Gastroenterology Topic Reviews Flashcards

Question

Initial management of stable, witnessed, button battery ingestion (location unknown)

Answer 1

10 mL (2 tsp) honey every 10 minutes up to 6 doses OR sucralfate suspension 10 mL every 10 minutes up to 3 doses Honey or sucralfate is not routinely recommended for gastric location but can be given until esophageal location is ruled out

Answer 2

1. confirmed short ingestion time ( < 2 hours) 2. battery size < 20 mm 3. absence of clinical symptoms 4. age > 5 years

Answer 3

Endoscopic removal with surgery present If there is evidence of esophageal injury start IV antibiotics. Can consider CT angio or MRI to determined proximity of injury to the aorta.

Answer 4

After endoscopic removal, NPO and antibiotics with serial MRI every 5-7 days until injury seen to recede from aorta

Answer 5

After endoscopic removal, NPO and IV antibiotics, esophagram to exclude leak before advancing diet

Answer 6

consider outpatient observation with repeat x-ray in 48 hours (BB > 20 mm) or 10-14 days ( BB < 20 mm) if failure to pass in stool

Answer 7

assessment of esophageal injury and endoscopic removal within 24-48 hours If esophageal injury is present make NPO and start IV antibiotics and consider CT or MRI

Answer 8

SUPERIOR MESENTERIC ARTERY SYNDROME Occurs due to compression of the third duodenal segment by the superior mesenteric artery (SMA) against the abdominal aorta. Typically occurs when there is a reduction in the aortomesenteric (AO) angle <25*. Most commonly occurs due to rapid weight loss resulting mesenteric fat pad depletion.

Answer 9

* RAPID WEIGHT LOSS * (anorexia nervosa, malabsorbtive disease, prolonged bed rest, immobilization, AIDS, cancer, paraplegia) * POST SCOLIOSIS OR SPINAL FUSION SURGERY * * EXAGERRATED LUMBAR HYPERLORDOSIS * * POST ABDO SURGERY * (peritoneal adhesions, duodenal malrotation, Ladd's bands, mesenteric tension from ileoanal pouch anastomosis) * HYPERMETABOLISM * (trauma or burns) Other causes: - Congenitally short or hypertrophic ligament of Treitz - Abdominal aortic aneurysm - Extra abdominal compression (e.g. body cast)

Answer 10

- Intermittent epigastric pain - Nausea / bilious vomiting - Anorexia + Early satiety - Weight loss - Dilation of stomach - Aggravating factors: Symptoms WORSEN POST-PRANDIALLY and when SUPINE - Alleviating Factors: Symptoms alleviated with the release of the angle (ex: prone knee to the chest or left lateral decubitus position)

Answer 11

UPPER GI SERIES = Gold Standard Dilated stomach & proximal duodenum. Delay in passage of contrast and vertical cut-off of air through 3rd portion of duodenum. CT ABDO (Can also diagnose SMA): - Normal = Aortomesenteric artery (AO) angle of 38-65* and a distance of 10-28mm - SMA Diagnosis = AO angle <25* and aortomesenteric distance of <8mm. ABDO XR (NOT DIAGNOSTIC of SMA Syn): May show dilated stomach and proximal duodenum, decreased distal bowel gas.

Answer 12

CONSERVATIVE: - FLUID & LYTES correction - NG INSERTION (gastric decompression) - NUTRITIONAL REHAB: TPN / NJ feeds (goal to increase mesenteric fat pad + increase the AO angle) - POSTURE THERAPY (Relieve obstruction by laying in left lateral decubitus position or prone with knees to chest) SURGICAL: (Gastrojejunostomy vs Strong procedure (ligament of Treitz division) vs Duodenojejunostomy)

Answer 13

T cell Immune-mediated enteropathy caused by a permanent sensitivity to gluten in genetically susceptible individuals

Answer 14

Type 1 diabetes mellitus Autoimmune thyroiditis Down syndrome Turner syndrome *Williams syndrome *Selective IgA deficiency First-degree relatives with celiac disease

Answer 15

*Failure to thrive (falling off growth curve, esp around 6-24 mo); wt loss *Iron-deficiency anemia resistant to oral iron GI Sx: -chronic or recurrent diarrhea, constipation -distended abdomen (celiac belly); abdo pain -anorexia; vomiting, irritability Non-GI Sx: -Dermatitis herpetiformis -Dental enamel erosions -Osteopenia/osteoporosis -Short stature -Delayed puberty -Arthritis

Answer 16

dermatitis herpetiformis (see RC photo) *Severely pruritic Vesicles and papules bilateral/symmetric elbows, knees, buttocks Skin biopsy = Granular IgA deposit Tx with gluten free diet and dapsone

Answer 17

Elevated Anti-Tissue Transglutaminase IgA (TTG-IgA) with normal IgA (if low total IgA, perform TTG IgG, EMA or DGP) PLUS small intestinal biopsy (Non-biopsy dx: TTG IgA >10x ULN + positive EMA + positive HLA DQ2/8 )

Answer 18

Deamidated gliadin peptide (TTG IgA is unreliable if <2yrs)

Answer 19

< 2 y/o immunosuppressant low gluten diet Protein Losing Enteropathy (PLE) Dermatitis herpetiformis

Answer 20

gluten free diet lifelong repeat TTG 6mo after GF diet (measure compliance), then yearly TTG (monitoring for contamination with gluten)

Answer 21

Mortality 2-3x higher than general population, mostly due to GI malignancies Anemia Low folate, B12, B3, ADEK, thiamine, zinc osteopenia poor growth essential fatty acid deficiency

Answer 22

mucocutaneous freckling (hyperpigmented macules in mouth) GI hamartomatous polyposis - polyps may present with GI bleeding or as lead point in intussusception presents in first 10 years of life

Answer 23

Autosomal Dominant

Answer 24

colon cancer breast and reproductive tumours 8yrs + begin screening for colon cancer with MRE examine for sex cord tumours (Large-cell calcifying Sertoli cell tumor of the testes -> feminizing manifestations)

Answer 25

Oropharyngeal dysphagia - immediate difficulty swallowing - Neuromuscular - MG, CNS tumours, MS, Polymyositis - Structural - Tumours, foreign body, diverticulum Esophageal dysphagia - delayed difficulty (food getting stuck) - Neuromuscular (solids and liquids) : intermittent (esophageal spasm), progressive (scleroderma, achlasia, diabetic neuropathy) - Structural (solids only) - intermittent (EoE, schatzki ring, esophageal web) - progressive - Reflux structure, esophageal cancer

Answer 26

infiltration of the esophgeal epithelium by eiosinophils - >15/hpf

Answer 27

infants and toddlers - vomiting, feeding problems, poor weight gain Older children and teens - solid food dysphagia with food impacts, chest/epigastric pain Commonly have atopy.

