GI (Seth's Additional info) (10%) Flashcards
MCC of appendicitis in kiddos
lymphoid hyperplasia d/t infection
when does vomitting happen with appendicitis?
AFTER pain (as a result of the pain basically)
when does pain from appendicits radiate to the RLQ?
Once the parietal peritoneum becomes irritated
Explain obturator sign
RLQ pain with internal & external hip rotation with flexed knee
explain psoas sign
RLQ pain with right hip flexion/extension (raise leg against resistance)
Imaging of choice for appendicitis in kiddos
US
followed by surgical consult
what is colic 2ndary to GI problem? When is there relief?
Sudden onset of loud crying (paroxysms may persist for several hours) with facial flushing & circumoral pallor
* Abdomen is distended, tense – legs drawn up
* Temporary relief with passage of feces or flatus
MC age of colic
< 3 months old
Management of colic
Symptomatic as it goes away
Burping, proper feeding, exam to r/o other causes
Constipation is not having a bowel movement after ____ days or ____/week
3 days
or <2/week
or s/s of constipation
An outlet delay etiology for constipation makes you think of
Hirschsprung’s disease
Overview of management of constipation
Fiber, water, bulk forming laxatives, osmotic laxatives, stimulant laxatives
MOA of fiber
retains water & improves GI transit
What are the bulk forming laxatives?
Think the names of things that are bulky (wheat/sugar names)
Psyllium, Methylcellulose, Polycarbophil, Wheat dextran
MOA of bulk forming laxatives
absorbs water & increases fecal mass –↑ frequency & softens the stool consistency w/ minimal effects
What are the osmotic laxatives?
polyethylene glycol (PEG, mirilax), lactulose, sorbitol, saline laxatives (milk of magnesia, magnesium citrate)
can cause hyperMg
think milk / mg2+
MOA of osmotic laxatives
causes H2O retention in the stool (osmotic effect pulls H2O into gut)
What are the stimulant laxatives?
Bisacodyl, Senna
busy senna is stimulated
MOA of stimulant laxatives
increases acetylcholine-regulated GI motility (peristalsis) & alters electrolyte transport in the mucosa
all of the laxatives may cause bloating/flatulence, but stimulant lax (busy senna) may cause ____
diarrhea
think of the MOA of increasing gut transit
what is the % bw loss of the following lvls of dehydration?
mild:
mod:
severe:
mild: 3-5%
mod: 6-9%
severe: 10%+
memorize mod, then the others are just above or below
cap refill for the following lvls of dehydration
mild:
mod:
sev:
mild: <2 seconds
mod: 2-3 seconds
sev: 3+ seconds
what is the double bubble sign seen in
Duodenal Atresia
what is the pathophy of duodenal atresia?
complete abscence or closure of a portion of the duodenum, leading to a gastric outlet obstruction
what is the presentation of duodenal atresia upon birth?
bilious vomitting paired with abd distension
diagnosis of duodenal atresia
abd xray showing double bubble
upper GI series preop to assess GI tract
what is the structure that seperates bilious from nonbilious vomitting?
Ampulla of vater
of the descending duodenum
at or distal = bilious
what exactly is the double bubble sign?
distended air-filled stomach + smaller
distended duodenum separated by the pyloric valve
Intial management of duodenal atresia
decompression of GI tract + electrolyte and fluid replacement
definitive mng of duodenal atresia
Duodenoduodenostomy
what is encopresis?
Repeated passage of feces into inappropriate places (clothing or floor) whether involuntary or intentional
typically d/t anx causing overflow incontinence from chronic constipation
minimum requirement to be dx with encopresis
age
frequency
4+ yo
once a month for 3 months
is encopresis mc in males or females
males
associated with ADHD and conduct d/order
Mng of encopresis
behavorial and r/u other etioligies
MC age for FB ingestion
6 months - 3 yo
once beyond the ____ objects typically pass but with an increased risk of complications such as bowel obstruction,
perforation, erosion to adjacent organs – abdominal pain, N/V, fever, hematochezia, melena
esophagus
imaging for inhaled FB
bronchosopy if not seen on xray
mng of FB in esophagus with no s/s and known time of ingestion
1) observe for 24 hr with serial xray
2) remove obj with endoscopy if it does not pass into the stomach by 24 hours
what point should a FB be immediately removed with endoscopy (4)?
