GI SAQ Flashcards
1.Please match the following case scenarios with the appropriate nutritional supplements.
a) 4 month old male with a chylothorax.
b) 2 year old neurodevelopmentally delayed child with G-tube.
c) 3 month old male with confirmed eosinophilic enteritis.
d) Neonate born to an HIV-positive mother on antiretrovirals, both of whom live in rural sub-Saharan Africa.
Options: Pediatric formula 1.0 kcal/ml Breast feed ad lib Hydrolyzed protein formula Elemental formula with 0% fat
4mo chylothorax = elemental formula with 0% fat
2yo G-tube = pediatric formula 1.0kcal/mL
3mo eosinophilic enteritis = hydrolyzed protein formula
HIV+ sub-Saharan Africa = breastfeed ad lib
- Young girl with CP who is in a wheelchair with contractures. Other than weight, what are three anthropometric measures of nutrition that can be used?
- Arm span
- Mid-upper arm circumference
- Subscapular skinfold thickness
- Triceps skinfold thickness
- Presented with growth curves. Child with severe spastic CP presents with height 3rd, and weight «3rd. Has intermittent choking with feeds. There is no vomiting or diarrhea. They are not on any medications and are otherwise healthy. What are FIVE things you want to do for management
- OT/SLP feeding assessment
- Video fluoroscopy feeding assessment to look for aspiration
- Consider NG feeds and consider G-tube in discussion with family
- Dietician consult to look at caloric intake and how to increase calories
- Consider trial of thickened feeds (depending on results of feeding study)
- kid with celiac disease, taking megavitamins has pseudotumour cerebri
a. What is the cause?
Hypervitaminosis A
- Vegan kid
a. Deficient in?
b. What’s the worse complication of vitamin b12?
A. Vit B12, Vit D, linolenic acid, possibly calcium, zinc, Iron
B. Developmental regression
- Kwashiorkor kid
a. Gets rash with sun exposure, what is he deficient in?
b. Name 3 things you would do to ensure he gets refed safely
A. Niacin
B.
1. Treat hypoglycemia, hypothermia, or infection
2. Treat dehydration if present
- PO/NG rehydration when possible with ORS
- IV fluids only if severe hypovolemia or shock
3. Slow + cautious refeeding
- formula with 75kcal/100mL
- 80-100kcal/kg/d
- Small amounts + frequent intervals b/c decreased intestinal motility + gastric acid production
4. Monitor + treat electrolyte abnormalities
5. Start dietary supplements: vit A, folate , thiamine, iron (once in rehabilitation/wk 2-6)
- Name a medical condition (in a baby) that is a contraindication to breastfeeding.
Galactosemia
Phenylketonuria
- An 11 month old baby girl presents with a history of diarrhea and failure to thrive. She also had developed the rashes shown in the figures. The symptoms started shortly after switching from breastmilk to formula. Please identify the diagnosis to explain these symptoms.
Zinc deficiency
- TPN – list four metabolic complications (2 points)
- Conjugated hyperbilirubinemia
- Electrolyte deficiency
- Trace element deficiency: Fe, Zn, Cu, Se
- Vitamin deficiency: B1,2,6,12, C, A,E, folic acid
- Hypo/hyperglycemia
- Hypercalcuria
- Hypertriglyceridemia
- Liver steatosis
Long term metabolic complications
- Parenteral nutrition associated liver disease
- Bone disease
11 4 effects of excess vitamin D (2 points)
- Hypercalcemia
- Nausea, vomiting, poor feeding, constipation
- Altered LOC (lethargy, confusion, hallucinaions, coma)
- Arrhythmias
- Hypernatremia
- Nephrocalcinosis + nephrolithiasis
Tx
- IV NS +/- loop diuretic: leads to increased Na + Ca excretion in urine
- prednisone: blocks absorption of Ca
- Calcitonin: lower Ca by inhibiting bone resorption
- bisphosphonates: inhibit bone resorption
- last resort: hemodialysis
12 A 13 year old girl comes to you with a BMI of 24 (have to plot…… plots at 90th %ile). Interpret the BMI.
What is considered a healthy BMI?
Overweight
<5%tile are underweight
>85%tile are overweight
>95%tile are obese
- Breastfed baby of a vegan mom. What deficiency are you concerned about?
Vitamin B12 Vit D Linolenic acid Zinc (if >7mo) Iron Calcium (breastmilk usually not impacted, but strict vegans are usually deficient)
- After a recent Listeriosis scare, a family decides to change to a vegetarian diet. They are at risk of what nutrient deficiency?