Answer 28

- Symptoms related to esophageal dysfunction. - Eosinophil-predominant inflammation on esophageal biopsy, \\≥15 eosinophils per HPF - Exclusion of other causes

Answer 29

Upper endoscopy - Edema + Rings + Exudates + Furrows + Strictures - Histology shows eosinophilia (>15 eos/HPF) +/- Labs show peripheral eosinophilia, elevated IgE level +/- UGI series: (useful for ruling out other DDx, to see stricture/caliber/length) +/- Intraesophageal pH testing (useful for ruling out other DDx like GER)

Answer 30

- Initial treatment high dose PPI x 8 weeks then repeat EGD. - If repeat EGD on PPI shows >15 eos/HPF then its EoE. If <15 eos/HPF then its PPI-REE/GERD/NERD Dietary management (Successful in 70-98%) Elimination of IgE mediated allergens + 2-6 food elimination diet (dairy, gluten/wheat, eggs, soy, peanuts/tree nuts, fish/seafood) or use of amino-acid based formula - Corticosteroids (induces remission in 90%) fluticasone (without spacer) or budesonide (suspension) for ~6-8 weeks = Systemic: severe dysphagia causing dehydration and weight loss (limited use in practice) Biologics = Dupilumab +/- Dilatation (last resort)

Answer 31

chronic liver disease resulting from excessive fat accumulation in the liver

Answer 32

ALT If ALT > 2x ULN (52 M; 44 F) for >3mo, evaluate for NAFLD or chronic hepatitis If ALT >80 -> increased clinical concern and timely evaluation If normal -> repeat q2-3y if still has RFs

Answer 33

insulin resistance, prediabetes, diabetes, dyslipidemia, central adiposity, family history

Answer 34

- diagnosis of exclusion requiring presence of hepatic steatosis and exclusion of other causes besides NAFLD. - liver biopsy is gold standard - u/s not able to differentiate steatosis from NASH

Answer 35

Behavioural modification at home for parents - Parents should provide a predictable eating schedule, with 3 meals and 2 snacks per day, allowing the child to choose how much to eat in order to avoid power struggles and to allow the child to learn to respond to satiety cues

Answer 36

SSD (DSM) Definition: A. ≥ 1 somatic symptoms that are distressing or result in SIGNIFICANT DISRUPTION of DAILY LIFE. B. EXCESSIVE THOUGHTS, feelings, or behaviors related to the somatic symptoms or associated health concerns, as manifested by ≥ 1 of the following: - Disproportionate and persistent thoughts about the seriousness of one’s symptoms. - Persistent high level of anxiety about health and symptoms. - Excessive time and energy devoted to these symptoms or health concerns. C. Although any one somatic symptom may not be continuously present, the state of being symptomatic is persistent (typically >6 mo).

Answer 37

Must include both of following in otherwise healthy infants aged 3-12mo: 1) Regurgitation ≥ 2x / day for ≥ 3 weeks 2) No retching, hematemesis, aspiration, apnea, failure to thrive, feeding or swallowing difficulties, or abnormal posturing

Answer 38

Must include all of the following for ≥ 2 months: 1) Repetitive contractions of the abdominal muscles, diaphragm, and tongue 2) Effortless regurgitation of gastric contents, which are either expelled from the mouth or rechewed and reswallowed 3) ≥ 3 of the following: - Onset between 3 - 8 mo - Does not respond to management for GERD and regurgitation - Unaccompanied by signs of distress - Does not occur during sleep and when the infant is interacting with individuals in the environment

Answer 39

Conjugated hyperbili is >17 mmol/L or 20% total

Answer 40

Must include ALL of the following: 1) ≥ 2 periods of unremitting paroxysmal vomiting with or without retching, lasting hours to days within a 6-month period 2) Episodes are stereotypical in each patient 3) Episodes are separated by weeks to months with return to baseline health between episodes of vomiting

Answer 41

Must include ALL of the following: 1) An infant who is < 5 months of age when the symptoms start and stop 2) Recurrent and prolonged periods of infant crying, fussing, or irritability reported by caregivers that occur without obvious cause and cannot be prevented or resolved by caregivers 3) No evidence of infant FTT, fever, or illness 4) Caregiver reports crying/fussing for > 3 hours / day or > 3 days / week. 5) Total daily crying is confirmed to be > 3 hours when measured by ≥ 1 prospectively kept 24-hour diary.

Answer 42

Must include ALL of the following: 1) DAILY painless, recurrent passage of ≥ 4 large, unformed stools 2) Symptoms last > 4 weeks 3) Onset between 6 - 60 months of age 4) No FTT if caloric intake is adequate

Answer 43

Must occur in an infant < 9 months of age: 1) ≥ 10 minutes of straining and crying before successful or unsuccessful passage of soft stools 2) No other health problems

Answer 44

Must include 1 month of ≥ 2 of the following in infants up to 4 YEARS of age: - ≤ 2 defecations / week - Hx of excessive stool retention - Hx of painful or hard bowel movements - Hx of large diameter stools - Presence of a large fecal mass in the rectum --- ** In toilet trained children, the following additional criteria may be used: - ≥ 1 episode / week of incontinence after the acquisition of toileting skills - History of large diameter stools which may obstruct the toilet

Answer 45

Excitement Illness / Infection Stress 75% of children will have episodes that start on waking in the morning

Answer 46

Must include ALL of the following: 1) ≥ 2 periods of intense, unremitting nausea and paroxysmal vomiting, lasting hours to days within a 6mo period 2) Episodes are STEREOTYPICAL in each patient 3) Episodes are SEPARATED by WEEKS to MONTHS with return to baseline health between episodes 4) After appropriate evaluation, the symptoms cannot be attributed to another medical condition **Not part of the diagnostic criteria, but vomiting episodes are more common in the morning. Can be associated with epigastric/abdo pain, diarrhea, fever, autonomic instability. **

Answer 47

- Reassurance - AVOID TRIGGERS (Ex: Avoid excessive energy output, poor sleeps, fasting, trigger foods) - SUPPLEMENTAL CARBS for fasting episodes (pre-exertion, pre-bed) - MIGRAINE HEADACHE lifestyle modifications (Regular aerobic exercise, Regular meal schedules, Caffeine avoidance)

