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Gastroenterology > GI > Flashcards

GI Flashcards

1
Q

True or false - children with encopresis feel the urge to defecate

A

false - they don’t
encopresis is fecal soiling: defined as the involuntary passage of decal material in an otherwise healthy and normal child
decal soiling almost always associated with severe functional constipation

treatment of chronic constipation and encopresis:
- aggressive colon clean out, with multiple enemas
- PEG to help with drawng fluid in so that the stools can leave
- should be continued for a minimum of several months (while rectum returns to size)
-

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2
Q

Name 4 tests that might be considered for refractory contsiptation

A 
serum calcium 
TSH
celiac disease
Sweat test if clinically makes sense
MRI of spine - r/o spina bifida occulta or tethered cord
anorectal manometry (motility disorder)
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3
Q

Important historical questions for diarrhea

A

meds (Abx)
immunosuppression
sick contacts, travel, food (incl unsafe water, milk, raw shellfish, juice/fructose, daycare, pets, food prep)

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4
Q

In which patients can salmonella be especially scary?

A

in neonates or compromised host, can be life threatening

other causes of diarrhea which are life-threatening
intussusception, HUS, Hirchprung with toxic megacolon, pseudomembranous colitis, IBD with toxic megacolon

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5
Q

True or false - any newborn with true diarrhea should be taken very seriously and possibly referred to a tertiary centre

A

true - reasons why:
greater potential for dehydration
associated with major congenital intestinal defects:
- electrolyte transport (congenital sodium or chloride losing diarrhea)
- carb absorption (ie congenital lactase deficiency)
- immune-mediated defects (autoimmune enteropathy)
- villous blunting - ie microvillus inclusion disease
can get viral gastro to, bt need to think of these other causes

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6
Q

What is the best test for diagnosing fat malabsorption?

A

72 hour decal fat - gold standard
ingest high fat for 3-5 days, all stool for 72 hours
need to get dietary history also for coefficeicn of fat absorption
steatorrhea: >7% of dietary fat is malabsorbed, in normal infants, up to 15% can be malabsorbed
other tests: sudan stain, steatocrit, absorbed lipids after standardized meal

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7
Q

What is the best stool test to diagnose GI protein loss

A

fecal alpha antitrypsin measurement - most useful stool marker of protein malabsorption, also need to measure the serum to make sure that they don’t have alpha1antitrypsin (should be false-negative)

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8
Q

True or false - fecal leukocytes are present in secretory diarrhea

A

false - inflammatory diarrhea is where there are fecal leukocytes and RBCs, and is characterized by dystntry (symptoms and bloody stools)

secretory diarrhea - characterized by watery diarrhea and absence of decal leukocytes

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9
Q

What are the most common infectious causes of secretory diarrhea

A 
food poisoning - toxigenic
staph aureus
bacillus cereus
clostridium perfringens
Enterotoxic e. coli
vibrio cholerae
giardia lamblia
cryptosporidium species
rotavirus
norwalk-like virus
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10
Q

What are the common infectious causes of inflammatory diarrhea

A 
Shigella
invasive e coli
salmonella species
campylobacter species
C. diff
entamoeba histolytica
yersinia enterocolitica
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11
Q

What percentage of infants <12 months with salmonella gastroenteritis have positive blood cultures

A

between 5-40% may have positive blood cultures
(vs rare in >12 months)
10% can have meningitis, osteomyelitis, pericarditis, pyelonephritis

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12
Q

What is the most common cause of traveler’s diarrhea

A

enterotoxigenic E. coli - most commonly identified cause
depending on location, other bacteria (i.e. campylobacter in soothest asia)
viruses -noroviru, rotavirus
parasites - giardia, cryptosporidium can be present

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13
Q

What is the treatment for traveler’s diarrhea in children

A

TMP/SMX
imodium for children >2 years old
consider cipro in teens

prophylactic antibiotics - do decrease frequency but not routinely recommended because of med risks
best prvention is avoiding previously peeled raw fruits and vegetables and and beverages with tap water

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14
Q

true or false - antibiotic therapy for shigella diarrhea eliminates organisms from feces

A

true - it also shortens the duration of diarrhea

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15
Q

true or false - antibiotic therapy for campylobacter diarrhea prevents relapse

A

true - it does prevent relapse and shotens duration of illness

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16
Q

Which children with salmonella should receive antibiotic children

A 
age <12 months
bacteremia
metastatic foci
enteric fever (ie typhoid)
immunocompromised
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17
Q

Which children with yersinia should get treated with abx?