Vitamin B12
Vit D
Linolenic acid
- An ex-28 weeker is now 9 weeks old and is ready for discharge. Does he need iron supplementation. Explain your answer.
Yes, if exclusively breastfeed needs 2mg/kg/d by 1mo until weaned to iron-fortified formula or beginning complementary foods due to premature infants have lower stores of iron and depletion of stores by 2-3mo of age
- Mom asks how to prevent poor dentition in her soon-to-be-born child. Name 3 suggestions you would give her.
- Dental assessment for infants within 6mo of their first tooth appearing and no later than 1y of age
- Wipe baby’s gums with soft, clean, damp cloth 2X/d
- Once teeth appear, use soft bristle toothbrush. Start fluoride toothpaste at 3yo.
- No milk to fall asleep. Minimize juice.
- What is the criterion for a child to be called “obese”? What is the criterion for a child to be called “overweight”?
If >=2yo, use CDC normative BMI percentiles
Overweight if BMI 85-95%tile
Obese if >=95%tile
Extremely obese if BMI >=120% of 95%tile or >=35kg/m2
If <2yo, obese if wt for recumbent length on WHO chart is >=97.7%tile
- Child with BMI over 31.
How do you calculate BMI (give formula) (1) ?
What are 5 diseases that he is at risk for (3) kg/m2
BMI = wt (kg)/ ht(m) squared
- T2DM
- Hyperlipidemia
- Metabolic syndrome
- HTN!
- OSA
- SCFE
- MI
- Stroke
- Atherosclerosis
- A mother comes in with her newborn baby and tells you that she lives out in the country where they have well water. What should she do about vitamins and fluoride? What do you tell her about each (be specific) (2)
Vit D 400 units daily
Fluoride How does fluoride prevent caries? 1. Inhibits plaque 2. Inhibits demineralization 3. Enhances remineralization of enamel
Too much fluoride leads to dental fluorosis = abnormal enamel development
- no fluoride before teeth have erupted
- Give supplemental fluoride in >6mo if
1. concentration in drinking water <0.3ppm (optimal is 0.7 ppm)
2. Child does not brush teeth at least 2X/d
3. Child high risk of caries
4. Use preparations to maximize topical effect: mouthwash, lozenges, drops, chewable tablets - Fluoride in municipal water supplies + toothpaste
List 4 criteria for cyclical vomiting syndrome.
ROME IV. ALL
- > =2 episodes in 6mo of intense, unremitting nausea + paroxysmal vomiting. Lasts hours to days.
- Stereotypical pattern for each pt
- Episodes separated by wks to months. Return to baseline health in between episodes
- After appropriate medical evaluation, Sx cannot be attributed to another illness
- 4 year old is getting NG feeds 4 boluses a day. For the last 4 days, he has been having sweating, cramping and sometimes profuse diarrhea 1 hour after feeds.
A. What is the most likely reason for dumping?
B. Name 2 pathophysiological mechanisms for why this is happening.
A. NG migrated to NJ
B.
1) Osmotic load: rapid emptying of hyperosmolar fluid into the small intestine
2) Infusion at high rate into the small intestine does not have time to be absorbed for nutrients, therefore dumping
- 13 year old, previously healthy adolescent male presents with retrosternal chest pain. He has had three months of progressive dysphagia with solids.
a. What are the two most likely causes?
b. What are three additional possible causes?
A. Most likely causes
- EoE
- Esophageal stricture secondary to GERD
B. Additional possible causes
- Achalasia
- Vascular ring
- Mediastinal mass
- Esophageal web causing intrinsic mechanical obstruction
- Aside from micronutrient deficiency and malabsorption, name 3 sequelae of short gut syndrome (3)
- Complications of long term central line access - thrombosis, sepsis
- Complications of long term parenteral nutrition - liver failure, cholestasis
- Bacterial overgrowth
- Renal stones (hyperoxalaruia secondary to steatorrhea)
- Psychosocial impact of chronic illness
- Child with CP and G-tube for 2 years, who has been growing well with it, now comes with acute abdominal pain. Name 4 “complications” (they used this wording) of indwelling enteral tubes that could explain this presentation.