Answer 48

1. Refer to GI (**Royal College Answer**) 2. Lifestyle modifications (Avoid triggers, supplemental carbs when fasting, regular aerobic exercise/meals, avoid caffeine) 3. Prophylactic Therapy: Children ≤5yr: - Antihistamine: Prophylactic CYPROHEPTADINE (1st line) - Beta Blocker: Prophylactic Propranolol (2nd line) Children >5yrs: - TCA: Prophylactic AMITRIPTYLINE (1st line) - Beta Blocker: Prophylactic Propranolol (2nd line)

Answer 49

ACUTE CVS TREATMENT (based on phase): Phase 1: Prodromal - NSAIDs - ABORTIVE THERAPY ASAP in prodrome or vomiting phase may terminate the attack. Children >12 years SUMATRIPTAN. Phase 2: Vomiting 1) Supportive Care - Quiet, dark, less stimulating environment - VS q4hr 2) REHYDRATION: - Fluid Bolus - 0.9% NS 10-20ml/kg - Maintenance IVF with Dextrose - D10 + 0.45NS + KCL x 1.5 maintenance - Allow PO fluid intake if tolerated 3) ANTIEMETIC: - Ondansetron q6h 4) SEDATIVES: - Lorazepam IV q6h - Diphenhydramine IV q6h 5) ANALGESICS: - Ketorolac IV q6h Phase 3: Recovery - Patient becomes hungry and slowly advances PO intake

Answer 50

Must include ALL of the following: 1) Bothersome nausea as the predominant symptom, occurring ≥ 2x / week and generally not related to meals 2) Not consistently associated with vomiting 3) After appropriate evaluation, the nausea cannot be fully explained by another medical condition *Criteria fulfilled for ≥ 2 months prior to diagnosis

Answer 51

Must include ALL of the following: 1) On average, ≥ 1 episodes of vomiting / week 2) ABSENCE OF SELF-INDUCED VOMITING or criteria for an eating disorder or rumination 3) After appropriate evaluation, the vomiting cannot be fully explained by another medical condition *Criteria fulfilled for ≥ 2 months prior to diagnosis

Answer 52

Must include ALL of the following: 1) Repeated regurgitation and rechewing or expulsion of food that: - Begins soon after ingestion of a meal - Does not occur during sleep 2) Not preceded by retching 3) After appropriate evaluation, symptoms cannot be fully explained by another medical condition. 4) An eating disorder must be ruled out. *Criteria fulfilled for ≥ 2 MONTHS prior to diagnosis

Answer 53

abdominal pain, constipation, nausea, diarrhea, bloating, dental problems, weight loss

Answer 54

Behavioural = reinforce correct eating behavior while minimizing attention to rumination -Diaphragmatic breathing -Chewing gum postprandially

Answer 55

Must include ALL of the following: 1) Excessive air swallowing 2) Abdominal distention due to intraluminal air which increases during the day 3) Repetitive belching and/or increased flatus 4) After appropriate evaluation, symptoms cannot be fully explained by another medical condition *Criteria fulfilled for ≥ 2 months prior to diagnosis

Answer 56

Must include ≥ 1 of the following bothersome symptoms ≥ 4 days / month for ≥ 2 months prior to diagnosis: - Postprandial fullness - Early satiation - Epigastric pain or burning not associated with defecation - After appropriate evaluation, symptoms cannot be fully explained by another medical condition

Answer 57

Abdominal pain ≥ 4 days / month over ≥ 2 months associated with ≥ 1 of the following: - Related to defecation - A change in frequency of stool - A change in form (appearance) of stool - In children with abdominal pain and constipation, the pain does not resolve with resolution of the constipation - After appropriate evaluation, symptoms cannot be fully explained by another medical condition *Criteria fulfilled for ≥ 2 months prior to diagnosis

Answer 58

Must include ALL of the following occurring ≥ 2x: 1) Paroxysmal episodes of intense, acute periumbilical, midline or diffuse abdominal pain lasting ≥ 1 hour or more (should be the most severe and distressing symptom) 2) Episodes are separated by weeks to months 3) The PAIN is INCAPACITATING and interferes with normal activities 4) STEREOTYPICAL pattern and symptoms in the individual patient 5) The pain is associated with ≥ 2 of the following: - Anorexia - Nausea - Vomiting - Headache - Photophobia - Pallor 6) After appropriate evaluation, the symptoms cannot be fully explained by another medical condition *Criteria fulfilled for ≥ 6 months prior to diagnosis

Answer 59

Age <5yrs: - Cyproheptadine (1st line) - Propranolol (2nd line) ≥ 5 yrs: - Amitriptyline (1st line) - Propranolol (2nd line)

Answer 60

Must be fulfilled ≥ 4 days / month AND include ALL of the following: 1) Episodic or continuous abdominal pain that does not occur solely during physiologic events (e.g., eating, menses) 2) Insufficient criteria for IBS, functional dyspepsia, or abdominal migraine 3) After appropriate evaluation, the abdominal pain cannot be fully explained by another medical condition *Criteria fulfilled for ≥ 2 months prior to diagnosis

Answer 61

Must include ≥ 2 of the following occurring ≥ 1x / week for a ≥ 1 month with insufficient criteria for a diagnosis of IBS: - ≤ 2 DEFECATIONS in the toilet per week in a child of a developmental age of ≥ 4 years - ≥ 1 episode of FECAL INCONTINENCE incontinence per week - History of RETENTIVE POSTURING or excessive volitional stool retention - History of PAINFUL or HARD BOWEL MOVEMENTS - Presence of a LARGE FECAL MASS in the rectum - History of LARGE DIAMETER STOOLS which can obstruct the toilet - After appropriate evaluation, symptoms cannot be fully explained by another medical condition

Answer 62

Must include ≥ 1-month history in a child with a developmental age ≥ 4 years of ALL of the following: 1) DEFECATION in INAPPROPRIATE PLACES to the sociocultural context 2) NO evidence of FECAL RETENTION 3) After appropriate evaluation, the fecal incontinence cannot be explained by another medical condition

Answer 63

1. CASEIN 2. Whey, specifically the BETA-LACTOGLOBULIN component of Whey. Casein and beta-lactoglobulin are the two most allergenic and heat-resistant proteins

Answer 64

IgE-mediated (IMMEDIATE): - Anaphylactic reaction involving multiple systems (urticaria +/- angioedema +/- vomiting +/- wheezing +/- hypotension) Non-IgE/cell-mediated (DELAYED): - Food-specific IgE is typically absent + GI reaction after exposure to food is delayed +/- may have chronic presentation - Types = FPIAP, FPE, FPIES Mixed IgE & non-IgE/cell-mediated (DELAYED): - Symptoms are delayed and depend on extent of eosinophilic infiltration of affected organs - Types = Eosinophilic esophagitis (EoE), Allergic eosinophilic gastrointestinal diseases (EGIDs)

Answer 65

Exposure of gut mucosa to broken down milk (or other pro-allergic) proteins → localized inflammation of distal colon → dense eosinophilic infiltration of rectosigmoid mucosa.