____ time of ingestion
____ s/s
the object is a ___ or _____
1) unknown time of ingestion
2) ANY s/s
3) battery
4) sharp obj
when would you NOT need to remove a battery ASAP?
if it is distal to the pylrous (in the small intestine basically)
same for any obj
an asympomatic small blunt obj in stomach should be monitored for ___ days but should be removed if it does not pass the pylorus by then
21-28 days (3-4 weeks)
if an obj is this size ___ it should be removed endoscopically if in the stomach
> 3 cm
monitor w/ serial imaging if beyond pylorus
same management as a sharp obj!
t/f you should induce emesis immediately if a patient consumed acid/alkali
FALSE
ABCs
Abrupt onset of watery non-bloody diarrhea, abdominal cramping, vomiting
E coli
probs traveling
MCC of gastroenteritis in adults in NA
norovirus
fecal-oral and just hydrate
dem cruiseships
t/f although vomitting is common, the predominant symptom for norovirus is diarrhea
FALSE
vomitting is
diarrhea non-bloody, watery, and no leukocytes
Rotavirus is MC in
young unimmunized children between 6 months – 2 years of age
MC outbreak of rotovirus
daycare
common cause of diarrhea outbreak here
why do we vaccinate for rotovirus?
more severe s/s in childhood (still nonbloody diarrhea)
dx of rotovirus
PCR
common food ingested that cause staph GE
think dairy/eggs at room temp
egg salad picnic = buzz phrase
dairy, mayo, meat, egg, salad
MC symptom of staph poisoning
vomitting
somtimes diarrgea
Abx treatment of staph poisoning
NONE
symptomatic fluid replacement
gottem ;)
MCC of traveler’s diarrhea
E coli
how do you typically get an E coli poisoning?
Contaminated food & water
dx of e coli GE
Gram-stain & cultures
it’s a bacterium
MCC of bacterial enteritis
Campylobacter Enteritis
ricewater stools
V cholerae
copious watery diarrhea = “rice water stools” (gray with flecks of
mucus & has a “fishy odor” but no fecal odor, blood or pus)
V cholerae GE is gram ____
negative
what typically causes a v cholera outbreak
contaminate food/water (shellfish)
poor sanitation and overcrowding
Pathophys of v cholera
exotoxin causing secretory diarrhea leading to profound dehydration
dx of v cholera GE
PCR or stool cultures
typically mng of V cholera is symptomatic like most nonbloody diarrhea, but consider these abx:
tetracyclines (-cycline)
typically if severe illness, comorbid conditions, or high fever
MCC of death from seafood consumption in US
V. vulnificus: gastroenteritis, necrotizing fasciitis, cellulitis
test of choice for C diff
C. difficile toxin (stool)
what might sigmoidoscopy show for c dif?
psedomembranosus
apart from vanc, ___ can be used for c dif
metroniadozle (flagyl)
the go to for recurrence of c dif is vanc, but after ____ recurrences, consider _____
3 recurrences
fecal microbiota transplant
this GE mimics appendicitis
Yersinia Enterocolitica
your son has appendicitis
MCC of Yersinia Enterocolitica
contaminated pork
poultry
complication of Yersinia Enterocolitica
mesenteric lymphadenitis
treatment of Yersinia Enterocolitica
Fluid & electrolyte replacement mainstay of treatment
Severe: Fluoroquinolones, Bactrim
MC antecedent event in post-infectious Guillain-Barre syndrome
Campylobacter Enteritis
camping near the bar
MCC of Campylobacter Enteritis
eating undercooked turkey
upon stool culture of Campylobacter Enteritis, you will see oragnisms with this buzzword
gram-negative, “S, comma or seagull shaped” organisms
mainstay of mng of Campylobacter Enteritis like most diarrhea is fluid replacement - but consider these abx
erythromycin
my son is camping
what bacterial GE can lead to GI hemorrage?
