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Flashcards in Gastroenterology Deck (51)
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1

Protein Intolerance (Milk Protein-Induced Enterocolitis)

o Majority of cases result of Milk Protein (can be from mom’s consumption of milk)
o Presents age2-8w
o Eczema
o Enteropathy
Diarrhea, Severe reflux/vomiting, colicky abdominal pain Chronic blood loss in stools can lead to anemia
Protein loss in stools causes FTT & Edema
o Enterocolitis Acute
Diarrhea, painless blood & mucus in stool
Protein loss in stools causes FTT & Edema o Tx
Breastfeeding mother remove protein (Milk & Soy)
Can continue to breast feed
Resolves by 1-2 y/o
Elemental (hydrolyzed) formula

2

Hirschsprung Disease

o Typically rectosigmoid colon
o Also associated w/ Down Syndrome
o Normal meconium consistency
o S/Sx
Rectal examination reveals tight anal canal may lead to explosive expulsion “Squirt Sign”
Bilious or Feculent vomiting (newborns), abdominal distension, constipation (older children)
Failure to pass meconium Or delayed (>48 h)
o BariumSwallow
Dilated proximal bowel w/ narrow distal segment
o Dx
Screen
Anorectal manometry Diagnostic
Lack of ganglionic cells (NCC migration) on punch biopsy

3

Duodenal Atresia

o 1⁄4 Down Syndrome
o S/Sx
Bilious Vomiting w/in first 2 days of life Double Bubble Sign on XR
Air w/in distended stomach and proximal duodenum
o HxofPolyhydramnios
o Dx
Prenatal Ultrasound
o Associated with Down Syndrome
o Tx
Nasogastric decompression first IV Fluids & ABx
Surgery

4

Diarrhea/Vomiting and Dehydration

o Most commonly caused by Viral Gastroenteritis
o Hyponatremic, hypovolemic, hypoosmotic, low urine sodium, low serum osmolarity

5

Celiac

o Presents between 6m and 2y
o Gluten is in wheat, barley, rye, &oats
o S/Sx
Fatigue, weight loss
Diarrhea, vomiting, bloating
Abdominal pain & large foul smelling stools Dermatitis Herpetiformis
Erythematous Vesicles on extensors o Pruritic
o Associated w/ Vitiligo and T1DM
o Malabsorption
Osteoporosis/osteomalacia
Can lead to iron deficiency anemia
o Dx
Biopsy
Short villi, deep crypts, & vacuolated epithelium w/ lymphocytes
IgA endomysial Ab & Serum Tissue Transglutaminase Ab IgG in IgA deficient pt.
o Tx
Corticosteroids for severe diarrhea

6

Short Bowel

o Malnutrition with carb & fat malabsorption w/ steatorrhea FTT
o Distalresection
↓ B12 & Bile Acid reabsorption
o Causes
Congenital
Gastroschisis, volvulus, or atresia that require resection Crohn’s, tumors, & radiation enteritis
o Complications
TPN cholestasis w/ resulting Gallstones Bacterial overgrowth
TPN induced Liver failure
o Tx
Early enteral feedings for remaining bowel & liver function Liver transplant

7

GER

o Normal physiologic state in which stomach contents move retrograde
o “HappySpitters”
w/out GERD Sx
Benign emesis/spitting up
Not related to over feeding
Resolves by 6-12m
o Tx
Reassurance
Positioning therapy

8

Colic

o Crying in another wise healthy infant for >3h daily (usuallyevening), >3x per week, for a
duration of >3w
o Tx
Soothing techniques

9

GERD

o Infantspresentw/
Emesis/spitting up, Suboptimal calorie intake (feeding refusal), & if severe FTT Irritability
Sandifer Syndrome
Torticollis w/ arching of the back from painful esophagitis o Older Children presents w/ Typical GERD Sx
o Causes
Inappropriate Transient LES Relaxation (TLESR)
o Complications
Upper/lower Airway Disease
Induces bronchopulmonary constriction o Riskofaspiration
Chronic Laryngitis
William Martin MD MBA 2016 TTUHSC SOM OC USN
2.23.2015
o Hoarseness,wheezing,vocalcordnodules Barrett’s esophagus
FTT
Esophageal strictures o Dx
pH probe is gold standard
Bronchoscope w/ alveolar lavage when aspiration is strongly suspected o Tx
Conservative
Positioning & meal timing first (before pharmacotherapy)
Thickened feeds
H2 Blockers & PPI
Motility agents
Metoclopromide
o High side effects (1/3)
Drowsy, restlessness
↑ LES tone or Gastric Emptying Surgery
Nisses Funoplication
o Usually followed with gastrostomy tube to maintain
feedings/nutrition while stomach adjusts to ↓ volume