Answer 66

Age of Onset: - First 6mo of life (usually first1-4 weeks of life) Clinical Features: - Intermittent, slow-in-onset HEMATOCHEZIA in otherwise healthy growing infant - No emesis, no diarrhea, no FTT Exam: - Normal physical exam Resolution of symptoms: - Within 3 days of removing trigger protein, complete resolution after 2 weeks.

Answer 67

FPIAP is a CLINICAL DIAGNOSIS with resolution of symptoms after removal of trigger food (within 3days - 2weeks). NO further investigations are required. --- - Bloodwork: NOT REQUIRED! (usually normal, can have anemia, peripheral eosinophilia, hypoalbuminemia) - Food-specific IgE tests: NOT REQUIRED! Often negative. - Food-specific RAST: NOT REQUIRED! Often negative. - Oral Food Challenge (OFC): NOT REQUIRED! - Colonoscopy + Biopsy: NOT REQUIRED!

Answer 68

GOAL: Elimination of trigger food in maternal or infant diet 1. Elimination of maternal diet cows milk +/- soy (+/- egg +/- corn) 2. RD involvement (for baby and mom) 3. Maternal Calcium (500mg BID) and Vit D supplementation 4. If symptoms persist then can transition to extensively hydrolyzed formula (<10% will require elemental formula) 5. Allergist referral is NOT usually required unless trigger not identified.

Answer 69

Resolution of Initial Symptoms: - Within 3 DAYS (max 2weeks) of removing offending protein from maternal diet or changing to hydrolyzed formula. Achieve Tolerance to Trigger Protein: - Typically achieve tolerance by 12mo of life. - Re-challenge: Parents can trial challenge with fresh pasteurized cows milk at 12mo AT HOME.

Answer 70

Age of Onset: - Early infancy Clinical Features: - Diarrhea (in infancy) - FTT - Steatorrhea - Emesis - Abdominal distension - Lack of acute symptoms (unlike FPIES) Exam: - Exam consistent with FTT Resolution of symptoms: - Within 2-4 weeks of removing trigger protein.

Answer 71

Diagnosis requires BLOODWORK + ENDOSCOPY / gastroscopy with BIOPSY ---- Bloodwork: Shows peripheral eosinophilia, fat soluble vitamin deficiency, anemia, hypoproteinemia, prolonged coagulation time Endoscopy (jejunal biopsy): VILLOUS ATROPHY + CRYPT HYPERPLASIA Stool tests: fat malabsorption

Answer 72

GOAL: Elimination of trigger food in maternal or infant diet 1. Elimination of maternal / infant diet cows milk AND soy (+/- egg +/- corn) 2. RD involvement (for baby and mom) + Monitor growth / nutrition carefully 3. Maternal Calcium (500mg BID) and Vit D supplementation if breastfeeding 4. If symptoms persist then can transition to extensively hydrolyzed FORMULA or elemental formula 5. Allergist referral is NOT usually required unless trigger NOT identified.

Answer 73

Resolution of Initial Symptoms: - Within 2-4 weeks of removing offending protein from maternal diet or changing to hydrolyzed formula (longer than FPIAP and FPIES). Achieve Tolerance to Trigger Protein: - Typically achieve tolerance by 12-18mo of life. - Re-challenge: Parents can trial challenge with fresh pasteurized cows milk at 12mo AT HOME.

Answer 74

Age of Onset: - 2-7 MONTHS of life (when introducing solids into diet) Clinical Features: - Onset of symptoms 1-4hrs after ingestion of trigger protein - PROFUSE REPETITIVE VOMITING - PALLOR - LETHARGY - Watery or bloody diarrhea - UNWELL APPEARING (dehydration, hypovolemic shock, hypothermia, hypotension, aLOC, hypotonia, metabolic acidosis, methemoglobinemia) - Lack of cutaneous or resp symptoms of anaphylaxis Resolution of symptoms: - Within 24hrs of removing trigger protein.

Answer 75

FPIES is a CLINICAL DIAGNOSIS (1x major + ≥3x minor criteria) with resolution of symptoms after removal of trigger food (typically within 24hrs). NO further investigations are required. Technically OFC (Oral Food Challenge) is GOLD STANDARD. But OFC only indicated if trigger food protein unclear or atypical symptom time course. --- - Bloodwork: NOT REQUIRED! (In acute episode can show Anemia, Leukocytosis with Neutrophilia, peripheral Eosinophilia, Thrombocytosis, Hypoalbuminemia, Non-AG Metabolic Acidosis, Methemoglobinemia) - Food-specific IgE tests: NOT REQUIRED! Often negative. - Food-specific RAST: NOT REQUIRED! Often negative. - Colonoscopy + Biopsy: NOT REQUIRED!

Answer 76

1. Rehydration (Bolus + Maintenance IVF) 2. Antiemetic (Ondansetron) 3. +/- IV Steroids (rarely in severe cases)

Answer 77

GOAL: Elimination of trigger food in maternal or infant diet 1. Elimination of cows milk +/- soy (or whatever the trigger protein is deemed to be) from infant diet 2. RD involvement 3. If symptoms persist then can transition to extensively hydrolyzed formula (<10% will require elemental formula) 5. Allergist referral REQUIRED - as OFC (Oral Food Challenge) to be done by allergist / hospital at 12mo to test tolerance.