in the name
Enterohemorrhagic E. Coli O157:H7
MC age of Enterohemorrhagic E. Coli O157:H7
extremes of age (old/young)
Abx for Enterohemorrhagic E. Coli O157:H7 are ____
CONTRAINDICATED
may lead to HUS d/t release of shiga-like toxins
only Bactrim is an option, but firstline is **fluid replacement **
pea soup diarrhea is seen in ___
also, you often see _____ in this condition
typhoid/ enteric fever
rose spots/ salmon colored spots from trunk to extremeitis
green and non-bloody paired with bradycardia and fever
Abx for typhoid fever are
-floxacin
oral rehydration is the go to
MCC of foodborne disease in US
nontyphoid salmonella
classic diarrhea of salmonella
also peasoap (more brown/green though and may be bloody)
MC type of shigellosis seen in US
Shigella sonnei
fecal oral and highly virulent
How does shigella affect the host
Highly virulent - “Shiga” toxin that is neuro, entero, and cytotoxic
fecal oral
Explain the classic s/s of a shigella infection
Lower abd pain
explosive watery diarrhea that progress to mucoid and bloody
febrile seizures
classic CBC finding of shigella
Leukemoid reaction showing WBC > 50k
treatment of shigella
like everything, fluids + electrolytes and abx if severe
what is heartburn aka?
pyrosis
gs dx of typical GERD
24-hour ambulatory pH monitoring
gs dx of GERD with alarm symptoms
endoscopy
MC sex for autoimmune hep
female
young women
Autoantibody findings of autoimmune hep type 1
positive ANA and smooth muscle antibodies
Autoantibody findings of autoimmune hep type 2
anti-liver/kidney microsomal antibodies,
increased IgG
treatment of autoimmune hep
Corticosteroids 1st line
also can do: CS + Azathioprine, or 6-Mercaptopurine
suddenly, your patient has jaundice, URI symptoms, and a decreased desire to smoke - you are thinking ____ so you decide to treat with _____
Acute viral hep
Conservative mng
what type of condition is Rey’s syndrome and what is the typical history?
fulminant hepatitis in children given ASA after a viral infection
explain the s/s of Rey’s syndrome
rash of hands + feet
vomiting
liver dmg
encepholpathy
dilated pupils
multi organ failure
hypoglycemia (hepatic gluconeogensis)
increased ammonia (encepholapthy)
treatment of reye syndrome
symptomatic
definitive = liver transplant
Hirschsprung Disease is a congenital _____ d/t absence of ____, leading to a functional obstruction
megacolon
ganglion cells
Hirschsprung Disease is a failure of complete____ migration leads to an absence of ________ (Auerbach & Meissner plexuses), which leads to failure of relaxation of the aganglionic segment & subsequent functional obstruction
neural crest
enteric ganglion cells
what is a key finding of Hirschsprung Disease during the first couple days of life?
Neonatal intestinal obstruction: meconium ileus (failure of meconium passage 48+ hours) in a full-term infant
leads to Bilious vomiting, abdominal distention, no stool in rectal vault, failure to thrive
(Abdominal distention → decreased blood flow → deterioration of mucosal barrier → bacterial proliferation →..)
What does a contrast enema show for Hirschsprung Disease?
transition zone (caliber change) between normal & affected bowel
helpful for sx planning
what can you use as a screening test for Hirschsprung Disease and what does it show?
Anorectal manometry: as a screening test (measures anal sphincter pressure); increased anal sphincter pressure & lack of relaxation of the internal sphincter with balloon rectal distention
definitive dx of Hirschsprung Disease
rectal biopsy
mng for Toxic Megacolon
bowel rest, bowel decompression w/ NG tube, broad-spectrum antibiotics (Ceftriaxone + Metronidazole),
fluid & electrolyte replacement
what type of hernia is most often d/t a patent process vaginalis?
indirect inguinal
Hessel bach’s triangle is associated with a ___ hernia and is comprised of _____
direct inguinal hernia
RIP
rectus abdominus
inferior epigastric vessels
pouparts (inguinal) ligament
when is surgical repair indicated for congenital umbilical hernia?
at 5+ yo
usually resolves by 2 yo
MCC of bowel obstruction in children 6 months to 4 yo
intussception (telescoping of proximal intestinal segment into adjoining distal lumen → bowel obstruction)
MC location of intussuception
ileocolic junction
MC etiology of intussception
idiopathic
Classic triad of intussception
vomiting + abdominal pain + passage of blood per rectum
“currant jelly” stools
for intussception, on PE you feel a _____ shaped mass in the _________or hypochondrium
sausage-shaped
right upper quadrant
what do you feel in the RLQ of intussecption and why?
