GI2 Flashcards
What are 3 steps to management of chronic constipation?
- complete evacuation of colon via use of oral stool softeners
- sustained evacuation via a regular stooling schedule, high fiber diet, oral stool softeners
- weaning of stool softeners as rectal tone recovers with continued stooling schedule and dietary management
Recurrent small pellet stools vs Infrequent massive stools - > what mechanism does it suggest
Recurrent small pellet stools - incomplete evacuation
infrequent massive stools - functional decal retention
Distal GI obstruction : abdo distention, narrow stool caliber, lack of encopresis
What age group is most likely to present with intusseption?
Oski says: most common in toddlers, intermittent episodes of severe generalized abdo pain, leathery may be a prominent finding
sausage shaped palpable RUQ mass, currant jelly stools - late finding
Nelson says - most common obstruction 3 month -6 year, most common abdo emergency in <2 year old
3 infectius aetiologies of esophagitis in immunocompromised patients?
Oski says:
- candida
- HSV
- CMV
also think of neutropenic enterocolitis (typhlitis), GVHD in immunocompromised patients with abdo pain
True or false - giving a patient with severe acute abdo pain morphine will interfere with your ability to establish the correct diagnosis
false - it should not interfere with your ability to establish the correct diagnosis
What is the most common cause of chronic and or recurrent abdominal pain in children?
functional abdominal pain - when no organic disease that explains the symptoms
Rome 3 criteria - categorizes functional abdo pain into 4 different disorders
- functional dyspepsia - above umbilicus, not better with poop, stool no change
- IBS: relieved by defecation, change in frequency or type or stool
- childhood functional abdo pain: episodic or continuous abdo pain, decreased activity, often other somatic complaints
- abdo migraine : paroxysmal episodes, >1 hour, in between normal, pain interferes with normal activities
can have other symptoms of migraine also (anorexia, nausea, vomiting, headache, photophobia)
Name other major causes of chronic or recurrent abdo pain in children?
functional abdo pain, lactose intolerance, constipation, MSK pain, parasites, reflux esophagitis, H. pylori gastrictis, PUD, mesenteric lymphadenitis, IBD (in order of prevalence)
What are two clinical signs of upper GI bleed?
- hematemesis
2. melena
What is the main clinical sign of lower GI bleed?
hematochezia (bright red blood from the bum)
How to tell the difference between upper and lower GI bleed ?
NG lavage - upper GI bleed - bloody, with lower GI will be clear
What is the best indicator of significant acute blood loss?
orthostasis is the best indicator of this
hematocrit is not a reliable indicator of acute blood loss
occur blood loss can lead to iron deficiency anemia - (low MCV, high RDW)
What is the Apt test?
used in neonates to determine the possibility of apparent GI bleeding
what it is : looks at the difference between maternal and fetal Hg (can be used prenatal too)
+ve means that it is baby’s blood, -ve means that it is mother’s blood 9Ie swallowed)
Two most common causes of bloody stools in infants <6 months?
- milk protein allergy
2. rectal fissure
Difference between lower GI bleed with abdo pain and without abdo pain?
with pain - intussuseption
without pain - Meckel’s
intestinal bleeding - late sign of obstruction
Differential diagnosis for rectal pain in children
hemorrhoids, anal fissure, infections (GAS dermatitis , tx with penicillin, bacterial abscess, pinworms), foreign body, rectal prolapse (CF), inflammatory (proctitis), IBD +-perianal fistula, neoplasm, trauma)
What is the scientific name and treatment for pinworm?
Enterobius vermicularis
can do the tape test
present with rectal itching
treatment is mebendazole
normal liver size in newborns? in children?
<2 cm in chilren
normal span: 4-5 cm in infants, 6-8 cm in oler chilren
True or false biliary atresia can result in hepatomegaly?
true - leads to a cholestatic picture - TPN cholestasis, choledochal cysts and CF can also lead to cholestasis and hepatomegaly
interestingly also malnutrition can lead to hepatomegaly in infants (Oski table 12.8)
Which test is more specific for hepatocellular injury, ALT or AST?