Answer 78

FPIAP - Re-Challenge Procedure: - At 12 MONTHS of life tolerance to trigger protein is usually achieved, parents can trial challenge with fresh pasteurized COWS MILK at 12mo AT HOME FPE - Re-Challenge Procedure: - At 1-2 YEARS of life tolerance to trigger protein is usually achieved, parents can trial challenge with fresh pasteurized COWS MILK at 12mo AT HOME FPIAP - Re-Challenge Procedure: - At 12-18 MONTHS of life tolerance to trigger protein is usually achieved, an OFC with trigger protein should occur with allergist / hospital supervision

Answer 79

UNCONJUGATED - Physiologic - Hemolytic – immune (ABO etc), non-immune (sepsis/DIC, Hbopathy, ezymopathy (G6PD), membranopathy (HS)) - Non-hemolytic – physiologic, breastmilk, bruising/cephalohematoma, polcythemia - Clearance - Breastmilk jaundice, Gilbert, Cirgler-Najjar - Increased enterohepatic circulation - GI obstruction, dehydration/breastfeeding jaundice CONJUGATED – Hepatocellular (ALT should be high) - Medications, TPN - Infection – Sepsis, TORCH, viral hepatitis, UTI - Metabolic – many IEM (galactosemia, tyrosinemia), A1AT, hemochromatosis, Wilson’s, hypothyroidism - Vascular/ischemic – HF, shock, hypoxia, Budd chiari - Endocrine: panhypotpit, hypothyroid Idiopathic - Mass/Neoplastic – hepatoblastoma CONJUGATED - Biliary/Obstructive – small intrahepatic or large extrahepatic - Mass - Duct plugging – CF, inspissated bile syndrome - Ductal paucity – Alagille - Ductal plate malformation – AR-PCKD - Biliary atresia!! - Choledochal cyst - Biliary sludge, gallstone

Answer 80

Rare congenital dilatation of the biliary tract that can cause progressive biliary obstruction and cirrhosis Most common type is type 1 (dilation of CBD)

Answer 81

abdominal pain, jaundice and a palpable mass - usually present before 10 years old Can present with Charcot's triad - abdominal RUQ pain, fever, jaundice

Answer 82

Roux-en-Y choledochojejunostomy excision of cyst

Answer 83

Malignancy (cholangiocarcinoma), cholangitis, pancreatitis, cholelithiasis, post-op stricture at anastomosis

Answer 84

shows neutrophilic intestinal inflammation

Answer 85

When normal (<50 µg/g in kids), IBD can be ruled out with confidence Refer for endoscopy if >250

Answer 86

Distinguishing functional GI illness from IBD (active neutrophilic inflammation)

Answer 87

Overall when oral feeding is UNSAFE, INADEQUATE or INEFFICIENT Neurologically impaired Poor oral intake and weight gain despite optimizing calories Recurrent aspiration or prolonged feeding times GERD, if it leads to insufficient oral intake Dysmotility despite medical treatment Expected prolonged need for NG feeds (more than 3-6 months)

Answer 88

Hematemesis or melena Epigastric dull pain (relieved by eating) and nausea Feeding difficulties Vomiting

Answer 89

Upper endoscopy with biopsies from esophagus, stomach and duodenum, H.pylori.

Answer 90

gram-negative, S-shaped rod transmitted fecal-oral or waterborne Majority are asymptomatic but can present with epigastric abdo pain; red flags are occult blood in stool, weight loss, vomiting, nighttime awakening

Answer 91

False negs if on acid suppressant (PPI), antibiotics or GI bleed

Answer 92

Urea breath test or stool antigen (better for kids <6yo) ONLY for confirmation of eradication of disease

Answer 93

PPI-Amoxicillin + Clarithromycin x14d If resistance to Clarithromycin consider metronidazole or bismuth based

Answer 94

HYPERcalcemia HYPOkalemia Celiac disease Lead poisoning Mercury poisoning Hypothyroidism Ulcerative colitis Medications CNS disorders: CP, NTD, Hirschsprung’s Lactose intolerance Hypothyroidism

Answer 95

abdominal distension, vomiting, fever, anorexia, weight loss, poor weight gain, blood in stool

Answer 96

Must include ≥ 2 of the following occurring ≥ 1x / week for a ≥ 1 month with insufficient criteria for a diagnosis of IBS: ≤ 2 defecations in the toilet per week in a child of a developmental age of ≥ 4 years ≥ 1 episode of fecal incontinence per week - History of retentive posturing or excessive volitional stool retention - History of painful or hard bowel movements - Presence of a large fecal mass in the rectum - History of large diameter stools which can obstruct the toilet - After appropriate evaluation, symptoms cannot be fully explained by another medical condition

Answer 97

Clinical dx based on history and physical Look for alarm signs P/E: DRE, look for spinal dysraphism, lower extremity reflexes AXR not routinely recommended unless to R/O fecal impaction in a child who is otherwise difficult to examine W/u if red flags: Extended lytes Celiac screen TSH Spinal imaging Barium enema (to screen for Hirscsprungs), rectal biopsy (dx test for Hirschsprungs)

Answer 98

- education of mechanism - behavioural modificaiton (timed toileting, remove punishments, physical activity, diary stool frequency) - dietary modifications with higher fibre and water intake - fecal disimpaction: PEG 3350 1-1.5g/kg/day x3 days with maintenance dosing afterwards x6 months MINIMUM

Answer 99

No known evidence of chronic liver dz Biochemical evidence of injury Hepatic-based coagulopathy (threshold changes +/- HE) INR >1.5 not corrected by Vit K with Hepatic Encephalopathy (HE) INR > 2 without HE

Answer 100

Drugs: Acetaminophen overdose Anticonvulsants Ecstasy Organic mushrooms INH Metabolic Wilson’s disease Galactosemia Tyrosinemia Fatty acid oxidation disorder Mitochondrial Alpha-1 antitrypsin deficiency Neonatal hemochromatosis Immune: autoimmune hepatitis Infections: hepatitis A, B, E; HSV, EBV, Enterovirus, adenovirus, parvo B19, coxsackie virus Ischemic: shock, Budd Chiari, cardiac HLH Indeterminate/Idiopathic (50%)

Answer 101

Anorexia, nausea, vomiting Fatigue, malaise, lethargy, irritability Jaundice (+ dark urine, pale stools, pruritus) Bleeding (varices, GI tract) Ascites (22%), hepatomegaly, splenomegaly Hypoglycemia, lactic acidosis, coagulopathy Pancreatitis, ARDS AKI

