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545 > Week 9: GI, endo > Flashcards

Week 9: GI, endo Flashcards

1
Q

What is the definition of diarrhea?

A

WHO: 3+ loose or liquid stools/day OR more frequent than normal

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2
Q

DIARRHEA

what is the most common cause of infectious diarrhea worldwide?
-what is the most common cause of acute gastro (medically attended)?

A

Rotavirus most common worldwide

norovirus #1 for gastro

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3
Q

what is timeline for:

  • acute diarrhea
  • persistent diarrhea
  • chronic diarrhea
A

acute: sudden onset and resolution within 2 weeks
persistent: acute onset lasting >2 weeks, <1 month
chronic: lasts 30 days or more, associated with specific cause eg IBD

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4
Q

Common causes of acute diarrhea

A
  • viral gastro (esp rotavirus): preceding URTI symptoms, vomiting, diarrhea no blood or mucous
    bacterial: usually unwell, high fever , mucus or blood in stool (campylobacter, shigella, salmonella)

parasites usually last long time

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5
Q

what are some signs of Hirschsprung (congenital megacolon)

A

small watery stools
abdo distention
poor appetite
poor growth

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6
Q

common causes of persistent diarrhea?

risk factors

A

no cause detected for most causes

-caloric and protein malnutrition, vit A and zinc deficiency, prior infection, male, young age (6-24 months old), young maternal age

consider shigella, E coli, HIV, starvation

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7
Q

common causes of chronic diarrhea

A

IBD
IBS
high consumption of fruit/carbonated beverages
antibiotic/NSAID use

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8
Q

describe diarrhea associated with IBS

A

• No diarrhea at night (compared with infectious/secretory diarrhea)
• Usually partially formed/liquid first stool in AM, worse throughout the day
• BM after each meal, 3-10 stools with mucus/day
• Alternate with constipation
• Remember ABCD (abdo pain, bloating, constipation, diarrhea)
Systemically well: no weight loss, stunted growth, fever, etc. Good appetite

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9
Q

diet recommendations for diarrhea

A

-hydration +++
ORS if needed

full resumption of normal diet

  • high fat low carb diet accelerates improvement
  • avoid lactose
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10
Q

Constipation

Rome IV criteria

A
  • defecation frequency 2x or less per week
  • fecal incontinence 1x/week for toilet trained kids
  • retentive posturing
  • pain with defection
  • large diameter stools that obstruct toilet
  • palpable rectal fecal mass

2 or more criteria for one month

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11
Q

Risk factors for chronic constipation

A

think GU

hydronephrosis, UTIs, enuresis

also family hx constipation, genetic predisposition

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12
Q

Describe the vicious cycle of constipation

A

Vicious Cycle of Constipation
• If ongoing suppression of urge to defecate: rectosigmoid and entire colon becomes dilated and impacted
• Contractions are weaker, less effective
• Positive feedback loop: withholding stool worsens constipation –> stretch receptors accommodate distended rectum, contractile forces fail to cause complete evacuation
• Child becomes desensitized to rectal distention
• Delayed defecation –> hard bulky stool –> painful
• Child learns to tighten external anal sphincter and gluteal muscles
• Results in intentional and prolonged suppression of defecation

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13
Q

What DDX should you consider if “explosive” passage of stool after DRE?

what are the red flags?

A

Hirschsprung (congenital megacolon)
-rectal exam induces gush of air

Risk of toxic megacolon and enterocolitis
-lethargy, signs of sepsis, peritoneal signs, bloody diarrhea

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14
Q

What DDx would you consider with delayed passage of meconium (>24 hours after birth)?

A

Hirschsprung

cystic fibrosis

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15
Q

What are some causes of functional constipation?

A
  • poor diet and fluid intake
  • stool withholding
  • high consumption (>24 oz/day) of cow’s milk, cheese, sugary fruit juice
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16
Q

Potential causes of constipation

A
  • functional
  • stool withholding (acute stressors)
  • intestinal malrotation
  • Hirschsprung
  • hypothyroidism
  • anorectal malformation
  • side effect of medications
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17
Q

What is the goal of treatment for constipation?

A

1 to 2 soft painless stools/day

-no less than every other day

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18
Q

What is the 3 pronged approach to constipation management?

