GI Flashcards
(211 cards)
1
Q
28 yr old G1 Po0 with no prenatal care came in with contractions saying her water broke that morning. A quick bedside US showed a term sized infant and polyhydramnios. Due to the size and position of the infant she couldn’t see much else beside grossly normal skeleton and head size.
What fetal abnormalities lead to polyhydramnios?
A
not swallowing fluid, kidney problems, obstruction is the most common cause
2
Q
You (and everyone) immediately notice the mass of intestines outside the baby. As you lay the baby on the warmer you can see that the intestines are separate from the cord and there are no other organs visible.
A
Gastroschesis
3
Q
Functional abdominal pain… sx caused by, work up
A
Sx without pathologic correlate
Lab tests/ work up negative
Variant of normal anatomy
4
Q
Organic problems… sx caused by, workup
A
Sx caused by a distinct pathological entity
Labs and workup indicative of underlying pathology
Disease state -requires intervention
5
Q
CBC shows
A
infection, inflammation, bleeding
6
Q
Chem 7 shows
A
hydration
7
Q
LFTs show
A
Bili/ALT /AST/ Alk Phos/ GGT
Coags : PT / PTT / Fibrinogen
8
Q
amy and lipase show
A
pancreas
9
Q
xray shows
A
Gas patterns, dilation, ileus, retained stool, obstruction
10
Q
Barium swallow or barium enema shows
A
Reflux, obstruction, malrotation , ulcer, certain IBD
Colon size, obstruction,intususseption, US
Pylorus, gallbladder, appendicitis
11
Q
CT shows
A
Mass, appendicitis
12
Q
Endoscopy shows
A
Gastritis, ulcers
13
Q
what are the most common sources of acute abd pain in young children
A
Malrotation, intussusception, incarcerated hernia, congenital anomalies
14
Q
what are the most common sources of acute abd pain in older children?
A
appendicitis
15
Q
Chronic abdominal pain is ____70-90% of time
A
Functional
16
Q
what are functional problems? 2 ex chronic
A
constipation or IBS
17
Q
chronic abd pain is ____10-30% of time:
A
Organic
18
Q
short list of causes of chronic abd orgainic pain
A
Gastritis/ulcer
Lactose intolerance
Parasites
Gall bladder disease
19
Q
what are symptomos of chronic fxnl abd pain
A
periumbilical – or not, Pain day and night No weight loss May have pallor, N/V/F Little relationship to bowel habits May be IBS (bloating, postprandial pain, lower abdominal distension)
20
Q
what are useful tests in chronic fxnl abd pain
A
CBC, UA/UC , stool for occult blood
21
Q
how do you treat chronic fxnl abd pain?
A
: reassurance and explanation of functional pain
Fluids, diet, activity, sleep, emotions
22
Q
what is IBS also called
A
Recurrent Abdominal Pain Syndrome of Childhood
23
Q
what is IBS?
A
Abnormal electrophysiology of bowel wall
Familial
24
Q
when does IBS start and what are symp?
A
Often have diarrhea as infants, then constipation as older children
Abdominal pain in early school years
Often stress-associated, risk of school avoidance
Rarely awakens at night
25
how do you treat IBS
Important not to “medicalize”
| Increased fiber in diet may be helpful
26
what is the most common cause of vomiting?
Viral Gastroenteritis
27
what are other things that could cause vomiting
-Obstruction, and acute or chronic inflammation of GI tract
-CNS inflammation, pressure or tumor
-Metabolic derangements
IEM, sepsis, drug intoxication
28
projectile vomiting is a result of
high obstruction, ie pyloric stenosis
29
what does bilious vomit mean?
obstruction
Beyond ampulla of vater … duodenal, jejunal, ileal, colonic
** Malrotation
30
what does bloody vomiting mean?
mallory weis tear
Gastritis
Peptic ulcer?
31
vomiting in neonates what should you think?
obstruction or stenosis
32
what is forceful nonbilious vomiting in neonates?
pyloric stenosis
33
what else should you thing for vomiting in neonates?