Answer 102

Coagulopathy: prolonged INR, PTT Fibrinogen (low) Factor V and VII (low) Bilirubin, AST, ALT, alk phos, GGT High Ammonia Glucose (low) CBC, urea, creat, blood gas, lytes, extended lytes Viral serology: Hepatitis A, B, C, EBV, CMV AIH: Immunoglobulins, anti-LKM, anti-SMA, ANA Wilson: Serum copper, ceruloplasmin, 24-h urinary Cu Serum α-1-AT Ferritin Liver imaging – AUS + Doppler Liver biopsy (later investigation if confirmed or unknown etiology post Ix)

Answer 103

Autosomal recessive, gene ATP7B found on Chromosome 13 (13q14.3) It is important to screen all first degree relative

Answer 104

1. Elevated urine copper 2. Low ceruloplasmin 3. Mild elevation of transaminases, low alk phos 4. Hemolytic anemia (DAT negative) 5. Conjugated hyperbilirubinemia

Answer 105

Kayser-Fleischer rings on slit-lamp exam Neurologic derangement

Answer 106

Copper chelators - D-penicillamine and Trientene Zinc - decreased intestinal absorption of copper Avoid dietary copper

Answer 107

OTC analgesics can be used as monotherapy for mild to moderate pain or as co-therapy for moderate to severe pain Ibuprofen is more effective than acetaminophen for the treatment of childrens pain IN fentanyl is an effective analgesic for moderate to severe pain with no IV access. IV morphine is common once access is established. Codeine should never be used for acute pain

Answer 108

recurrent or persistent pain for > 3 months

Answer 109

psychological, physical, occupational and pharmacological therapy combined pharmacologic: antidepressants (eg amitrypitilne) or anti-epileptics (eg gabapentin, pregabalin)

Answer 110

Must include 1 month of ≥ 2 of the following: - ≤ 2 defecations / week - History of excessive stool retention - History of painful or hard bowel movements - History of large diameter stools - Presence of a large fecal mass in the rectum In toilet trained children, the following additional criteria may be used: - ≥ 1 episode / week of incontinence after the acquisition of toileting skills - History of large diameter stools which may obstruct the toilet

Answer 111

>2 of the following occurring at least once per week for a minimum of 1 month - ≤ 2 defecations / week - ≥ 1 episode / week of incontinence - history of retentive posturing - history of painful or hard bowel movements - presence of large fecal mass in the rectum - history of large-diameter stools that can obstruct the toilet

Answer 112

1. systemic symptoms such as fever, abdominal distension, weight loss or poor weight gain, decreased appetite, and bloody diarrhea 2. onset before 1 month of age 3. delayed passage of meconium 4. failure to thrive 5. intermittent diarrhea and explosive stools 6. abnormal neurological examination 7. no response to treatment

Answer 113

PEG cleanout (1 g/kg for 3 days) and maintenance (0.2 - 0.8 g/kg) - treat for 6 month minimum

Answer 114

1. Low intake of VitD rich foods (consuming <2cups/day of milk or fortified soy beverage, low consumption of fish and sea mammals) 2. Lack of Vit D supplementation during pregnancy 3. Use of certain medications (ex: some antiretrovirals and antiepileptics 4. Multiple pregnancies 5. Smoking

Answer 115

Mother not ingesting sufficient Vit D supplements or otherwise at risk for for Vit D deficiency (regardless of infant feeding mode)

Answer 116

1. Low intake of Vit D rich foods 2. Mother has risk factors for VitD deficiency 3. Lack of Vit D supplementation during infancy

Answer 117

1. Darker skin pigmentation 2. Food insecurity 3. Obesity 4. Living in communities North of 55* latitude (Edmonton is 53) 5. Living i area where Vit D deficiency is prevalent 6. Extensive use of sun block or skin coverage by clothing or lack of exposure to outdoors 7. Low socio-economic status

Answer 118

1. Vitamin D deficiency (malabsorption, CKD, nutritional deficiency) 2. Calcium deficiency (low intake, prematurity, malabsorption) 3. Phosphorous deficiency (low intake, prematurity, aluminum-containing antacids) 4. Renal losses (McCune-Albright syndrome, Fanconi syndrome, distal RTA)

Answer 119

1. Widening of epiphyseal plate 2. Loss of zone of calcification at epiphyseal/metaphyseal interface 3. Cupping, splaying, stippling and formation of cortical spurs at the growth plate, best seen at the distal ulna 4. Osteopenic shafts of long bones 5. Thin cortices

Answer 120

1. Delayed motor milestones (delayed walking or standing, frequent falling) 2. Delayed growth / FTT 3. Fractures 4. Hypoplasia of dental enamel 5. Decreased muscle tone 6. Leg pain 7. Cardiomyopathy 8. Hypocalcemic seizures 9. Increased risk of infection 10. Increased sweating in infants see RC photo

Answer 121

Low calcium, Low Phosphate, High PTH, Low 25-Vit-D, High ALP

Answer 122

Calciferol (2000-1000 units/day) Calcium 100 mg/day

Answer 123

Acute toxicity: - N/V - Vertigo - Blurred vision

Answer 124

Teratogenic: cleft palate, cardiac abnormalities Chronic: alopecia, dry skin, carotenemia, HSM, hepatic toxicity, arthralgia, IIH, bone anomalies (swelling & pain of long bones, bone fragility)

Answer 125

- Dry conjunctiva - Bitot spots - foamy, white/grey patches on the outer conjunctiva) - Night blindness - Dry skin with follicular hyperkeratosis

Answer 126

Wet Beri Beri (Cardiovascular) - presents with tachycardia, cardiomegaly, high output heart failure, peripheral edema, dyspnea Dry Beri Beri (Neurologic Form) - symmetrical peripheral neuropathy, muscle weakness, areflexia, foot drop Wernicke-Koraskoff syndrome

Answer 127

- Edema of mucous membranes - Chelitis; Stomatitis; Glossitis

Answer 128

Pellagra- present with 3 Ds: 1. Dermatitis (Hyperpigmentation in sun exposed areas) 2. Diarrhea 3. Dementia (CNS sx, confusion, hallucinations, irritability, ataxia, seizures)

Answer 129

- Listlessness, IRRITABILITY, Insomnia - FTT; Vomiting - Microcytic ANEMIA; Decreased Ab formation - Difficulty walking, weakness, seizures - Nasolabial SEBORRHEIC DERMATITIS, CHELOSIS, GLOSSITIS, STOMATITIS