A
  • diet
  • behavioural modification
  • medications
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19
Q

Describe diet and behaviour modification for constipation

A

Diet:
• decrease intake of simple carbs (sugar), refined/processed carbs, saturated fat, processed meat, dairy (milk and cheese)
• Increase fruits, vegetables, whole grains, legumes, tree nuts
• Prune juice, pear/peach/apricot nectar
• Dried fruit (raisins, cranberries): rich in sorbitol and helpful
• Increase fibre, whole grain breads, brown rice
• Continually introduce new food items

Behaviour modifications:
• Consistent toilet hygiene: sticker/star reward chart
• Sit on toilet 1-2x/day for 8-10 min each time, preferably after a meal
• Discourage longer toilet sitting

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20
Q

Describe use of PEG 3350 for constipation

  • starting dose
  • titration
  • common side effects
A

PEG 3350
• Better tolerated than other oral laxatives, tested +++ in kids and safely used
• Tasteless, odourless, dissolve in any beverage
• Not systemically absorbed, stress to parents that PEG does not lead to dependence
• Starting dose 0.4-1 g/kg/day
• Titrate up or down every 2-3 days
• High dose PEG for disimpaction: 1-1.5 g/kg/day max 100 g/day
• Most common lack of response to PEG: inadequate dosing
Side effects: gas, abdo pain, loose stools

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21
Q

Treatment of chronic constipation

-duration of treatment?

A

can take up to 6-12 months

-treat minimum 2 months until having 1-2 BMs/day without difficulty for minimum 1 month, then gradual wean

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22
Q

what is the typical presentation of appendicitis?

A
  • periumbilical pain migrating to RLQ
  • pain BEFORE nausea/vomiting
  • fever, tachycardia
  • low grade fever in first 24 hours
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23
Q

what would labwork for appendicitis typically show?

A

CBC:

  • leukocytosis (elevated WBC) = perforation
  • shift to left (immature white blood cells)
    urinalysis: pyuria
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24
Q

what is the imaging of choice for appendicitis?

A

ultrasound (gold standard)
85% sensitive, 90% specific

CT if US did not confirm/exclude appendicitis

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25
Q

what is non-surgical management of uncomplicated apppendicitis?

A

-if symptom duration is <5-7 days then unlikely perforation

IV abx followed by 10 days of po abx
-90-95% success rate with 20% recurrence rate at one year

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26
Q

what is the most accurate way to assess degree of dehydration?

A

-compare current weight with recent pre-illness weight

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27
Q

what is the most useful sign to detect dehydration of 5% or more?

what about dehydration at 3-5%?

A

> 5%: cap refill

3-5%: skin turgor, resp disturbance

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28
Q 
For kids under age 5:
% of body weight loss for:
-mild dehydration
-moderate dehydration
-severe dehydration
A

mild: 5% or less
moderate: 6-9%
severe: 10% or more

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29
Q

For kids 5 and older:

% of body weight loss for:

  • mild dehydration
  • moderate dehydration
  • severe dehydration
A

mild: 3%
moderate: 6%
severe: 9%

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30
Q

what is the treatment for mild dehydration in kids?

when is IV hydration needed?

A

ORS preferred

*also preferred if moderate dehydration

IVF if severe dehydration, intractable vomiting, shock, anatomical defect

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31
Q

What are some parent education points for ORT?

A

• Need to add on additional fluid for replacement of losses (see third column in table 80.5)
• Relate mL to common household measures
○ Eg 5 mL = 1 tsp, 15 mL = 1 TBSP
• Small frequent feeds: volumes of 5-15 mL via syringe or teaspoon every 2-5 min better tolerated
○ Labor intensive for parent but can successfully deliver 150-300 mL/hour
• Diarrhea often increases (frequency and amount) during initial treatment with ORT
• Primary goal of ORT is to rehydrate, not to stop diarrhea
• Diarrhea will resolve spontaneously
• No longer recommend “gut rest” –> early refeeding with return to formula/milk and solids is a priority
Red flag signs etc.

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32
Q

how is emesis categorized?

A

bilious vs non-bilious

time (acute vs chronic vs cyclic)

bilious - think obstruction

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33
Q

what is a complication of severe vomiting?