```
-Obstruction
Duodenal atresia and stenosis
Malrotation / volvulus
Pyloric stenosis- forceful, nonbilious
-MetabolicAcidosis
Sepsis
Metabolic disorders / Inborn errors of metabolism
```
34
Vom first thing in the morning with HA might mean
CNS related
35
in older children vomiting is d/t
Viral Illness
Strep pharyngitis
UTI
Otitis media
36
if chronic vomiting think...
consider CNS
37
if with pain or bilious emesis in older children?
bowel obstruction, peptic disorders, appendicitis
38
what labs should you do for vomiting?
Electrolytes, BUN/Cr , CBC, UA/UC , amylase, lipase, LFT
39
what will US pick up for vomiting?
pyloric Stenosis, gallstones, renal stones, hydronephrosis, biliary obstruction, pancreatitis, appendicitis, malroattion, intussusception.
40
what should you do if you suspect appendicitis?
CT
41
how do you treat vomiting?
Treat underlying cause if identified
Management of fluid and electrolytes
Anti-emetics: very carefully
42
Acute diarrhea nearly always
infectious
43
how do you manage viral diarrhea?
Management is supportive – fluids, Na, K
Oral rehydration, starvation prolongs diarrhea
Avoid lactose is helpful
44
what is the most common cause of diarrhea in kids?
rota virus
45
what does rotavirus affect?
Rotavirus affects small intestine
46
how does rotavirus present?
Vomiting first in 80-90% pt followed by low fever
| Diarrhea next .. Can last 4-8 days
47
who does rotavirus affect and when
Mainly infants 3-15mo
| Peaks in winter ….. Transmitted fecal- oral
48
what are complications of rotavirus
Pt become dehydrated / hypernatremic, metabolic acidosis, ketosis from poor intake
49
how do you treat rotavirus?
No antidiarrheal medications- ineffective, poss worsening illness
should be vaccinized at 246 mo
50
what are bacterial causes of diarrhea in kids?
Bacterial – Campylobacter, Salmonella, Shigella, E. coli, Yersinia, C diff
51
Shigella patients often have
high fever
52
Suspect if blood in stool (colitis); if foreign travel
bacterial diarrhea
53
what is shigella dysenteriae?
Shigella dysenteriae, Shigatoxin producing bacteria (E coli O157:H7)
54
how do you work up bacterial diarrhea?
CBC stool culture
55
what is chronic diarrhea?
Healthy appearing – probably functional
| Normal 5-8 stools /day for infants
56
if have wt loss FTT and seem ill with diarrhea what should you think?
probably organaic
57
what are fxnl causes of chronic diarrhea?
Functional causes
Irritable bowel syndrome
Toddler’s diarrhea
58
what are organic cuases of chronic diarrhea?
Organic causes
Food allergies
Malnutrition / Malabsorption syndromes
Impaction
59
what are causes of malabs diarrhea?
Lactose Intolerance
Celiac disease (gluten enteropathy)
Cystic fibrosis
steatorrhea
60
what are other causes of diarrhea?
Inflammatory bowel disease
Hirschsprung’s disease
Immune deficiency syndromes
61
what is Psedomembranis colitis caused by?
C diff
62
who gets cdiff
pt taking abx (Clindamycin, cephalosporins, ampicillin
63
how does cdiff present?
Fever, tenesmus, abdominal pain with diarrhea
64
how do you treat cdiff?
oral metronid or vanco
65
what is definition of chronic constipation?
2 or more of the following for 2 months:
1) < 3 BM/Wk 2)> 1 episode of encoporesis/wk 3) impaction of rectum with stool 4) stool that plugs toilet 5) retentive posturing and fecal withholding 6) pain with defecation
66
what is most childhood constipation
functional
67
what are fxnl constipation causes?
Withholding
| Slow transit times (Irritable Bowel Syn.)
68
what are organic causes of constipation?
Hirschsprung’s disease (obstruction)
Hypothyroidism, cystic fibrosis, anorectal malformation
69
what is hirschsprungs disease?
poor innervation of lg intestines: Absence of Meissner and Auerbach plexi
Sympathetic hyperactivity leading to tonic contraction (doesn’t relax)
70
what is encorpresis?
Chronic constipation with dilatation of rectal ampulla and fecal soiling -- soft stool comes out around
71
what does encorpresis require?
Requires stool evacuation followed by chronic management to avoid reaccumulation of stool,
Stool softeners important
72
how do you treat constipation non pharm? 2 ways
-Diet
Whole grains, fruits, and vegetables. Recommended fiber amount, add 5 to age until 15 then adult amount.