Answer 130

- Ataxia - Sensory neuropathy

Answer 131

- Macrocytic anemia - Sensory predominant neuropathy hx of exclusive goat milk formula, methotrexate or phenytoin use. if Mom has B9 deficiency --> baby may have neural tube defects, low birth weight and premature FYI: Dx = macrocytosis + low folate levels Tx = folic acid, enriched cereals, grains, dark leafy veg

Answer 132

- MACROCYTIC ANEMIA (pernicious anemia); Low reticulocytes; Thrombocytopenia; Neutropenia - Peripheral neuropathy; Weakness - Paraethesias; Impaired proprioception - Loss of DTRs - Confusion - Hx of vegan/vegetarian diet or short gut

Answer 133

- BLEEDING GUMS; Epistaxis; Petechiae & Ecchymoses - POOR WOUND HEALING - Coiled CORKSCREW HAIRS; Follicular Hyperkeratosis; PERIFOLLICULAR HEMORRHAGES - ARTHRALGIAS; Pseudoparalysis; "Woody edema" & LEG SWELLING (*knees & ankles - Scurvy "scorbutic rosary" of costcochondral junction + sternal depression

Answer 134

“Scorbutic Rosary” from vit C deficiency

Answer 135

- Myopathy / muscle weakness - Ataxia - Vision loss; Retinal degeneration - Hemolytic Anemia - Vit E def can occur from fat malabsorption

Answer 136

- Elevated INR - Hemorrhagic disease (of newborn)

Answer 137

Timing of onset: - Classically occurs after weaning from breast milk to formula or cow’s milk Symptoms: - SYMMETRIC RASH (vesiculobullous, eczematous, dry, scaly) in specific locations (PERIORAL, PERINEAL areas, acral, cheeks, knees, elbows) - CHRONIC DIARRHEA - GROWTH DELAYS - INTEGUMENT CHANGES (Glossitis, stomatitis, paronychia, atypical Hair (peculiar reddish tint) +/- alopecia) Can also have irritability, delayed wound healing, and ocular changes (conjunctivitis, blepharitis)

Answer 138

1. anatomical abnormalities 2. gastric dysmotility 3. medical and psychiatric conditions leading to consumption of non foods

Answer 139

abdominal x-ray can suggest a bezoar which is then confirmed on US, fluoroscopy or CT

Answer 140

Bezoars in the stomach can usually be removed endoscopically Large bezoar need to be surgically removed

Answer 141

1. Mucosal inflammation (IBD, celiac, EOE), erosion, or ulceration 2. Infection: C. difficile, CMV, giardia, H. pylori, measles, TB 3. Non-infectious: Allergic gastroenteropathy, celiac disease, HSP, IBD, polyposis, portal HTN, NEC, SLE 4. Intestinal lymphangiectasia 5. Secondary causes: CHF, pericarditis, thoracic duct damage, post cardiac surgery (Fontan)

Answer 142

Fecal alpha-1 antitrypsin or fecal calprotectin Small bowel contrast studies: thickened folds Endoscopy: mucosa with snowflake pattern, lesions are patchy (need multiple biopsies); histology shows dilated lacteals decrease protein (non selective): low albumin, low transferring, low immunoglobulins, low ceruloplasmin, low fibrinoge

Answer 143

Treat underlying disease Nutritional support: high protein, low fat with high-medium chain triglyceride (MCT) diet, supplement fat soluble vitamins Diuretics for edema Consider IV albumin if symptomatic

Answer 144

Deficiency in alpha 1 antitrypsin which is a protease inhibitor synthesized in the liver that protects alveoli from destruction by neutrophil elastase. Abnormal a-1 antitrypsin forms polymers that damage hepatocytes

Answer 145

jaundice, hepatomegaly and acholic stool first 1-2mo of life conjugated hyperbili, pruritis high AST/ALT/GGT Can resolve or develop cirrhosis.

Answer 146

Low serum A1AT level* plus confirmatory phenotype with gel electrophoresis (or confirmatory genotype) *serum A1AT can be falsely elevated if inflammation present (acute phase reactant)

Answer 147

Risk of hepatocellular carcinoma Asthma

Answer 148

Counsel to avoid smoking Liver transplant if hepatocellular carcinoma, end-stage liver disease with portal HTN

Answer 149

Eating disturbance resulting in one or more of: (1) weight loss or failure to gain weight appropriately (2) nutritional deficiency (3) dependence of enteral feeds or supplements (4) significant psychosocial dysfunction *No evidence of body image distortion

Answer 150

GER: passage of gastric contents into the esophagus (with or without regurgitation and vomiting) GERD: GER leading to troublesome symptoms and/or complications

Answer 151

CLINICAL - excessive crying, back arching, regurgitation and irritability no diagnostic tests required unless there are red flags, which warrant peds GI referral

Answer 152

constitutional: -wt loss, lethargy, fever -excessive irritability/pain timeline red flags: -onset of regurg/vomiting <1wk or >6mo -persisting >12mo (ie still needing PPI) GI sx red flags: -forceful vomiting persistently -nocturnal vomiting -bilious emesis -bleeding (hematemesis, rectal bleed) - abdo distension -chronic diarrhea

Answer 153

Barium swallow – useful to evaluate for anatomic abnormalities (hiatal hernia, malrotation, pyloric stenosis, duodenal web, duodenal stenosis, antral web, esophageal narrowing, Schatzki’s ring, achalasia, esophageal stricture, and esophageal extrinsic compression) Video fluoroscopic swallow study (VFSS) – does not assess for GER but does assess for oropharyngeal dysphagia and aspiration which can mimic GER EGD with biopsy – to detect complications of GERD (such as strictures, Barrett esophagus), to diagnose conditions that predispose to GERD (such as hiatal hernia) or to diagnose conditions that might mimic GERD (such as eosinophilic esophagitis, infectious esophagitis)

Answer 154

avoid overfeeding thicken feeds continue breastfeeding (*Do NOT recommend positional therapy in sleeping infants)

Answer 155

cow’s milk elimination in mom’s diet for breastfed infants or, hydrolyzed protein or amino acid based formula

Answer 156

4-8 wk of PPI (omeprazole, lansoprazole, rabeprazole, etc.) then try to wean 2nd line: H2 receptor blocker (ranitidine) side effects of PPI: NEC, pneumonia, URTI, C Diff FYI Refer to peds GI if infants can't be permanently weaned from PPI by 6 to 12 months of age