- Perforation or colocutaneous fistula
- G-tube obstruction -> gastric outlet obstruction
- Bleeding
- Infection - wound, peritonitis
- Peristomal leakage
- Buried bumper syndrome (long term consequence of tight apposition of the external bolster of G-tube against abdo wall. Internal bolster of G-tube slowly erodes into gastric wall, causing pain + inability to infuse feeds)
- Child with restricted eating.
a) List 2 risk factors for refeeding syndrome:
b) List 2 electrolyte abnormalities in refeeding syndrome
A. RFs
- Weight at <80% expected weight for height
- Rapid re-introduction of nutrition
- Electrolyte abnormalities prior to reintroduction of nutrition
B. Electrolyte abnormalities
- Hypophosphatemia
- Hypokalemia
- Hypomagnesemia
- due to large surge of insulin after carbs given after prolonged period of malnutrition -> intracellular transport of key ions that are lost with malnutrition
- hallmark is severe hypophos -> weakness, rhabdo, neutrophil dysfxn, cardioresp failure, sz, altered LOC, sudden death
- A 4 year old boy has had pain and non-bilious vomiting today. An ultrasound shows an intussusception (ileo-colic). As the emergency physician, you recommend an air enema reduction. Before going ahead with the procedure, the parents want to know more about the risks of air enema reduction:
a. What are the chances of successful reduction with air enema?
b. What are the chances of a perforation with air enema?
c. What are the chances of a recurrence after air enema?
d. What are 2 contraindications to using air enema?
A. 90% successful
B. 0.1% with air enema (1% with barium or hydrostatic/saline)
C. 10% recurrence rate (5% with surgical reduction)
D. Contraindication
1. Peritonitis
2. Suspected perforation
3. Suspected bowel necrosis
4. Refractory shock
5. Suspected lead point -> multiple recurrences
- A 1 month old baby has total bilirubin of 180, conjugated bilirubin of 85. What are 5 conditions that could cause this and name the 1 diagnostic test for each condition.
Conjugated hyperbilirubinemia
- UTI - urine culture
- Galactosemia - RBC GALT enzyme analysis
- Hypothyroidism - TSH, fT4
- A1-Antitrypsin deficiency .- serum a1-antitrypsin assay
- Biliary atresia - HIDA scan, liver biopsy
- Choledochal cyst - AUS
- A 1 month old baby girl presents to the ER because she has been fussy over the last 2 days. She is afebrile, thriving, and otherwise well. On examination, you discover an abdominal mass. Name 3 NON RENAL causes for this abdominal mass.
- Neuroblastoma (most common infnatile malignancy, most common extracranial solid tumour)
- Liver hemangioma
- Intussuception
- Hepatomegaly
- Hepatoglastoma
- GI duplication cyst
Hydronephrosis (most common kidney mass in infants)
Wilms + nephroblastoma (usu 2-5yo)
10) Name 4 dermatologic manifestations of inflammatory bowel disease
- Pyoderma gangrenosum
- Erythema nodosum
- Aphthous ulcers
- Chelitis
- Sweet syndrome: acute febrile neutrophilic dermatosis (sudden onset of fever, increased WBC, tender red well-demarcated papules + plaques with dense infiltrates by neutrophil granulocytes on histology)
Look at pictures in notes
11) Name 5 vitamins/micronutrients that could be deficient in a 4 year old who is strictly vegan.
a. Why does a vegan kid need to take in 1.5x as much protein as a normal kid?
b. What is the risk of taking in so much more fiber?
5 vit/micronutrient deficiencies in strictly vegan
- Vitamin B12
- Vitamin D
- Omega 3 + Omega 6 FA. DHA, EPA, Linolenic acid
- Zinc
- Calcium
- Iron
A. Because plant protein harder to digest, therefore same total intake does not provide same quantity of essential amino acids
B. May limit intake of adequate calories and interfere with absorption of minerals.
(Constipation)
12) . A 4 year old with encopresis and infrequent, large caliber painful stools presents to your office.
a. What are 2 important parts of the physical examination?
b. You find a hard fecaloma in the rectum. What are 3 management steps for this patient?
A.
- Abdominal exam including rectal exam
- Neurological exam to see if spinal pathology
B. Clean out
- Peg 3350 or Peglyte, then maintenance
- Adequate hydration
- Regular toileting regimen
13) A child was at a restaurant 1.5 hours ago and had a hamburger + drink. Shortly thereafter, he was noted to be drooling and not tolerating his own secretions at all. You do an X-ray and find a Toonie stuck in the upper 1/3 of his esophagus. You consult GI/surgery for urgent scope + removal.
a. How soon is the soonest you can safely proceed with the removal as per anesthesia guidelines given his NPO status?
b. What are 3 indications for urgent removal of an esophageal foreign body?