A

none for gastro alone

indicated if septicaemia or other localized infection

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18
Q

Name differential for diarrhea in newborns

A 
congenital shot gut
congenital lactose intolerance
malrotation with intermittent volvulus
ischemia
defective sodium-hydrogen exchange
congenital chloride diarrhea
microvillous disease
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19
Q

Stool Na is 70 mmol/L and Cl is 20 mEq/L. Is this osmotic or secretory diarrhea?

A

osmotic diarrhea Na 135 mOsm (concentrated), pH70, Cl>40 , mOsm 6.0, no improvement with fasting

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20
Q

What is the osmotic gap of stool

A

osmolality of the decal fluid minus the sum of the concentrations of the decal electrolytes

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21
Q

How should you manage a child with secretory diarrhea?

A
  1. take off feeds
  2. rehydrate and fix lytes
  3. investigation for:
    - enteric pathogens
    - baseline malabsorption w/u
    - proximal small bowel damage
    **if suspect problems with the mucosa, do a small bowel biopsy , if abnormal, give parenteral alimentation and refeeding
    electron microscopy - may reveal congenital abnormalities of the microvillus membrane and brush border
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22
Q

What are some hormonal causes of secretory diarrhea?

A
  1. VIP oma
  2. hypergastrinoma
  3. carcinoid syndrome

consider this if initial studies are negative

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23
Q

What is the most common cause of bloody diarrhea in infants <1 year?

A

allergic or non-specific colitis

usually attributed to cow’s milk protein formula, can occur in breastfed from transmission of maternal dietary antigens

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24
Q

How can you make a definitive diagnosis of C. diff

A

sigmoidoscopy

pseudomembranous plaques or nodules

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25
Q

How helpful is eosinophilia as a diagnostic sign of parasite disease?

A

normally total eosinophil count is not >500/mm3
screening tool: poor PPV (15-55%), negative predictive value is better (73-96^) especially if eosinophil count remains normal

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26
Q

What are the most common presentations of giardiasis?

A
  1. asymptomatic carrier
  2. chronic malbsorption with steatorrhea and FTT
  3. acute gastro
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27
Q

Gold standard for diagnosis of giardia? best non invasive test

A

gold standard: duodenal biopsy (close to 100%)
single-stool exam and stool ELISA for Giardia >95%

other tests: single stool exam for trophozoites or cysts, 3 stool exams, duodenal aspirate, string test

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28
Q

Name some groups of patients at particular risk of giardiasis

A

1 CF

  1. Chronic pancreatitis
  2. Achlorhydia
  3. agammaglobulinemia
  4. hypogammaglobinemia
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29
Q

Potential complications of amebiasis - most common organ it goes to

A

Entamoeba histolytica - to LVR in 10% of patients, to other organs less commonly:
- liver abscess, pericarditis, cerebral abscess, empyema

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30
Q

What is the triad of findings in acrodermatitis enteropathica

A

diarrhea
hair loss
dermatitis

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31
Q

What is the inheritance of acrodermatitis enteropathica

A

autosomal recessve

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32
Q

Which is the other main differential for the clinical presentation of acrodermatitis hepatica

A

dietary zinc deficiency -zinc deficiency can give the same clinical presentation

  1. found in kids with long-term TPN
  2. also in perms with decreased stores and increased requirements
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33
Q

What age of kids most commonly presents with toddler diarrhea?

A

6-40 months
often after enteritis and abx treatment
DO NOT HAVE: fever, pain or growth failure
don’t usually have malabsorption

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34
Q

What are some possible causes of toddler diarrhea

A
  1. too much fruit juice
  2. intestinal hypermotility
  3. increased bile acids and sodium
  4. prostaglandin abnormalities of the intestine

DIAGNOSIS OF EXCLUSION
possible investigations should include: disaccharide intolerance, protein hypersensitivity, parasitic infestation, IBD

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35
Q

Which ethnicity is most likely to have late onset lactase deficiency?

A

Vietnamise - 100% (?)

in US: Native American 90%
Black 75%
Hispanic 50%
White 20%

in World:
Filipino 55%, French 32%, Dutch 0%

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36
Q

True or false - lactase levels are high in infancy

A

yes they are, and then they decline progressively, after age 5, lower levels (so deficiency a bit of a misnomer) ->essentially if they take too much lactose, get symptoms
see chart for differential of secondary lactose deficiency

37
Q

How is lactose intolerance diagnosed

A

most common test - hydrogen breath test - feed them lactose after fasting, collect air (fermentation of carb by bacteria leads to hydrogen after lactose ingestion); peak hydrogen >20 ppm is considered positive test
need colonic bacteria - therefore recent antibiotics not a good idea
direct measure of lctse levels - biopsy of duodenum or jejunum during scope

38
Q

What is the classical clinical presentation of celiac disease

A

9-24 month old child
FTT, diarrhea, abdo distention, muscle wasting and hypotonia
weight decreases before height
can get irritable and despressed, vomiting less common
can also get edema, rickets and clubbing
can be more subtle also

39
Q

What are possible non GI manifestations of celiac disease?