Answer 157

Arteriohepatic dysplasia, causes paucity of bile ducts ie no bile ducts

Answer 158

AD inheritance – JAG1 >> NOTCH2

Answer 159

*Cholestasis – jaundice, acholic stools as neonate, progressive severe pruritis, Cirrhosis later in life High ALP, GGT, conjugated bili modest elevation in ast/alt *hepatomegaly in all pts Facial – broad forehead, deep set hypertelorism, under-developed mandible, bulbous tip nose Eye – posterior embryotoxin (see photo, vison unaffected), hypertelorism (widely spaced eyes) CVS – pulmonary artery stenosis, Moyamoya (stroke), xanthomas (++ high cholesterol, but not atherosclerotic) Butterfly vertebrae, Spina bifida renal problems short stature, pancreatic insufficiency

Answer 160

either JAG1 or NOTCH2 gene mutation Fam hx Cholestasis (with intrahepatic bile duct paucity) Cardiac murmur/heart disease Skeletal anomalies (eg Butterfly vertebrae) Ocular findings (vision NOT affected) Renal anomalies Structural vascular anomaly Characteristic facies

Answer 161

ONLY children who you suspect have PUD Should not be done as initial testing for iron deficiency anemia (could be considered for refractory IDA) Should not be done for those with functional abdominal pain Should not be done with epigastric pain that is not suspected to be PUD Should not be done as workup for short stature. Could be considered when investigating causes of chronic ITP.

Answer 162

Always with EGD. At least 6 gastric biopsies needed. Unless testing for chronic ITP --> then can do non invasive testing with stool antigen test Testing should wait at least 2 weeks after stopping PPIs and 4 weeks after stopping antibiotics Do NOT use antibody tests (IgG, IgA) for H pylori in serum, saliva, urine etc

Answer 163

Patients with PUD, ulceration, scarring who are identified as having H pylori Others --> not clear Incidental findings, antral nodularity, H pylori gastritis --> no clear evidence to treat

Answer 164

If suspectible to Clarithromycin (CLA)and Metronidazole (MET): PPI - Amox - Clarithromycin If resistant to CLA, susceptible to MET: PPI - Amox - MET If resistant to MET, susceptible to CLA: PPI - Amox - CLA If resistant to CLA and to MET: PPI - Amox - MET with high dose Amox or bismuth-based OR PPI- Amox-MET-CLA Unknown: PPI - Amox - MET All for 14 days

Answer 165

Should do a urea breath test OR a 2-step stool antigen test 4 weeks after completion of antibiotic therapy for H Pylori to assess eradication

Answer 166

If you have a patient with functional abdominal pain / heartburn / vague abdominal pain symptoms etc, in adults they would do a stool antigen test and treat for H Pylori if positive (this is "test and treat") We do NOT do this in children. Only look for H Pylori WITH A SCOPE and generally ONLY if you suspect PUD (with some rare exceptions like chronic ITP or refractory IDA).

Answer 167

Inherited - Acrodermatitis enteropathica Autosomal recessive Affects intestinal absorption and transport of zinc Acquired - impaired zinc excretion in breast milk (most common)

Answer 168

Diarrhea Skin eruption: well demarcated erythematous plaques → specifically perioral/ perianal areas alopecia Irritability FTT

Answer 169

Plasma zinc level Tx with zinc supplement

Answer 170

Hematemesis or melena Dull, aching epigastric pain and nausea "Classic symptom" is epigastric pain alleviated by the ingestion of food

Answer 171

H Pylori NSAIDS (most common) Steroids Infectious gastritis Zollinger-Ellison syndrome (gastrin-secreting tumours) Chronic disease (Crohn's, celiac) Idiopathic

Answer 172

Calcium Inciting event results in excessive intracellular calcium signalling within a few acinar cells

Answer 173

Idiopathic Gallstones Ethanol Trauma (blunt abdominal trauma) Systemic conditions (sepsis, shock, SLE, JIA, IBD, HUS, others) Infections (mumps, CMV, HSV, others) Drugs (VPA, L asparaginase, 6-MP, azothioprine) Structural abnormalities (pancreaticobiliary junction malunion, annular pancreas, pancreas divisum) Metabolic diseases (DKA, organic acidemias, a-1-antitrypsin, prolonged TPN, hyperlipidemia) Genetic mutations (CTFR, SPINK 1, others)

Answer 174

As per INSPPIRE criteria, a diagnosis of AP requires at least 2/3 of the following: (1) abdominal pain compatible with AP (2) serum amylase and/or lipase values 3 times upper limits of normal (3)imaging findings consistent with AP

Answer 175

Lipase usually is increased within 6 hours of symptoms but peaks at 24-30 hours and remains elevated for a week lipase is more sensitive and specific marker for AP Amylase is secreted from several organs including the salivary glands. Amylase levels can also be altered by the etiology of pancreatitis. Amylase can also normalize by 24 hours after onset of symptoms, limiting usefulness.

Answer 176

Decompensated liver failure, renal failure, intestinal inflammation (including celiac disease and inflammatory bowel disease), abdominal trauma, diabetic ketoacidosis, and head trauma

Answer 177

Blunt abdominal trauma Multisystem disease (eg HUS, IBD) Biliary or obstructive (eg choledochal cyst) Drug toxicity Anatomic (annular pancreas, pancreas divisum)

Answer 178

Xray usually non specific - CXR may show pleural effusions, pericardial effusion, pulmonary edema - Abdo XR may show snetinel loops, dilation of the transverse colon, ileus, ascites (diffuse haziness) CT most helpful for diagnosis of pancreatitis However can have normal imaging in pancreatitis US helpful to diagnose biliary stones MRCP and endoscopic retrograde cholangiopancreatography are essential in the investigation of recurrent pancreatitis, nonresolving pancreatitis, disease associated with gallbladder pathology

Answer 179

No definitive labs for diagnosis Imaging probably most helpful in dx However should send these: - IgG - ANA - Anti LKM - Anti dsDNA

Answer 180

Analgesia Fluid, electrolyte and mineral balance should be restored NG suction is useful in patients who are vomiting

Answer 181

Age < 7 Lower body weight Elevated WBC LDH > 2000 Other predictors of severe disease at 48 hours: - increased serum calcium - serum albumin - BUN - high fluid requirements

Answer 182

Liver enzymes, ALP and GGT, and bilirubin Triglyceride level Calcium level

Answer 183

Provide fluid resuscitation Prevent long term complications (fluids can help preserve pancreatic perfusion and microcirculation which helps prevent formation of microthrombi and progression to severe disease)

Gastroenterology Topic Reviews Flashcards

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