A

dehydration
failure to thrive, starvation
esophageal tears and hematemesis (Mallory-Weiss)

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34
Q

DDx for vomiting in newborns and infants?

A
  • overfeeding (more likely to be regurgitation)
  • food allergies
  • GERD
  • UTI
  • OM
  • pyloric stenosis
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35
Q

Pyloric stenosis

  • age group?
  • risk factors?
  • symptoms?
A

• Pyloric stenosis: most common surgical condition associated with vomiting in infancy
○ M>F ages 2 weeks to 2 months
○ Risk factors: firstborn, male, high birthweight, early exposure to erythromycin
○ Non-bilious projectile emesis, often has curdled milk
○ Appetite intact, eager to eat
○ May have fewer bowel movements and constipation or mucous-laden stools

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36
Q

DDx for vomiting in children

A

-gastro
-acute infection (UTI, OM, strep)
-labyrinthitis
-DM
CNS: tumour, infection
-cyclic vomiting
-appendicitis
-cholecytitis

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37
Q

describe pattern of cyclic vomiting

A
  • recurrent episode of vomiting, completely well in between
  • assoc with family hx migraines
  • triggered by emotions, fatigue, infection
  • resolves in late childhood/early adolescence
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38
Q

DDx for bilious vomiting

A
  • obstruction
  • pancreatitis
  • paralytic ileus
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39
Q

signs and symptoms of intussception

A
  • intermittent abdo pain/irritability
  • palpable abdo mass
  • red currant jelly stool (mixed blood and mucous)
  • vomiting (bile think obstruction)
  • lethargy
  • looks well in between
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40
Q

what is the definition of colic (rule of 3’s)

symptoms of colic?

A

> 3 hours/day
3 days/week
3 weeks duration

starts at age 2-3 weeks, ends by 3 months

  • prolonged fussiness
  • symptoms usually start after feeding, late in the day
  • responds to rhythmic motion (bouncing)
  • otherwsie well
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41
Q

hep D: common co-infection with which type of hepatitis?

A

hep B

hep D needs HBsAg for replication

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42
Q

What are some acute signs of hepatitis?

A
  • flu-like symptoms (fever, malaise, anorexia, n/v)
  • diffuse abdo pain
  • jaundice (not always in peds)
  • DARK URINE and LIGHT STOOL
  • pain over liver
  • hepatomegaly
43
Q

complication of hepatitis A?

A
  • does not become chronic

- can have fulminant hepatitis

44
Q

how is hep B transmitted?

A

-bodily fluids

  • only serum, sexual fluids (semen and vaginal), saliva are contagious
  • vertical transmission
45
Q

how is hep E spread?

A

water, fecal oral
*esp monsoon in endemic areas

  • most common viral hepatitis in the world
  • acute infection is self-limiting
  • high risk of fetal loss for pregnant women
46
Q

what is Fitz-Hugh-Curtis syndrome?

A

-liver inflammation associated with PELVIC infections

  • RUQ pain, perihepatitis
  • usually from chlamydia or gonorrhea
47
Q

Hepatitis A IgM suggests _____ infection

Hepatitis A IgG suggests ______ infection

A

IgM: acute

IgG: vaccination or previous infection

48
Q

Functional abdominal pain:

diagnostic criteria:
-must have ____ per month for minimum of _____ months

A

FAP-NOS: functional abdominal pain not otherwise specified:
4x/month for a min of 2 months PLUS ALL OF THE FOLLOWING:
• Episodic or continuous that does not occur solely with physiological events (eating, menses)
• Does not match IBS, functional dyspepsia, or abdominal migraine

Cannot be explained with another medical condition

49
Q

visceral pain is caused by _____ fibres
-well or poorly localized?

somatic pain is caused by _____ fibres
-well or poorly localized?

A

visceral pain:

  • slow unmyelinated C fibres
  • poorly localized
  • kids are RESTLESS

somatic pain

  • rapid myelinated A fibres
  • well localized, sharp
  • kids are lying STILL
50
Q

how is functional abdominal pain different from acute/chronic pain?