10

Choledochal Cyst

o Congenital abnormality of biliary ducts
Dilation of intra or extra-hepatic biliary ducts or both o S/Sx
Infants
Jaundice, acholic stool (like biliary atresia)
Children
Abdominal pain, jaundice, recurrent pancreatitis, dark urine ↑Bilirubin
o Dx
US or MRI
Cystic Extrahepatic mass

11

Hypertrophic Pyloric Stenosis

o Projectile Vomiting Nonbilious
Early in life, three to five weeks
Hypokalemic, hypochloremic, metabolic alkalosis (loss of H+)
High PCO2
Hypokalemia results from ↑ aldosterone in response to volume
depletion from vomiting
HCl, H2O, and NaCl lost in vomit
Will still seem hungry
o Risk Factors: w/ Trisomy 18, first born male, erythromycin, formula feeding
o Physical
Olive Mass (epigastric/RUQ)
Peristaltic Wave in abdomen after feedings
o Dx
US
Thickened and elongated pylorus Barium Swallow
May show string sign
o Small amount of barium getting past
o Tx
Correct electrolytes/dehydration (DON’T OPPERATE IF ELECTROLYTE
ABNORMALITIES)
Must correct, IV hydration + Potassium
Partial pylorectomy

12

Malrotation of the Gut & Midgut Volvulus

o Bilious vomiting

13

Intussusceptions

o Peak5to9m
Before age 2 typically
o Ileocolic intussusceptions most common
Viral Gastroenteritis can also cause a lead point through inflammation of the Peyer’s patches
Hematomas from HSP & Mekel’s can also serve as lead points o S/Sx
Sudden crampy/colicky abd pain
Periods of Colic and then normal behavior (playing laughing) or
lethargic
Vomiting
Currant Jelly Stools (Bloody Mucus) from edema and sloughing of mucosa
Sausage shaped mass in RUQ o Dx
US
Target Sign
o Tx
Air/Contrast enema is gold standard
Avoid hydrostatic if prolonged, perforated, or peritonitis o Air is preferred
Coil Spring Sign
May reduce the intussusceptions (therapeutic)

14

AbdominalRigidity

Peritoneal Process

15

Restlessness

Colicky Pain

16

Constant Abdominal Pain

Suggests strangulation or torsion

17

Intestinal Obstruction PE

High pitched bowel sounds, abdominal distension, tenderness, & visible peristalsis

18

Peritonitis

↓/absent bowel sounds
Rigidity w/ guarding
Rebound Tenderness

19

Appendicitis

Pain referred to T-10 (umbilicus) PE
Tenderness @ McBurng’s
Guarding
Rebound Tenderness
↑ WBC and neutrophils

20

Acute Pancreatitis

Uncommon in children Causes
Trauma #1, idiopathic #2, infection
S/Sx
Pain @ periumbilicus & epigastric
o Radiatestoback
Severe w/ blood along the fascial planes
o Gray Turner Sign
Bluish discoloration of the flanks
o Cullen Sign
Bluish discoloration of periumbilical
Labs
↑ Amylase
↑ Lipase
Abdominal US for Dx CT for complications
Pseudocyst formation Tx
ABx if Necrotizing
Small Pseudocyst can resolve on own, but large ones may require

21

Cyclic Vomiting Syndrome (CVS)

o Acute and frequent vomiting that resolves spontaneous w/ no Sx in between episodes
o FHxofmigraines
o Thought to be linked to abdominal migraines
o Dx
Criteria
≥3 episodes in 6-month
Easily recognizable to family
Lasts 1-10d
Vomiting ≥4 times/hr @ peak
No Sx in between episodes
No underlying condition
o Tx
Antiemetic (ondansetron [Zofran]) If FHx of migraines: Sumatriptan