A
  1. dermatitis herptiformis
  2. iron deficiency anemia - unresponsive to supplement therapy
  3. arthritis and arthralgia
  4. dental enamel hypoplasia
  5. chronic hepatitis
  6. osteopenia and osteoporosis
  7. delayed puberty
  8. short stature
  9. hepatitis
40
Q

Screening test for celiac disease

A

anti TTG and IgA and anti-endomysial antibodies - highly sensitive and specific for celiac
because low code - initial screen should be TTG
antigliadin antibodies: NOT as sensitive or specific so not recommended as first-line screening ; check IgA since selective IgA deficiency most common primary immunodeficiency in western countries, more common in patients with celiac disease

41
Q

How do you do definitive diagnosis of celiac disease?

A

small bowel biopsies -
1st one on gluten: villous atrophy, increased crypt mitoses and disorganization and flattening of the columnar epithelium (villous blunting)->after gluten free diet, these findings should reverse completely

42
Q

Name common conditions with increased risk of celiac disease

A
  1. DM1
  2. autoimmune thyroiditis
  3. Down syndrome
  4. Turner syndrome
  5. William syndrome
  6. selective IgA deficiency
  7. 1st degree relative with celiac disease
43
Q

How can you investigate for pancreatic insufficiency?

A

measure decal pancreatic elastase
pancreatic insufficiency - can cause fat malabsorption (i.e. in CF)
decreased measure is associated with pancreatic insufficiency
False positive (i.e. decreased measurement): when sample from diarrhea

44
Q

How much body fluid is lost with mild dehydration, moderate dehydration, severe dehydration?

A

mil: 100 ml/kg fluid loss with >10% weight loss

45
Q

What 3 characteristic are most accurate to predict 5% dehydration?

A
  1. cap refil
  2. skin turgor
  3. abnormal resps
46
Q

true or case - the BUN is a good way to measure dehydration in a kid

A

not very reliable - doesn’t increase until GFR falls to 1/2 normal, then rises by about 1% each hour
may rise even less in a fasting child with disease, 80% of patients with 5-10% dehydration my have a normal BUN

47
Q

What two substances are transported (coupled) at the intestinal brush border

A

sodium and glucose
coupled transport, facilitated by sodium glucose cotranspoter
ORT - enough sodium, glucose, osmolarity to maximize cotransportation and avoid problems of excessive sodium intake/additional osmotic diarrhea
one problem with ORT - not enough calories, however how, making more with cereal or polymers to help

48
Q

A child presents with diarrhea and mild dehydration. How should you rehydrate him?

A

ORT should be used
rapidly - 50-100 ml/kg over 3-4 hours PLU should replace ongoing losses (from the diarrhea)
as soon as rehydrated, should start an age-appropriate unrestricted diet, continue nursing
formula fed - don’t need to dilute, usually don’t need special formula
don’t need labs or meds

49
Q

Which of the following interventions are recommended still for diarrhea?

a) switch to lactose-free formula
b) clear liquids such as ginger ale
c) avoid fatty foods
d) BRAT diet
e) avoid food for 24 hours
f) none of the above

A

f) none of the above

we shouldn’t do any of the things listed anymore
why:
lactose free - usually unnecessary in infants, only in severe malnutrition and dehydration MAY have a small role
clear liquids - lots of these have lots of sugar, increase osmotic diarrhea
fat might reduce intestinal motility
bananas, rice and applesauce and toast diet - unnecessarily restrictive, poor nutrition
don’t need to avoid food - early feeding decreases the intestinal permeability of infection, reduces illness duration and improves nutritional outcome

50
Q

Name 3 benefits of oral ondansetron for gastroenteritis?

A

decreases risk of persistent vomiting
reduces need for IV in ER department
reduces hospitalization (also CPS statement on this); ORT after ondansetron

other meds for anti emetics (i.e. domperidone, metoclopramide, prochlorperazine and promethazine) not supported by guidelines

51
Q

What are some possible side effects of anti motility agents?

A

**usually not for children < 3 year old
examples: imodium (loperamide), diphenoxylate and atropine (lomotil), tincture of opium (Paregoric): can case drowsiness, ileum and nausea, potentiate the effects of certain bacterial enteritises (Shigella, Salmonella) or accelerate the course of antibiotic-associated colitis
also limited evidence in kids

52
Q

What is the big concern with pepto-bismol?

