-HBs (-)
Hepatitis B susceptible
Hepatitis B screening:
- HbsAg (-)
- anti-HBc (+)
- anti-HBs (+)
Immune due to natural infection
Hepatitis B screening
- HbsAg (-)
- anti-HBc (-)
- anti-HBs (+)
Immune due to vaccination
Hepatitis B screening:
- HbsAg (+)
- anti-HBc (+)
- IgM anti-HBc (+)
- anti-HBs (-)
Acutely infected
Hepatitis B screening:
- HbsAg (+)
- anti-HBc (+)
- IgM anti-HBc (-)
- anti-HBs (-)
Chronically infected
Treatment for hepatitis A and E
Self-resolve, are not associated with chronic liver disease
Treatment for acute hepatitis B
Supportive care
Treatment for chronic hepatitis B or positive e-antigen
Interferon or Nucleoside analogs (entecavir, tenofovir, lamivudine, adefovir, telbivudine)
Treatment for hepatitis pts with cirrhosis
Transplant required
Treatment for hepatitis C
Ledipasvir-sofosbuvir OR sofosbuvir and velpatasvir
Usually due to increased indirect (unconjugated) bilirubin (the immature liver of a newborn is unstable to efficiently conjugate bilirubin due to decreased UGT enzyme activity)
Jaundice
Increased indirect bilirubin may be physiologic or pathologic. However, increased direct is always ________
Pathologic
Bilirubin > 20 mg/dL can lead to:
Kernicterus and neurotoxicity
Cerebral dysfunction and encephalopathy as a result of bilirubin deposition in the brain tissues (seizures, lethargy, irritability, hearing loss and mental development disorders). Infants are at risk when bilirubin is > ________
Kernicterus
> 20-25 mg/dL
Management of jaundice in newborns
Phototherapy used in all types
Exchange transfusion used in severe cases, ABO incompatibility, RH isoimmunization and hemolysis
Complete absence of closure of portion of duodenum leading to gastric outlet obstruction
Duodenal atresia
Signs/symptoms of duodenal atresia
Intestinal obstruction shortly after birth, leading to abdominal distention and bilious vomiting
Diagnosis of duodenal atresia
Abd XR - causes the double bubble sign
Treatment of duodenal atresia
Decompression of GI tract - NG tube
Fluid replacement
Surgical repair
Hernia that occurs lateral to the inferior epigastric artery
Indirect inguinal hernia
Indirect hernias are often congenital and occur due to a __________ _________ _________ ___________
Persistent patent process vaginalis
Most common overall type of hernias in women and men
Indirect inguinal hernia
Hernia that occurs medial to the inferior epigastric arteries within Hesselbach’s triangle
Direct inguinal hernia
Signs/symptoms of a strangulated hernia
Incarcerated hernia with systemic toxicity. Compromised blood supply - ischemic
Severely painful bowel movement
Management of inguinal hernias
Often require surgical repair
Strangulated are surgical emergencies
Management of umbilical hernias
Observation, will usually resolve by 2 years old
Surgical repair if still persistent in children > 5 y/o
Niacin (Vitamin B3) deficiencies are often due to:
Diets high in corn or diets which lack tryptophan
The three D’s of niacin deficiency:
Diarrhea
Dementia
Dermatitis
Risk factors for vitamin A deficiency:
Patients with liver disease, EtOHics, fat free diets
Signs/symptoms of vitamin A deficiency:
- Visual changes (night blindness), xerophthalmia (dry eyes)
- Impaired wound healing, dry skin, poor bone growth, taste loss
- Squamous metaplasia - Bitot’s spots
Bitot’s Spots
White spots on the conjunctiva due to squamous metaplasia of the corneal epithelium
Vitamin A Deficiency
Risk factors for vitamin C deficiency
Diets lacking raw fruits and green vegetables, smoking, alcoholism, malnourished individuals, elderly
Signs/Symptoms of vitamin C deficiency
Scurvy (3 H’s):
- Hyperkeratosis
- Hemorrhage (vascular fragility)
- Hematologic - anemia, glossitis, malaise, weakness
Risk factors for vitamin D deficiency
Breastfeeding without vitamin D supplementation
Lack of fortified milk or sun exposure
Signs/symptoms of vitamin D deficiency
- Rickets - bowed legs, fractures, costochondral thickening, dental problems
- Osteomalacia (adults): body pains, muscle weakness
Management of vitamin D deficiency
Ergocalciferol (vitamin D)
Loose stools, abdominal pain, and flatulence after ingestion of milk or milk containing products
Lactose intolerance
White children typically develop signs/symptoms of lactose intolerance ____________ hispanics or blacks
After
Diagnosis of lactose intolerance
Hydrogen breath test - hydrogen produced when colonic bacteria ferment undigested lactose
Usually performed after trial of lactose free diet
Treatment of lactose intolerance
Lactase enzyme preparations
Lactaid - prehydrolyzed mlk
Lactose free diet