A. Needs to be 8H NPO after solid foods
- clear fluids ok until procedure
- breastmilk 4H
- formula 6H
- solid foods 8H
B. Urgent removal of esophageal FB
- Esophageal obstruction (cannot tolerate secretions)
- Sharp object
- Battery
14) A 12 year old girl with Crohn’s disease has a 0.8mm renal stone obstructing her ureter resulting in a grade 3 hydronephrosis.
a. What is the most likely composition of the stone?
b. What are 2 indications for surgical removal of the stone?
c. What are 3 recommendations you could give her to avoid future stone formation?
A. Oxalate
Because chronic steatorrhea leads to calcium binding with fatty acids, leading to hyperoxaluria
B.
- Concurrent UTI (infected stone)
- Complete urinary obstruction, or partial obstruction of solitary kidney
- Symptomatic stone with unremitting pain despite analgesia
- Symptomatic stone that fail to pass after a trial of conservative therapy (2-4wks)
C.
- Adequate hydration
- Low fat diet
- Low dietary oxalate
- Maintain adequate calcium
- Reduce sodium intake
- Supplemental citrate
- Mg + Phos supplements (inhibit calcium oxalate precipitation when excreted in the urine)
15) 3-year-old boy with constipation and encopresis developed after toilet training. Otherwise unremarkable past medical history. Physical exam is normal except hard stool in the rectum. What is your acute and ongoing management? (5 lines)
Acute
1. Peg 3350 1-1.5g/kg/d clean out or Peglyte via NG clean out
Maintenance
- Peg 3350 0.5-1 g/kg/d daily, titrated as needed, for minimum 6 months
- Routine toileting using footstool
- Well balanced diet with adequate fibre
- Regular F/U with education
- Encourage exercise
- Praise, don’t punish
16) A boy with a previous liver transplant presents with a systemic illness including fever, lymphadenopathy, large red mass behind left tonsil, LAD.
a. What infectious organism are you concerned about?
b. What are three non-infectious complications that can be seen post liver transplant?
A. EBV
- most common transplant infections are EBV + CMV
B.
- Acute rejection (usually after first 2wks)
- Biliary strictures (most frequent surgical complication)
- Hepatic artery thrombosis
- Primary non-function of graft (rare in peds0
- Port vein or hepatic vein strictures/occlusions (rare)
17) 7 month old has nonbilious vomiting that was previously diagnosed as GERD. What are FIVE signs that this is not just GERD?
- Unexplained fever
- Weight loss
- Bilious emesis
- Signs of increased ICP
- Bloody stools
8) 15 yo female adolescent with LLQ pain and vomiting who states she is not sexually active. What are the three most concerning causes that you need to rule out.
- Ovarian torsion
- Bowel obstruction or perforation
- Ectopic pregnancy
- Appendicitis
19) AXR of bird’s beak
a. What’s the condition?
Bird’s peak looks like rapid tapering to a point
Achalasia (if esophagus)
Volvulus (if inferior part of right colon or sigmoid)
Pyloric stenosis
20) Teen with dysphagia, odynodysphagia with solids, name 3 differentials
- EoE
- Eosphageal stricture from GERD
- Infectious pharyngitis
- SJS/TEN
- Retropharyngeal abscess
21) Name 3 dermatological manifestations of a kid with IBD features
- Pyoderma gangrenosum
- Erythema nodosum
- Aphthous ulcers
- Sweet syndrome (acute febrile neutropenic dermatosis)
22) 14yo girl with steroid resistant Crohn’s Dx is started on azathioprine. 3 weeks later she starts complaining of epigastric pain, particularly after meals. What are two possible diagnoses?
- Peptic ulcer
- Pancreatitis (side effect of azathioprine)
- Hepatitis (AZA SE)
- Pneumonitis (AZA SE)
23) Indications to investigate abdominal pain (3)
- Nocturnal pain
- Unexplained fever
- Unexpected weight loss
24). Child diagnosed with Crohn’s disease. Was off school for 2-3 weeks, and now upon return to school, complains of abdominal pain first hour of school, and improves after going home. His Crohn’s disease is well control. (hx of separation anxiety). What counseling methods do you offer this family? (list 3)
Counselling methods
- CBT
- Biofeedback
- Guided imagery
- Relaxation techniques
If ask about Tx
- reassurance + education
- No evidence of serious underlying disorder
- Pain is real but no underlying cuase
25) 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.