Sorbital-containing fluids (prune or apple juice)
Consider milk elimination trial
-Behavior Modification-based on age and individual factors
Regular sitting on the toilet for 5-10minutes after meals/ gastrocolic reflex. Make sure child has a stepstool if they cannot touch the floor.
Motivation-rewards
Diary/calendar with stickers
Biofeedback-no resources as of yet.
73
what are signs of organic constipation? 5
No passage of meconium within 2 days of birth
Hard, infrequent stooling since birth, especially if breast fed
Poor growth/ development
Distended abdomen
Abnormally placed anus, commonly anteriorly
74
how do you treat constipation with pharm?
Laxatives(MAINSTAY
-Osmotic
Lactulose
Magnesium hydroxide
Magnesium citrate
PEG 3350 (MiraLax, Glycolax)-mix in smallest
amount of fluid like water or crystal light
75
what is the ideal consistency of poo?
ideal consistency- Soft mushy banana or peanut butter like.
76
what else besides laxatives do you treat constipation with?
```
Osmotic enema-phosphate enemas
Lavage-Polyethylene glycol-electrolyte solution (GoLytely)
Lubricant-Mineral oil
Stimulants
Senna-Little tummies
Bisacodyl
Glycerin suppositories
```
77
what are causes of GI bleeding that cause significant amt?
```
uncommon
Peptic ulcer disease
Meckel’s diverticulum
Colitis
Intussusception
```
78
what are causes of minor bleeding in GI
not uncommon
Anal fissures
Mallory-Weiss tear
Swallowed nasopharyngeal blood
79
what are the causes of rectal bleeding in infants?
Colitis (from milk protein) allergy, anal fissure, milk protein allergy
80
what are the causes of rectal bleeding in older children?
Inflammatory Bowel Disease, Meckel’s diverticulum
81
how do you work up GI bleed? labs, imaging
CBC/ CoAgs/ LFT’s/ Stool for blood and culture
xrays
Colonoscopy, Barium enema, CT with contrast
Meckel scan (nuclear med test)
82
what are functional obstructions?
Disordered paristalsis
Paralytic ileus
Septic ileus
Dysmotility
83
what are mechanical obstructions
Narrowing of lumen
Malrotation
Intraluminal obstruction
Meconium plug / CF
84
what are etiologies of obs?
Adhesive
Intussuseptive
Malignant
85
obstruction nonbilious vom? problem is?
proximal to ampulla of Vater
86
obstruction bilious vom? problem is
distal to ampulla of Vater
| often considered surgical issue
87
what is crampy midline pain from?
distension and increased paristalsis
88
what is pain Increasing or progressing in severity and frequency
suggestive of ischemia
89
if no stool in the first 24 hrs...
think about hirschprungs
90
if have fever obstruction could be
+ with gastroenteritis or UTI or sepsis
91
if have fever the obstruction is probably not
intestinal perforation
92
what can cause polyhydramnios?
doesn’t swallow… or obstruction
obstruction often high
esophageal atresia , duodenal atresia
93
what imaging do you do for obstructions?
KUB, crosstable lateral
94
Distension? Loops of bowel visible?
Ileus.
95
Discoloration? Neonates.. Blueish hue .
Perforation, bleeding
96
Erythema
underlying peritonitis
97
increased bowel sounds?
Paralytic ileus, obstruction, ischemia
98
palpations Bowel loops? Guarding? Rebound tenderness
Mass – intussesseption
| pyloric stenosis, early appendicitis
99
on a CBC with diff may show
Thrombocyptopneia
| left shift -> ischemia, sepsis
100
increased lymphocytes ->
viral, gastroenteritis
101
neutropenia
neutropenia -> poor sign
102
what is GER
is the exposure of the esophagus to gastric contents
103
is GER norm in infants?
yes norm to have weakened LES so acid goes up
104
what may cause reflux? 7
Increased frequency of sphincter relaxation
Decreased lower esophageal sphincter resting tone
Poor esophageal clearance of refluxed material
Slow gastric emptying
Eosinophilic Esophagitis
Food Allergies
H Pylori infection
105
how do you treat obstruction?
```
Hydration -> NS/LR IV
Sepsis treatment -> translocation of bacteria
broad spectrum antibiotics, anaerobes?