ALT is more specific for hepatocellular injury than AST
Patient with hepatomegaly, normal bill, and splenomegaly? Differentail diagnosis and investigations
CBC and abdo US DDx: 1. storage diseases 2. leukemia 3. lymphoma 4. CHF 5. parasitic infections
Patient with hepatomegaly, normal bill, no splenomegaly. Differential diagnosis and investigations?
abdo US< serology, +/- liver biopsy
DDx:
- autoimmune/viral hepatitis
- infectious liver cysts/abscesses
- glycogen storage disease
- primary/metastatic tumours
- obesity/steatohepatitis
patients with hepatomegaly, hyperbilirubinemia, mainly unconjugated. Differential diagnosis?
OSKI says table 12.9
- Hemolysis
- sepsis
- DIC
- coagulopathy
- CHF
(not sure if all of these will cause haptometagly, discuss)
patient with hepatomegatly, elevated conjugated bilirubin, elevated transminases and slightly elevated ALP?
inv:; viral serology, ceruoplasmin (low in Wilson), consider liver biopsy DDx: 1. hepatitis 2. Wilson 3. Drugs/toxins
patient with hepatomegatly, elevated conjugated bilirubin, slight elevated transminases and greatly elevated y elevated ALP?
U/S or cholangiography (i.e. think obstruction)
DDx:
- biliary obstruction
- choledochal cyst/tumours
- parasitic infections
- parenteral nutrition
What type of hyperbili in alpha 1 antitrypsin
direct (i.e. conjugated) according to OSKI
most common of unconjugated hyper bill in non neonate?
Gilbert disease - mildly impaired bill conjugation in 5-10 % of the population
type of hyperbili in viral hepatitis?
direct and indirect hyperbili?
1st choice of imaging for direct hyperbili?
U/S first, further studies may in code CT, MRI, cholangiography, HIDA scan, hepatobiliary scintigraphy
Which type of TEF is the most common?
type A - proximal blind pouch with fistula connecting distal esophagus to the trachea(note that picture in Oski is not totally perfect)
Which type of TEF is more likely to present later in life?
type C - H type fistula (otherwise intact trachea and esophagus, more likely to present like aspiration
True or false - achalasia is common in young children
false - only 5% in children under 5 years old
loss of LES relaxation leading to high resting LES pressure and absent or non peristaltic oesophageal contractions
clinical: vomiting, regurg, dysphagia
dysphagia with solids then liquids as the disease progresses
An upper GI shows a bird beak appearance, what diagnosis do you think about
ahalasia
gold standard for diagnosis is manometry
Tx: balloon dilataion or surgical myotomy of LES
True or case - Premies are more likely to have GERD
true
What are some risk factors for GERD in older children and adolescents
obesity
tobacco/alcohol/drug use
anatomic abnormalities - ie hiatal hernia
neuro impairement
True or false - upper GI can diagnose reflux
no, it is done to look for anatomic abnormalities
other tests:
- esophageal pH monitoring - help with acid reflux, not with non acid reflux
- impedance probe- newer modality, detects any fluid in the esophagus
endoscopy -anatomic abnormalities, GERD related esophagitis
What is Sandifer syndrome?
rare but classic in infants
GERD and sterotypic repetitive stretching and arching movements
True or false - putting a baby in an infant seat can help reflux
No! apparently its bad and no longer recommended
What are 3 consequences of inadequately treated severe GERD
- esophageal strictures
- Barrett’s esophagitis
- adenocarcinoma
What are 4 types of esophagitis commonly encountered
- eosinophilic esophagitis
- infectious esophagitis
- pill esophagitis
- corrosive esophagitis - ingestion of caustic substances
What will the test results be in eosinophilic esophagitis
increased eosinophils and igE
endoscopy with biopsy - >15-20 eosinophils/hpf
treatment: eliminate inciting foods, steroids (topical?)
occurs mostly in males, presents with vomiting, chest/epigastric pain, strictures, dysphasia, associated with atopy and food allergies
What are the most common pathogens associated with infectious esophagitis?