A

-dysregulation of brain-gut interaction and GI nervous system
-abnormal response of GI symptoms to physiologic functions (eating etc)
VISCERAL HYPERALGESIA
hypersensitization of GI tract

51
Q

if abdo pain improves with having BM, think _____

if abdo pain worsens with having BM, think _____

A

improves with BM: IBS

worse with BM: IBD

52
Q

abdominal migraine

symptoms

A

○ Recurrent paroxysmal episodes of intense, acute periumbilical, midline, or diffuse abd pain
○ Can last 1 to many hours
○ Can be incapacitating
○ Return to normal function for weeks/months between episodes
○ Interferes w/normal activity
○ Pallor, anorexia, photophobia, HA, N/V
Association with maternal migraines

53
Q

if pain wakens child from sleep, weight loss, slowed growth, consider DDx

A

-organic causes

eg IBS, celiac, PUD

54
Q

symptoms of mesenteric adenitis

A

looks like appendicits, not as unwell
nausea and vomiting
preceding URTI

55
Q

name some DDX of medical (non surgical) causes of abdo pain in school-aged or adolescent kids

A
  • IBS
  • functional dyspepsia
  • epigastric pain syndrome
  • abdo migraine
  • organic (celiac, IBD, PUD)
  • mesenteric adenitis
  • infection
  • viral hepatitis
  • pancreatitis
  • parasitic infection
  • pyelonephritis
  • sickle cell disease
  • acute intermittent porphyria
  • dysmenorrhea
  • PID
  • gallstones
56
Q

how is functional abdominal pain diagnosed?

A
  • normal physical exam
  • no red flag findings
  • negative stool for occult blood
57
Q

functional abdominal pain disorders in child/adolescent

top 5

A
  • functional dyspepsia
  • IBS
  • abdominal migraine
  • functional abdo pain NOS
  • functional constipation
58
Q

red flag signs on history for chronic abdo pain

A
  • weight loss (unintended)
  • dysphagia
  • significant vomiting (bilious, projectile)
  • chronic diarrhea
  • unexplained fever
  • back pain
  • Fam hx IBD, celiac, PUD
  • bloody diarrhea
  • melena
  • rash
59
Q

what are some potential complications of GERD?

A
  • esophagitis
  • Barrett syndrome
  • strictures
  • aspiration
60
Q

what is the common presentation for infants with GER?

A

recurrent non-forceful small volume emesis

  • not forceful, bilious or projectile
  • usually after feeding
  • a little bit fussy

-can also manifest as nighttime cough, wheezing, recurrent pneumonia

61
Q

What are some adverse effects of long term acid suppression:

A
  • headaches
  • diarrhea
  • constipation
  • nausea
  • increased rates of infections (CAP, gastroenteritis, necrotizing enterocolitis

in adults:
long term use linked to hip fracture, B12 deficiency

62
Q

hematochezia
-definition
UGI vs LGIB?

A

BRBPR

LGIB

63
Q

melena
-definition
UGI vs LGIB?

A

dark tarry stool
UGIB
-can also be blood from nosebleed
or side effect of med/food

64
Q

occult blood

-definition

A

hidden (ie not visible)

usually presents as IDA

65
Q

what are some non-bleeding causes of red-staining of emesis or stool?

A
  • cranberries, cherries, strawberries, beets, tomatoes, candy
  • amoxicillin, dilantin, rifampin
66
Q

what are some non-bleeding causes of tarry stools/emesis?

A
  • bismuth
  • activated charcoal
  • iron
  • spinach, blueberries, licorice
67
Q

common presentation of UGIB?

common presentation of LGIB?

A

UGIB

  • hematemesis
  • melena (not absolute, sometimes can have melena with LGI or hematochezia with massive UGIB)

LGIB
-hematochezia

68
Q

What differential should be considered in infants and toddlers with bloody diarrhea and diffuse abdo pain?

A

hemolytic uremic syndrome (HUS)

complications:
-intussusception, pancreatitis, obstruction, perforation

69
Q

what differential should be considered in children with hematochezia, vomiting, sudden severe abdo pain and purpura to lower extremities?