- CF
- Chronic constipation
- Meningocele
- Crohn’s disase
26). A 1 week old breastfed baby comes into your office for newborn care. There is bright red blood mixed in with the stool. The baby did not have any bleeding or bruising with the Vitamin K injection at birth or with the newborn screen. The anus appears normal and there is no evidence of a fissure. List the most likely cause of the blood in the stool.
Swallowed maternal blood
NEC
Midgut volvulus
27) A teenage boy comes to your office with recurrent episodes of yellow sclera, often following an upper respiratory tract infection. Liver enzymes are normal. Direct bilirubin is low, but indirect bilirubin is 47. There is no evidence of hemolysis on a blood smear. List the most likely cause.
Gilbert syndrome
mutation in the promoter region of UGT1A1, leading to decreased enzyme activity
28). A 9 year old boy comes into your ER with severe abdominal pain and bilious vomiting. He has presented in a similar manner on 3 previous occasions in the past 2 years. List the most likely underlying diagnosis [1 point] and one investigation you would do in about 1 week when he is feeling well [1 point].
- Intermittent midgut volvulus secondary to malrotation
2. Upper GI contrast with small bowel follow through
29). A teenage girl comes to your office. She has a known history of Ulcerative colitis. One year ago she had a total colectomy with a J pouch creation. She had an ileostomy until about 6 months ago, when it was closed. Now, she presents with a two week history of bloody diarrhea up to 10 times a day and abdominal pain. Stool cultures are negative. What’s the most LIKELY diagnosis? What is the best treatment?
- Pouchitis
2. Oral metronidazole
- Baby with GERD on formula feeds. What are 4 non-pharmacological management strategies?
- Thickened feed
- Change to Nutramigen or alimentum
- Small volume frequent feeds with regular intervals. Avoid overfeeding. Burp regularly
- Provide parental education + support
- A 18 month old boy presents with acute fulminant hepatitis without neurological symptoms. What are four steps you would do for supportive management?
- Transfer to transplant centre
- Monitor liver enzymes + function test
- Monitor and treat coagulopathy (vit K, FFP, cryoprecipitate, plts)
- Protein restriction + lactulose if signs of encephalopathy
- Two life-threatening complications of ulcerative colitis
- Toxic megalocolon
- Bleeding
- Perforation
- Adenocarcinoma
- Name the 2 most important factors in increasing risk of colonic adenocarcinoma in a patient with ulcerative colitis (be specific).
- Pancolitis
- Duration of disease
- Have PSC
- Name 2 signs of portal hypertension on physical exam in a child with some liver problem.
- Splenomegaly
- Esophageal varices
- Palmar erythema, vascular telangiectasia
- Caput medusa
- Jaundice
- Ascites
- Child with chronic diarrhea and weight loss. Name 4 possible diagnoses of hypoalbuminemia.
- Nephrotic syndrome
- Protein losing enteropathy
- Liver failure
- CHF
- Malignancy
- Malnutrition
- IBD
- Celiac disease
- Neonate on TPN. List four things that will increase his incidence of cholestasis.
- TPN for >2wks
- Low birth weight or preterm
- Complicated medical course
- Higher dose of carbs
- What 4 screening tests would you order in a child with suspected celiac disease?
- Anti TTG _serum IgA
- Anti EMA
- Iron studies
- CBC
- Infant has problem of vomiting with feeds and chronically wheezy. Upper GI shows indentation of upper esophagus. What are two diagnoses you consider (2)?
- Vascular ring/anomaly
2. Mediastinal mass/tumour
- Child with FTT, abdo distention, wasted limbs and buttocks, irritable. Diagnosed with Celiac disease.
List 4 other causes of small intestinal flat villi besides celiac dz.
Name 3 atypical presentations of celiac disease.
List 2 conditions that are associated with celiac disease.
A. Small intestinal flat villi
- Crohn’s disease
- Cow’s milk enteropathy
- Soy protein enteropahty
- Autoimmune enteropathy
B. Atypical presentations of celiac disease
- Refractory Fe deficiency anemia
- Osteoporosis/osteopenia
- Dental enamel defects
vs.
- Silent: pos histology, but no Sx.
- Latent: at some point had gluten-dependent enteropathy, but normal histology
- Potential: positive celiac disease serology but normal histology. +/- Sx
C. Associated conditions
- T1DM
- Selective IGA deficiency
- Autoimmune thyroiditis
- Down syndrome
- William
- Turner