- candida
- HSV
- CMV
rarer caues include: VZV, diphtheria, other bacteria
presentation: fever, dysphagia, odynophagia and retrosternal pain
candidal esophagitis, often associated with oral candidiasis
**if have oral candidal lesions, can try treating with oral fluconazole, otherwise need to do endoscopy with biopsy
What is pill esophagitis
meds with inadequate fluids, pill lodges in the oesophagus
doxycycline and other tetracycline derivatives are commonly associated
dx: odynophagia, retrosternal pain
tx: antacids and bland liquid diet until symptoms resolve
What are some causes of perforated oesophagus?
iatrogenic - endoscopy, NG/OG tube, suctioning
BOerhaave syndrome - increase in pressure from vomiting
blunt trauma
What to do if X rays are normal (looking for free air/pneumomediastinum) but high degree of suspicion for esophageal perforation
esophagram with water - soluble contrast
management: NPO, gastric drainiage, broad spectrum Abx, if large need surgery
Patient with known esophageal varicose presents with upper GI bleed. What to do?
present with hematemesis and/or melena
confirm via endoscopy
ABCs
octreotide
endoscopic - sclerotherapy, band ligation and/or thrombin injection
mechanical intervention - Sengstaken-Blakemore tube
severe or recurrent bleeding (vatical) may need surgery or shunt or liver transplant
Prevention: include sclerotherapy and beta-blockers
Age group for pyloric stenosis?
peak age >3 weeks of age, can present as early as 1 week or as late as 5 months
Risk factors for pyloric stenosis
male first born white \+ve family history erythromycin exposure
Risk of not correcting the alkalosis before surgery
risk of apnea
metabolic abnormality is hypochloremic, hypokalemic metabolic alkalosis, electrolytes are often normal
What is the cause of most primary PUD?
healthy, usually associated with H. pylori (low SES, crowding, poor hygiene), duodenal in origin
conditions with increase the risk of PUD:
- alcohol/caffeine/tobacco
- gastrostomy tubes
- NSAIDS
- burn injuries
- systemic illnesses
Cause of secondary PUD?
usually gastric, caused by underlying disorder including hypergastrinemia and Zollinger-Ellison syndrome
Clinically, how to tell the difference between gastric and duodenal ulcers?
gastric - pain worse with meals (especially spicy foods, caffeine)
duodenal - pain is better with meals
complications: bleed, perforation, obstruction
What is the gold standard for diagnosis of H pylori?
gold standard - biopsy
noninvasive tests stool antigen testing and urease breath test (low specificity)
What is Zollinger-Ellison syndrome
severe refractory PUD
autonomous gastrin secretion by a gastrinoma
often associated with MEN type I. recurrent, multiple atypically located ulcers and treated with PPI and octreotide to inhibit tumour growth
Name 5 anomalies/conditions associated with duodenal atresia?
Down syndrome congenital heart disease TEF malrotation renal anomalies
Where is the cecum in malrotation
in the RUQ
therefore fixes the mesentery on a narrow base
small bowel at increased risk for twisting on the pedicle of mesentery (volvulus)->leads to compromised bowel vascularity, may lead to schema and necrosis
>90% present in the first year of life
What is the embryonic origin of Meckel diverticulum?
remain of the embryonic yolk sac from the failure of the omphalomesenteric/vitelline duct to involute
1-3% of the population
most have ectopic gastric mucosa with secrete acid - leads to ulceration and bleeding of the adjacent intestinal mucosa
**can present with bleeding painless (most common), can also present with intussusception or volvulus
Rule of 2s for Meckel divericulum
2% of infants
2inches in size
2 feet from ileocecal valve
detected in patients <2 years old
Age group of intussusception
3 months to 3 years
Most common cause of intusussception
usually idiopathic or related to hypertrophied Peyer patch (which are LN) (following viral illness)
In an OLDER child (not in the typical age group): think more of a specific lead point - i.e. Meckel, lymphoma, polyp
What sign on abdo U/S may suggest intussuseption on abdo U/S or AXR?