A

Henoch schonlein purpura

70
Q

3 C’s associated with patho of ulcerative colitis

A

-autoimmune disease

  • crypt abscesses
  • circumferential
  • continuous (always starts at rectum, extends proximally, no breaks of normal tissue)
71
Q

ulcerative colitis

signs and symptoms

A

abdo pain: moderate to severe
LLQ

frequent diarrhea with mucous and blood

  • pain WORSE after defecation
  • nocturnal diarrhea
  • anemia
  • dehydration
  • cramping
  • tenesmus
  • fatigue
  • weight loss

kids may have fecal incontinence

72
Q

how to rank severity of ulcerative colitis

  • mild
  • moderate
  • severe
  • fulminant
A

mild: <4 stools/day
moderate: 4-6/day
severe: >6/day
fulminant: >10/day

73
Q

Workup for ulcerative colitis

what would tests show?

A

colonoscopy: ulcers (need biopsy)

CT: thickening of intestinal wall

Stool studies: N

CBC: anemia
CRP: elevated

74
Q

Crohn’s disease

what does it affect?

risk factors?

A

bum to gum (mouth to anus)

risk factors:

  • white
  • family hx
  • smoking
  • OCP
  • abx
  • NSAIDs
75
Q

Crohn’s disease

Patho (TST)

A

Transmural (ulcers entire depth of wall)

  • skip lesions (healthy tissue in between)
  • Thickening, fissures, strictures
76
Q

Crohn’s disease

signs and symptoms

A

-Abdo pain moderate to severe
-RLQ pain
-diarrhea (not grossly bloody)
abdo pain WORSE after defecation
-weight loss (more than UC)
-fatigue
-nausea/vomiting
-fecal incontinence in peds
-anorexia

77
Q

Crohn’s disease

workup and findings

A

colonoscopy with biopsy: transmural skip lesions

CT: intestinal thickening

Stool studies: N

CBC: anemia
CRP: elevated
Fecal calprotectin: 83-100% specific in adults

78
Q

positive fecal calprotectin is indicative of ______

A

inflammatory bowel disease

-helps to differentiate IBD vs IBS
-only covered by MSP if already diagnosed with IBD (as marker of progression of disease)
otherwise costs $110

79
Q

Risk factors for hyperlipidemia

-medications?

A

thiazide

  • beta blockers
  • hormones (specifically progestin)
  • clozapine
  • olanzapine
  • HIV meds
80
Q

Start screening children for hyperlipidemia between age ___ and _____ if risk factors present:

A

2 to 10 years of age

  • positive fam hx of dyslipidemia
  • fam hx of early CVD (<55 male, <65 female)
  • risk factors for CVD (overweight, obesity, HTN, smoking, DM)

Medical conditions:

  • organ transplant
  • SLE
  • nephrotic syndrome
  • on protease inhibitor for HIV
81
Q

signs and symptoms of malabsorption

A
  • chronic diarrhea
  • pale, greasy, foul-smelling stools
  • unintentional weight loss
  • RARE abdo pain

if carb malabsorption: watery diarrhea with ++gas and distention 90 min after eating

82
Q

what are the 3 hormones involved in primary adrenal insufficiency (Addison’s)?

A

DEFICIENCY in

  • aldosterone
  • cortisol
  • androgens
83
Q

symptoms of primary adrenal insufficency?

A
  • cravings for salty food
  • nausea, vomiting
  • fatigue
  • dizziness
  • weak and tired
  • altered LOC
  • hyperpigmentation
  • loss of pubic and armpit hair
  • decreased sex drive
84
Q

what are symptoms of adrenal / Addisonian crisis?

A

pain to abdomen, back, legs

  • vomiting and diarrhea –> dehydration
  • HYPOglycemia
  • HYPOnatremia, hyperkalemia, HYPOtension
  • LOC
  • death
85
Q

what is the hormone involved with Cushing’s?

A

cortisol excess

86
Q

what are the symptoms of Cushing’s?