NG decompression
Surgery
```
106
when is spitting up concerning?
PAIN causes Behaviors: Arching (Sandifer’s Syndrome), crying, oral aversion
GROWTH FAILURE Failure to Thrive (FTT) Pain during or after feeding results in
feeding difficulty
feeding aversion
decreased intake of food
PULMONARY COMPLICATIONS
ESOPHAGITIS
107
what are pulm complications of reflux?
Aspiration pneumonia
Broncho-pulmonary disease
Asthma/reactive airway disease
Apnea and bradycardia
108
what is esphagitis?
irritation of the esophagus
109
what cases of GER are disease and need treatment?
```
Pain in person of any age
Possible cause of severe colic
Family Stress
Crying
Not sleeping
Near-miss SIDS
```
110
what tests do you do for GER?
```
Upper GI Series
pH Probe/Impedance Scan
Video swallow study
Upper Endoscopy (EGD)
Gastric Emptying Study
```
111
what is Sandifer’s Syndrome halmarked by?
GER
112
what are easy treatments for GER?
Time-honored, sm freq meals, positioning
```
Thickened feeds:
-may or may not help
-risk of choking
-may decrease intake
Change of formulas
```
113
what are NOT approved with treatment of GER?
Prone position: NOT used now because of SIDS risk
114
what do you use pharm for GER
H2 antag, or PPIs
115
what is blackbox warning on reglan?
unacceptable irritability
116
what do you do if no meds work for GER
```
NG tube feeds
Surgical Procedures:
-Nissen fundoplication
-PEG procedure:
-G-tube, J-G-tube
```
117
what has syptoms of copious oral secretions,choking aspiration
TE fistula
118
how do you test for TE fistula?
unable to pass NG tube. Xray showing coiled NG tube at ~ T3
119
what is TE fistula associated with?
VACTERL
120
```
what has associated anomalies with
Vertebral 70%
Anal atresia 50%
Cardiac 30%
TE –F 70%
Renal 50%
Limb anomalies 70%
```
esophageal atresia
121
who gets umbilical hernias?
Girls> boys
| African Americans> others
122
how do you repair umb hernias
Repair surgically at 1-2 years if > 2 cm.
| Bands/taping doesn’t help
123
who gets ing hernias?
Boys > girls 9:1
| More prevalent in premature infants (30% in < 1000g)
124
how do you treat ing hernias?
Rarely incarcerated
| Surgical correction per surgeon.
125
what has Projectile, nonbilious vomiting
| Usually starts 2-6 weeks of life
pyloric stenosis
126
what causes pyloric stenosis?
Hypertrophy of pylorus - cause unknown
Progressive gastric outlet obstruction
oral Erythromycin in neonatal period has been associated with higher incidence of pyloric stenosis in infants < 30days
127
if kid shows Constipation, dehydration, weight loss, apathy think..
pyloric stenosis
128
what is the gold standard diag of pyloric stenosis
US
129
what is less common cause of peptic disease?
Hpylori
130
what is the common age of peptic ulcers?
12-18
131
what are causes of peptic disease?
In childhood most are secondary to underlying illness, toxins, or drugs causing a breakdown in mucosal defenses.
CNS disease, burns, sepsis, multiorgan failure
Pulmonary insufficiency, Crohn disease, RA
132
in kids under six sx for PUD are
vomiting and UGI bleeding
133
in older kids what is sx for PUD?
abd pain hours after meals
134
what is the most accurate test for PUD
UGI shows ulcer crater. Endoscopy most accurate test.
135
pain with peptic ulcer disease..
Pain usually several hours after meals
Can awaken pt at night
Eating relieves pain
Gastric ulcers may be more painful with eating
136
where are intestinal atresias most likely?
jejunum
137
what is intestinal atresia?
Complete or partial blockage by stenosis, webs or atresia
138
what is the end result of atresias?
End result is obstruction with dilated bowel proximally, small disused bowel distally
139
what obstruction presents sooner with distension and possible emesis
complete
140
sx =polyhydramnios, bilious emesis, abdominal distension within hours of birth
dudoenal atresia
141
what Can pass meconium normally
associated with
Esophageal atresia, intestinal atresias, cardiac and renal abnormalities
Down Syndrome 20-30%
duodenal atresia
142
what is the work up of duodenal atresia?