emptiness (Dance’s sign)
d/t telescoping of bowel that is no longer there
____ is the preferred intial test for intusseception which shows ____
US
donut/target sign
Pneomatic dilation and fluid/electrolyte correction is typically preferred for intussception, but _______ is diagnostic and theraputic
air or contrast anema
what is normal, physiologic jaundice of a newborn
seen on days 3-5
decrease in UGT (enzyme that conjugates bilirubin)
breast milk / feeding jaundice - should still breast feed0
when are you worried about pathologic jaundice?
within first 24 hours
persists 10-14+ days
increase in bilirubin daily
what bilirubin lvl do you see jaundice?
5+
what is kernicterus?
cerebral dysfunction and encephalopathy due to bilirubin deposition in brain tissue – can manifest as seizures,
lethargy, irritability, hearing loss, mental developmental delays
what bilirubin lvl do you see kernicterus?
20+
initial management of pathologic jaundice
phototherapy to conjugate the bilirubin
Four Ds of Dubin Johnson syndrome
Dubin
Direct bilirubinemia (isolated)
Dark liver (dx)
Don’t need to treat (avoid triggers)
Dubin Johnson syndrome is hyperbilirubinemia d/t decreased hepatocyte excretion of conjugated bilirubin d/t gene mutation _______.
MRP2
Pathophys of Crigler-Najjar Syndrome and what type of bilirubin prob it leads to
no UGT activitiy leading to to uncongugated (indirect) hyperbilirubinemia
no mng needed
inheritance of Crigler-Najjar Syndrome
autosomal recessive
spells CAR
what is the difference between Gilbert Syndrome and Crigler-Najjar Syndrome
very sim, but there is just reduced UGT activity
transient episodes of jaundice during periods of stress, fasting, alcohol, or illness
test of choice for lactose intolerance and what it shows and why
hydrogen breath test showing presents of hydrogen
hydrogen produced when colonic bacteria ferment the undigested lactose
Abd US for pyloric stenosis
“double-track”
barium GI series of pylroic stenosis (2)
String sign (thin column of barium through narrow pyloric channel), delayed gastric
emptying
Railroad track sign: excess mucosa in the pyloric lumen → 2 columns of barium
what vitamin is niacin/nicotinic acid?
B3
sources of niacin
meats
grains
legumes
3 Ds of niacin deficiency
dermatitis (photosensitivity)
diarrhea
dementia
overall functin of vitamin A
HIVES
Hematopoiesis
Immune function
Vision
Embryo dev
Skin/cellular health
Sources of vit A
Kidney/liver
Yolk
Leafing greens
common presentation of vitamin A def
Night blindness (or other ocular manifestation)
Impaired immunity
Squamous metaplasia
Bilot’s spots
think of HIVES
What are bilot’s spots?
white spots on the conjunctiva due to squamous metaplasia of the corneal epithelium
assocaited with metaplasia 2ndary to vit A def
3 H’s of scurvy (vit C def)
Hyperkeratosis (hairs with hemorrage)
Hemorrhage: vascular fragility of gums/skin/wound
Hematologic: anemia/ etc
most accurate dx of vit C def
Leukocyte ascorbic levels more accurate than serum ascorbic acid
Ricket’s is vit ___ def
D
presentation of Vit D def leading to osteomalacia
BONE ISSUES
asympomatic at first, but then
osteomalacia
bone pain/tenderness
bowing of long bones
decreased calcium/ phosphate / 25-hydroxyvitamin D levels
XR: **looser lines **and psedofractures
treatment = vit D with (Ergocalciferol)
presentation of Vit D def leading to rickets
3 months - 3 yo (need a lot of Ca2+ at this age)
can be d/t phophate wasting (Fanconi syndrome)
Delayed fontanel closure
genu varum (lateral bowing of femur and tibia)
XR costochondral junction enlargament
long bones with** fuzzy cortex**
decreased calcium/ phosphate / 25-hydroxyvitamin D levels
Vit D supplementation with (Ergocalciferol)