A
  • moon-shaped face
  • buffalo hump
  • truncal obesity
  • thin extremities
  • easy bruising and abdo striae
  • fractures (osteoporosis)
  • HYPERglycemia
  • HYPERtension
  • HIGHER risk of CVD
  • HIGHER risk of infections
  • delayed wound healing
  • amenorrhea
  • mental health disturbances
87
Q

Definition of precocious puberty

A

onset of puberty 2-2.5 SD earlier than population norms

  • before age 8 (F)
  • before age 9 (M)
88
Q

patho of precocious puberty

central vs peripheral

A

central: early maturation of hypothalamic-pituitary-gonadal axis
- sequential maturation of breasts and pubic hair (F) and penile enlargement and pubic hair (M)

-peripheral: excess secretion of sex hormones, exogenous sources of sex hormones, ectopic production of gonadotropin from germ-cell tumor

89
Q

delayed puberty

definition

A

-absence/incomplete development of secondary sex characteristics

  • absence of breast development by 13
  • absence of menarche by 16 or within 5 years of puberty
  • absence of testicular enlargement by age 13-14
90
Q

delayed puberty

potential causes?

A 
turner syndrome
klinefelter syndrome
-nutritional disorder
-celiac disease
-IBD
-anorexia
-hepatic disease
91
Q

what is the most common cause of hypothyroidism in children?

A

-autoimmune thyroiditis

92
Q

define subclinical hypothyroid

A

asymptomatic

high TSH, normal fT4

93
Q

define sick euthyroid

A

Hypothalamic-pituitary-thyroid axis transiently affected by any stress (disease, infection, surgery, fasting)

in acute phase: TSH low, then normalizes
-reverses spontaneously, does not need treatment

94
Q

what are some risk factors for hypothyroidism

A
  • DM1 or other autoimmune disorders
  • Down syndrome, Turner syndrome, mitochondrial disease
  • Family hx
  • Iodine excess or deficiency
  • Iatrogenic (neck irradiation, thyroidectomy, radioactive iodine ablation)
    Medications: Lithium and amiodarone
95
Q

peds specific impact of hypothyroidism?

A
  • decreased mental function (mental disabilities if present before age 2)
  • slow growth
  • delayed bone maturation
  • puberty: delayed or precocious
96
Q

what is the most common cause of hyperthyroidism in children?

A

Grave’s

97
Q

peds specific impact of hyperthyroidism?

A
  • difficulty gaining weight
  • growth acceleration
  • advanced bone age
  • delayed puberty
98
Q

what is the diagnostic test for Grave’s disease?

A

anti-TR antibody

99
Q

what is the risk and benefits associated with thyroid replacement in hypothyroidism for infants?

A
  • CVS: palpitations, tachy, afib, cardiac overload, arrythmias
    benefit: prevent neurocognitive impairment if treated in first 2-3 years of life
100
Q

congenital hypothyroidism

symptoms?

A 
jaundice
constipation
lethargy
hypotonia
poor feeding

if not detected: cognitive outcomes
failure to thrive

101
Q

IBS

What are the ABCDs

A

abdominal pain
bloating
constipation
diarrhea

102
Q

Rome Criteria for IBS

for children:
for adults:

A

kids: at least 4 days/month for 2 months
adults: at least 1 day/week for 3 months

103
Q

signs and symptoms of IBS in children:

A

○ Change to stool frequency (>4/day or <2/week) and consistency (hard/lumpy or loose/watery)
○ Pain improves w/defecation
○ Straining/urgency/feeling of incomplete evacuation w/BM
○ Passage of mucus
○ bloating/distension (less common in kids compared to adults)
○ Associated w/anxiety and multiple somatic symptoms
○ 30% kids also have dyspepsia (heartburn)
○ Symptoms can be precipitated by school-related problems, overeating or eating problems

104
Q

how would you counsel parents on early introduction of allergens?

A

• Actively offer common allergens (eg peanuts, cooked eggs) around 6 months old, NOT before 4 months old –> effective in preventing food allergy in some high risk infants
• High risk infants: eczema or immediate family member with eczema, food allergy, asthma, allergic rhinitis
• Most common allergens: egg, peanut, tree nuts, sesame, soy, wheat
• Give allergenic foods for first time at home
○ Give it at a time when they will be awake for 2 hours after
○ Make sure texture and size is age-appropriate to prevent choking
○ Offer small amount on tip of spoon, wait 10 min, then give rest of food at usual pace
○ Do not place food on skin first (can cause irritant effect)
• If there is no allergic reaction after first introduction:
Keep feeding that food item 2-3x/week to prevent development of food allergy

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