22

Cholecystitis

o Inflammation of the gallbladder
Most commonly w/ stones
Less commonly w/out (Acute Acalculous Cholecystitis)
o Uncommon in children unless:
CF, TPN, or Sickle Cell
o RUQPainw/Guarding
o +Murphy’sSign
Palpation of the RUQ upon inspiration, intense pain, inspiration ceases
o Imaging
US
Stone or thickened GB Wall
Cholescintigraphy may be useful
o Mild ↑ LFT & TB
o Tx
ABx
Cholecystectomy if peritonitis

23

Constipation

o Risk factors: Dairy, toilet training, school entry o S/Sx
Abdominal pain, passage of pellet like stools, 48h)
Increase fiber, limit cow’s milk, laxative (polyethylene glycol, mineral oil)

24

IBD

o Peaks 15 to 20 y/o & @ 50 y/o
o Includes
Crohn’s Disease
Ulcerative Colitis
o Tx
Immunosuppressive Agents
Induce long term remission
Corticosteroids
For acute exacerbation & induce remission

25

Ulcerative Colitis

o Limitedtocolon
o Continuous & Limited to the Mucosa Mucosa is friable and bleeds
o Typically bloody diarrhea w/mucosa
At least 3-4w
o Ranges in Severity
Rectal Bleeding, diarrhea, abdominal pain, Hypoalbuminemia
o P-ANCA
o Complication
Toxic Megacolon
↑ Risk for Colorectal Cancer
o Tx
Sulfasalazine
Can be cured w/ total proctocolectomy, but reserved for intractable colitis Immunosuppressive Agents & Corticosteroids

26

Crohn's Disease

o Any segment (mainly terminal Ileum)
Can have mouth ulcers
o Skip lesions & segmental inflammation o Transmuralinflammation
Fistulas, Crypt Abscesses, Strictures o Malabsorption
Vit B12, Zinc, Folate, Fe2+
o Perianal disease (verycommon) often precedes intestinal disease
Skin Tags, abscesses, fistulas
o ExtraintestinalManifestations
Much more common than in UC
FUO, arthritis, mouth ulcers, skin manifestations (erythema nodosum), weight
loss, malaise, and growth retardation
o Anti-SaccharomycescerevisiaeAb o Granulomas(30%)
o Imaging
String Size
Thickened bowel folds w/ narrowing of the tract
o Tx
Metronidazole
When fistulas presents
Esp. w/ inflammation
Immunosuppresive Agents & Corticosteroids
Azathioprine, cyclosporine, tacrolimus, TNF-α

27

GI Bleed

o Hematemesis
Coffee ground appearance
o Hematochezia
Bright red, lower GI or significant rapid upper GI o Melena
Dark tarry, upper GI (proximal to Ligament of Treitz) o Occult bleeding from GI
Guaiac +
False +
o Ingested iron False -
o Large amounts of ingested Vit. C

28

Upper GI Bleed

o Swallowed maternal blood
o Endoscopy if active bleeding w/hemodynamic changes
o Tx
Initial:
Fluid Bolus w/ IV access
Octreotide for varices
PPIs
Arteriographic embolization for serious bleeding
Vascular malformations

29

Necrotizing Enterocolitis (NEC)

Consider in any newborn w/ rectal bleeding, feeding intolerance, & abdominal distension
More common in prematures & Low birth weight
Immaturity of the stomach plus exposure to bacteria from enteral feeds leads to
bowel inflammation and damage
Caused by local ischemia, dilation, and infarction of loops of bowel
S/Sx
Abdominal distension, Hematochezia (or occult blood), pneumatosis
intestinalis (air in the bowel wall, double line/train track appearance)
Blood in NG tube
Complications
Intramural air spreading to portal vein (venous portal gas)
Later on intestinal perforation
o Pneumoperitoneum
Breast feeding reduces the risk of NEC
Tx
Mild
o Decompression, electrolyte repletion, IV ABx, serial abdominal exams checking for perforation
Severe (perforation)
o Severe if perforation (free air on lateral decubitus or under
diaphragm), fixed dilated bowel on serial X-rays, abdominal wall
cellulitis
o Surgical resection and reanastomosis (exploratory laparotomy)
Following surgery, parenteral feeds for 14d Allows for bowel rest

30

Juvenile Polyps

Lower GI bleeding:
#1 cause beyond infancy (>5y?)
Bleeding is painless, intermittent, & often streaky
Tx
Colonoscopy w/ polypectomy