A

can get salicylate overdose

53
Q

What are some adsorbent meds

A

ie attapulgite, kaolin-pectin can cause abdo fullness and interfere with other meds

54
Q

true or false - probiotics can help decrease Ab associated diarrhea in children

A

true, does this by replenishing the good bacteria in the gut
examples include :
lactobacillus GG, bifidobacterium bifidum, streptococcus thermophilus
also CPS statement about this

55
Q

What percentage of children may outgrow a peanut allergy

A

only 20%

food allergies after age 3 also less likely to be outgrown

56
Q

What is Heiner syndrome

is it IgE mediated

A

hematemesis and hemoptysis with failure to thrive
NOT ige mediated, causes chronic pulmonary disease
associated with milk allergy

57
Q

Are heated apples a common cause of oral allergy syndrome?

is oral allergy syndrome IgE mediated

A

nope, usually the allergens are heat labile, so heated (i.e. cooked apple)should be fine
oral allergy syndrome - is IgE mediated
get swelling of oral cavity after having certain fresh fruits/veggies, cross-reactivity to proteins in pollen

58
Q

True or false - skin-prick allergy testing is very sensitive for food allergies

A

true - negative test (<3mm wheal) can exclude IgE mediated food allergy
but low specificity (positive test is less meaningful)

59
Q

True or false - serum allergen-specific IgE levels have good positive predictive value

A

false - lots of false-positive values screening for lots of foods can result in unnecessary food avoidance , lots of variability

atopic patch testing - cell mediated resonse, likely better for late-phase allergens, but not well studied

60
Q

What is the gold standard diagnostic test for food allergy

A

dobule blind, placebo-controlled, food challenge - gold standard
fastint patient without recent antihistamine use, small quantities of the food are given, waiting for the reaction

61
Q

true or false - exclusive breast feeding decreases atopic dermatitis and cow milk allergy

A

true - it does for the first 2 years of life
hydrolysed formulas may delay or prevent atopic dermatitis
(again CPS statement on this topic)

62
Q

When does GER resolve?

A

almost all by 18 months of age (95-98%)
by 12 months - 75-85% resolve
by 6 months - 25-50% resolve

63
Q

When does GER become GERD

A

when physiologic GER - with feeding refusal, poor weight gain, painful emesis, chronic respiratory problems and other

64
Q

Which is the 24 hour pH probe

A

traditionally, 24 hour pH probe most reliable test for the diagnosis of GER, doesn’t detect nonacid reflux
multichannel luminal impednac e- a new test with pH probe to assess nonacid reflux

65
Q

What does a milk scan show?

A

can see postprandial flux and delay in gastric emptying, but can’t distinguish between physiologic and pathologic reflux

66
Q

True or false - upper GI study can indicated reflux?

A

nope, but it can detect anatomic abnormalities such as malrotation which might contribute

67
Q

What finding on endoscopy suggests possible reflux?

A

endoscope - histologic esophagitis suggestive but not diagnostic of reflux - absence of esophagitis does not rule out reflux

68
Q

What finding is often associated with Sandifer syndrome?

A

typically , an esophageal hiatal hernia is also present
Sandifer syndrome: paroxysmal dystonic posturing with opisthotonus and unusual twisting of the head and neck in associated with GER (secrets)

69
Q

True or case - milk-thickening agents improve the results of pH monitoring

A

false -
they DO reduce regurg and vomiting and help with weight gain, but don’t decrease episodes of GER and no effect on reflux index (with pH monitoring)

70
Q

Which pro motility agent has demonstrated efficacy in GERD?

A

cisapride - only pro motility medication with demonstrated efficacy in GERD (but other ones haven’t shown effectiveness)
only liited access because of increased prolonged QT and dysrhythmias

71
Q

What are some indications for fundoplication?

A
  1. recurrent aspiration
  2. refractory or Barrett esophagitis
  3. reflux associated apnea
  4. reflux associated failure to thrive (refractory to medical therapy)
    - wrap the gastric funds around eh distal esophagus, tighten the gastroesophageal junction
72
Q

What are the most common complications of fundoplication?

A
  1. dysphagia
  2. small bowel obstruction
  3. paraesophageal hernia
  4. gas-bloat syndrome: gagging, retching, nausea, abdo distention
  5. post fundo dumping
73
Q

What is the most common symptom of primary peptic ulcer disease?

A

abdo pain - 90% of patients
classically - related to meals - in children this association on half the time
nocturnal pain - 60% of patients (helps distinguish organic)
melena (1/3 of patients)

UNCOMMON features: vomiting, hematemesis, perforation

74
Q

What are the secondary causes of ulcers?