target/crescent sign
gold standard is an air or contrast enema
observation for 24-48 hours is key
Causes of ileum
infection
gut manipulation - ie surgery
metabolic abnormalities - hypercalcemia, hypokaelmia, acidosis, uremia and medications (ie loperamide, narcotics)
treatment: depending on aetiology - most resolve
ng decompression can help reliever symptoms
A patient with CF presents with recurrent episodes of partial/complete intestinal obstruction due to thick intestinal contents. what condition do you think of?
distal intestinal obstruction syndrome
A teenage boy is in a body cast after orthopaedic surgery and starts vomiting with severe abdominal pain . What is the likely diagnosis?
SMA syndrome
rare but series problem - occurs when SMA collapses onto and compresses the duodenum
rapid weight loss can lead to the SMA fat pad loss, predisposes the patient to SMA syndrome, especially in the supine position
True or false - Crohn’s disease affects males and females equally
true - in contrast, UC is more common females
Which is more common, Crohn’s or UC?
Crohn’s more common
Which is more likely to have GI bleeding? UC or Crohns?
UC more likely bleeding, Crohns more likely nausea and vomiting
Most common region involved in Crohn’s disease?
ileocolic (mouth to anus)
vs us is the colon
Name extraintestinal manifestations of Crohn’s disease?
extra intestinal more common in Crohn’s
- spondyloarthropathy
- aphthous ulcers
- erythema nodosum
- pyoderma gangernosum
- uveitis
- primary sclerosing cholangitis
in UC, extra-intestinal is rare, pyoderma gangernosum and primary sclerosing cholangitis more common in US
True or false both Crohn’s and UC are associated with toxic megacolon?
false - UC is strongly associated, no association with Crohn and toxic megacolon
True or false, both Crohn’s and UC have same increase in risk of cancer?
nope, UC increases the risk way more, crown’s does slightly
pANCA more likely in Crohn’s or UC?
more likely in UC
What is the treatment for Crohn’s disease
(depends on location and severity)
Medical - steroids, mesalamine, sulfasalazine, azathioprine, methotrexate, infliximab (in order of increasing disease severity)
Surgery: for refracory and/or severe localized disease; surgical intervention also often needed for strictures and fistulas
Treatment of UC
medical - similar to Crohn;s
Colectomy is CURATIVE for severe and/or refractory disease
Name 5 conditions associated with celiac disease
DM1 Down syndrome Turner syndrome autoimmune thyroiditis IgA deficiency
usually presents age 2-3 can present at any age
gluten in wheat and related grains such as rye and barley
Symptoms and Signs of celiac disease (table 12.11 Oski)
symptoms: FTT, weight loss, diarrhea, irritability, vomiting, anorexia or increased appetite, foul-smelling bulky stools, abdo pain adn/or distention, rectal prolapse
Signs: height <25th percentile, wasted muscles, abdo distention, edema, finger clubbing
Please name some non intestinal manifestations of celiac disease
osteopenia/osteoporosis short stature (weight decreases before height) delayed puberty anemia arthritis hepatitis dermatitis herpetiformis dental enamel hypoplasia brain calcifications neuro sx
Test for celiac disease
TTG - very specific
can be falsely negative with IgA deficiency
antigliadin antibodies - NOT useful because of low sensitivity and low specificity
t definitive dx : biopsy with villous atrophy
Main Ddx that is often confused with celiac disease
autoimmune enteropathy (often misdiagnosed as celiac)
true or false - congenital lactase deficiency is common
false - it is actually very rare
Clinical findings in malabsorption
diarrhea, steatorrhea, abdo distention, flatulence, poor growth
can lead to vitamin deficiencies
decal fat will be elevated
true or false diarrhea is present even in early lactose intolerance
false - usually presents with abdo pain and/or distention
best way to establish diagnosis - improvement with lctose-free diet and worse with lactose foods
tests include the breath hydrogen test, lactose tolerance test - too sensitive, common to have lots of case positives
What is absorbed in the different parts of the bowel
proximal small bowel - protein, carbs, some vitamins (fat soluble)
distal ileum B12
colon - absorb water
What are some common causes of shot-bowel syndrome
bowel resection - ischemic injury from NEC, malrotation, trauma etc
Congenital causes: multiple atresias, gastroschisis etc.