Xray = double bubble sign
Absence of gas distal to obstruction suggests atresia , severe obstruction
BE may help determine malrotation or atresia in lower GI
143
how do you treat duodenal atresia?
surgery – duodenoduodenoscopy (bipass stenosis)
144
what are common congenital issues?
Gastroschisis
Omphalocele
CDH
145
```
what is an Abd wall defect
Rt of umbilicus
No sac over intestines
Associated with atresias
Surgical correction
Motility probems common
```
gastroschisis
146
what is a Herniation through cord
Associated with anomalies
Esp cardiac
Liver and stomach involvement
omphalocele
147
Abdominal contents in chest due to failure in diaphragm formation at 8-10wk gestation
what is this?
Congenital Diaphragmatic Hernia
148
how do you treat CDH?
NPO, NG for gastric decompression, Surgery
149
if CDH is small....
Can present in toddlerhood with worsening respiratory distress and failure to thrive
150
what is Outpouching of ileum in mid to distal ileum
meckels diverticulum
151
what Can be a lead point for intussusception or volvulus
meckels divertic
152
what are symptoms of meckels?
Sx can mimic appendicitis if inflammed
| Dx: via history, nuclear medicine testing
153
how do you treat meckels?
surgery
154
what is absence of ganglion cells in all or part of the colon (colon unable to relax)
hirschsprungs disease
155
90% of infants with Hirschsprung’s in the first____ 24 hours of life.
fail to pass meconium
156
how do you treat hirschsprungs?
Surgery. Diverting colostomy, anastomosis
157
what are sx of hirschsprungs? in neonates
Neonatal – failure to pass meconium by 24 h
Vomiting (can be bilious), abdominal distention, poor feeding
Enterocolitis with fever, explosive diarrhea withhigh mortality.
Accounts for 15-20% of neonatal intestinal obstrx
158
what are sx of hirschsprung in late infancy?
obstipation and distension
159
what are sx of hirschsprung in older child?
constipation
160
what has Foul smelling stools and ribbon-like / abd distension with prominent veins
or FTT as the only presentation
hirshsprungs
161
what are complications of hirshsprungs and sx of it?
Major complication (25%): enterocolitis (fever, foul-smelling diarrhea – significant mortality)
162
what is Telescoping of bowel that causes progressive edema and ischemia
intussusception
163
what ages does intuss occur?
Occurs from 3 months to 3 years (peak 9 months)
164
what is the Hx of intuss?
~20 minute cycles of intermittent pain,
vomiting
Heme positive stools(jelly like) (95% of the time.)
165
how do you treat intuss?
Contrast enema are 95% diagnostic
| 60-80% therapeutic
166
what are complications of intuss?
CI: peritonitis, suspected perforation, shock
167
what is Most frequent cause of intestinal obstruction in 1st 2 yrs of life – idopathic
intuss
168
what presents as Paroxysmal pain and screaming, drawing up legs
Vomiting / Diarrhea 90%
Blood in stools with mucus 50% within next 12 hrs
Lethargy, febrile
intuss
169
Most common indication for emergency abdominal surgery in childhood
appendicitis
170
who gets appendicitis?
Frequency peaks ages late teenage years
171
what are sx of acute append?
Sx :Fever +/- N/V and periumbilical pain RLQ “mcburney’s point”
Peritoneal irritation
Anorexia, vomiting (sometimes bilious) , constipation, diarrhea
Atypical presentations serial exams
Children< 2yr often perf before surgery due to vague sx
172
what labs should you get for append?
Labs: WBC < 15K; pyuria, fecal leukocytes, guiac + stool occasionally ( obtain amylase/lipase/LFT/ UA /Ucx)
Studies: fecolith on xray ~60% , US shows thickened appendix in 93%
CT IS GOLD STANDARD
173
how do yu treat appendicitis
surgery whenever appendicitis cannot be ruled out
174
who gets IBD?
2nd generation but single greatest risk is fhx
175
where does crohns affect? sx?
```
anywhere in GI tract
Most often in terminal ileum (50-70%)
Obstruction, fistulas, absess formation
Perforation or hemorrhage rare
Not continuous –> skip lesions
Sx : abd pain, diarrhea, weight loss
Extra-intestinal symptoms suggest
RA, SLE, hypo pit
Fever, poor growth, uveitis, renal stones, erythema nodosum, microcytic anemia
BE for small bowel disease
Slight increased risk of colon cancer
```
176
UC where? sx?