A

Systemic disease: sepsis, acidosis, sickle cell, CF, SLE, renal failure, severe hypoglycaemia
traumatic injury: head trauma, burns, major surgery
drugs and toxins: steroids, NSAIDS, theophylline, tolazoline (nonselective alpha antagonist)), aspirin

75
Q

What is the first line therapy for H. pylori infection

A

most effective treatment remains uncle

current first line: amox, PPI and clarithromycin or metronidazole

76
Q

What is the cause of most peptic ulcer disease in adults?

A

H pylori
in kids, the relationship between gastric ulcera/recurrent abdo pain is more weaker , although stron relationship between astral gastric it and primary duodenal ulcer disease

in adults, most duodenal ulcers (90%) is caused by H pylori, gastric ulceration in 70%

77
Q

How can we detect H pylori?

A 
non invasive:
1. urea breat test
2. serology - doesn't distinguish between past and present infection (and lots of people are colonized with H pylori)
3. stool antigen test
Invasive tests: 
1. culture of gastric biopsy specimen
2. PCR of biopsy specimen
3. ID of histologic gastritis
4. special stains for H pylori
78
Q

how much blood volume is likely lost if there is hypotension and resting tachycardia in a bleeding patient?

A

likely 30% loss

remember that the Hg takes 12-72hours to equilibrate so should use vital signs instead to estimate blood loss

79
Q

What’s the best way to distinguish upper and lower GI bleed?

A

nasogastric lavage - bright red coffee ground - positive, (not pink tinged)
upper GI - proximal to ligament of Treitz
if negative - can rule out gastric esophageal or nasal sources, but still can be duodenal
initial NG insertion very important (because blood can increase the intestinal transit time, make it harder to determine the site)

80
Q

Causes of melena:

A

melena - denatured blood (by acid) usually before ligament of Treitz, can be seen in patients with Meckel diverticulum (as a result of denaturation by anomalous gastric mucosa even though it is a small intestine problem)

81
Q

Which of the following does not cause a false positive tat for blood in stool (i.e. hem occult)

a) red meat
b) ingestion of broccoli
c) iron
d) cantaloupes

A

c) iron does not cause false positive results

other causes of false positive: recent ingestion of red meat or peroxidase-containing fruits and veggies (i.e. broccoli, radishes, cauliflower, cantaloupes, turnips)

how it works: hemoglobin and its derivatives are catalysies for oxidation of guiac (hem occult) and produces a colour change

82
Q

What are some causes of false negative hem occult?

A
  1. ascorbic acid ingestion

2. delayed transit time/bacterial overgrowth (bacteria degrades the hemoglobin)

83
Q

What are some causes of lower GI bleeding in newborn and infants?

A

mucosal causes:
peptic ulcer disease, NEC, infectious colitis, eosinophilic/allergic colitis, Hirschprung
Structural causes:
intestinal duplication, meckel diverticulum, intussusseption

84
Q

A previusly asymptomatic 18 month old child has large amounts of painless rectal bleeding? (red but mixed with darker clots)

A

Meckel diverticulum - failure of the intestinal end of the omphalomesenteric duct to obliterate, 2% of the population, about 1/2 have gastric mucosa , 2x more in males, usually in 1st 2 years of life, most common presentation is massive pin less bleeding that is red or maroon in colour
tarry stool in 10% of cases , may have other minor episodes
presentation can vary from shock, intussusception with obstruction, volvulus or torsion
(the other big differential for painless rectal bleeding is juvenile polyps (although in thos age group more likely Meckel)

85
Q

What are two polyposis syndromes associated with increased risk of aenocarcinoma

A
  1. Peutz-Jeghers
  2. Juvenile polyposis coli
    as much as 30% increase
86
Q

Worldwide, what is the most common cause of GI blood loss in children?

A

Hookworm infection - caused by parasites nectar americanus, ancylostoma duodenal (often asymptomatic)
progressive microscopic blood loss, often leads to anemia as a result of iron deficiency

87
Q

Treatment of variceal bleeding?

A

massive bleed - always start with ABCs, CBC, LFTs, coats, crossmatch; for vatical bleeding specifically - diagnostic endoscopy, therapeutic endoscopy, vasopressin, octreotide

88
Q

Name the six most common causes of massive GI bleed in children

A
  1. esophageal varices
  2. Meckel
  3. hemorrhagic gastritis
  4. Crohn disease with ileal ulcer
  5. peptic ulcer (mainly duodenal)
  6. AVM

Gastroenterology (5 decks)

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