Treatment for hemorrhoids
internal - above the dentate line - correct the aetiology, sclerosis therapy, band ligation
external - reassurance and proper anal hygiene
How many imperforate anus are associated with other anomalies
50% Vertebral anomalies Anal anomalies Cardiac TEF E Radial displasia, renal anomalies Limb abnormalities
4 causes of rectal prolapse
usually idiopathic
can be associated with:
infections, malnutrition, IBD, chronic constipation
usually painless until chronic and/or ulcerated
treatment: correct underlying cause, reduce it and cauterization
A patient with RLQ pain and history and physical suggestive of appendicitis has a positive urinalysis, what is the problem?
in fact, it is likely still appendicitis - when appendix is inflamed and presses on the bladder, the bladder can get inflamed too - don’t get fooled
How does Hirschprung present n an older chip?
with long-standing and/or refractory constipation
most common presentation is in the neonatal period with failure to pass meconium
What is Rovsing sign
press on LLQ leads to pain in RLQ
Psoas sign
pain on extension of the right hip
Obturator sign
pain on internal rotation of the right hip - inflamed appendix in the pelvis
Treatment for already perforated appendix in stable patient
IV abx, drainage of abscess if present (debate about interval appendectomy)
What is annular pancreas
it is due to incomplete rotation of the ventral pancreatic bud
associated with :
polyhydramnios, Down syndrome, intestinal atresia, imperforate anus and malrotation
Presents as bowel obstruction, pancreatitis or biliary colic
most specific test for pancreatitis?
lipase >3 x normal
treatment is NPO and IvF and IV analgesics, slowly reintroduce diet
Recurrent pancreatitis - what investigations should you do?
lipid
calcium, phosphorus, bili
can consider imaging - US CT MRCP/ERCP
Medications which can cause pancreatitis
acetaminophen, alcohol, steroids, valproic acid, lasix
viruses which cause pancreatitis
enterovirus, EBV, hepatitis A/B, influenza, mycoplasma, mumps
Anatomical problems that cause pancreatitis
panceatic divisum (common)
annular pancreas
biliary tract malformations
gallstones
Systemic disease that cause pancreatitis
CF, DM, organic academia, SLE, hyperlipidemia
2 disease with pancreatic insufficiency
- Schwachman-Diamond - AR, pancratic insufficiency, neutropenia, metaphyseal dystosis, FTT, shot stature
- CF - 85% -90% have insufficiency by age 1 year
Pancreatic tumours in children - common or rare?
very rare
remember VIPoma - non alpha cel pancreatic tumours, secret VIP
watery diarrhea, hypokalemic metabolic acidosis
lab: increased VIP in blood
resection and octreotide
Complications of pancreatitis
hemorrhage
pseudocysts
U/S for diagnosis
Which vitamin K dependant factor is the most specific for liver injury?
factor VII - shortest half life
because the liver needs to make the clotting factors
Markers of hepatic synthetic dysfunction
prolonged PT/INR
hypoalbuminemia
hypoglycemia
Marker of hepatic clearance dysfunction
hyperammonemia
Ture or false- all patients with autoimmune hepatitis have autoantibodies on presentation
false - 20-30% don’t have autoantibodies on presentation
can present insidious or acute hepatic failure
2 types
What are some disorders associated with type I autoimmune hepatitis
tyroiditis, IBD, arthritis, rash, hemolytic anemia