```
Colon
Sx: rectal bleeding, diarrhea, abd pain
Extra-intestinal symptoms
Arthritic, uveitis, liver disease
Continuous disease – crypt absesses
Colonoscopy with mucosal biopsy best diagnostic
BE also has nearly pathognomonic findings
Increased risk of colon cancer
```
177
disease is a multifactorial, autoimmune disorder that occurs in genetically susceptible individuals.
celiac
178
what is trigger for celiac?
Trigger is an environmental agent-gliadin component of gluten. The enzyme tissue transglutaminase (tTG) has been discovered to be the autoantigen against which the abnormal immune response is directed.
179
what are classic sx of celiac?
```
Abdominal pain
Diarrhea, constipation
Gassiness, distention, bloating
Anorexia
Poor weight gain, FTT (but can be obese)
Irritability, lethargy
```
180
what are 2ndary problems in celiac
```
Anemia, fatigue
Vitamin deficiencies
Muscle wasting
Osteopenia
Short stature
Recurrent abortions / infertility
Delayed puberty
Dental enamel hypoplasia
Dermatitis Herpetiformis
Aphthous ulcers
```
181
only tx of celiac?
fluten free diet
182
how do you dx celiac?
Serum immunoglobulin A (IgA) endomysial antibodies and IgA tissue transglutaminase (tTG) antibodies. Sensitivity and specificity > 95%.
Testing for gliadin antibodies is no longer recommended because of the low sensitivity and specificity for celiac disease.
The tTG antibody test is less costly because it uses an enzyme-linked immunosorbent assay; it is the recommended single serologic test for celiac disease screening in the primary care setting.
IgA deficiency can give false negative
183
what is the gold standard of diagnostic of celiac disease
Confirmatory testing, including small bowel biopsy,
184
what is cholestasis? labs?
= reduced bile flow elevated direct bilirubin
185
generally appear well but jaundiced with
biliary atresia
186
what does biliary atresia progress to?
progresses to cirrhosis
187
how do you treat pyloric stenosis?
pyloromyotomy
188
how do you treat Imperforate anus and Hirschsprungs ?
temporary colostomy
189
how do you treat intestinal atresias?
primary anastomosis
190
how do you treat malrotation/adhesions?
lysis of adhesions and resection of nonviable intestine
191
how do you treat mec ileus?
therapeutic enemas (peds surgery)
192
what has Upper abdomen distended after feeding
pyloric stenosis
193
what labs do you do for pyloric stenosis?
Hypochloremic alkalosis, low K+
194
what will UGI show for pyloric stenosis?
narrowing of pylorus, retention of contrast
195
what is Due to abnormal movement of intestine around the superior mesenteric artery as intestine reenters abdominal cavity at ~10 weeks
malrotation
196
what is midgut volvulus?
duodenojejunal junction-> mid transverse colon. Supplied by superior mesenteric artery
197
what is the most common anomaly in malrotation?
cardiac
198
when do you malrotation present? and how?
>50% present as high obstruction in 1st weeks of life
| Bilious vomiting, distension, bleeding
199
what are late presentations of malrotations?
intermittent intestinal obstruction, malabsorption,diarrhea
200
what does UGI show for malrotation?
UGI shows abnormal placement of ligament of Treitz. (DJ junction rt of spine)
201
how do you treat malrotation?
Absolute Surgical Emergency .. Bowel ischemia and necrosis
202
what is a disease that is primarily of prematurity
Translocation of Bacteria to bowel wall.
NEC
203
what does radiography show for NEC?
pneumatosis, fixed loop, stacking of bowel, free air
204
how do you treat NEC
Medical NEC – ABX, bowel rest
| Surgical NEC - perforation
205
if pt is perfectly still what should you think?
peritonitis
206
if distended abd and loops of bowel visible on radiograph?
ileus
207
if have a blue belly
perforation or bleeding
208
if have erythema on belly
underlying peritonitis
209
increased BS
obs or gastroenteritis
210
decreased bowel sounds
paralytic ileus, obs, ischemia
211
palpation tenderness, guarding, rebound tenderness and distended bowel loops
intuss pyloric stenosis or early appendicitis
