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GI Flashcards

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1
Q

Name the 3 broad causes of Failure to Thrive

A

Decreased intake
Malabsorption
Hypermetabolism (neoplasm, inflammatory, chronic diseases)

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2
Q

3 board categories (major macronutrients) of malabsorption

A 
Protein malabsorption (CF, Schwachmann diamond)
Fat malabsorption (choestasis, CF)
CHO malabsorption (enzyme deficiencies, dietary causes)
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3
Q

What are the extraintestinal manifestations of Celiac Disease

A
  1. dermatitis herpetiformis
  2. dental enamel hypoplasia of permanent teeth
  3. osteopenia/ osteoporosis
  4. short stature
  5. delayed puberty
  6. iron deficiency anemia
  7. hepatitis
  8. arthritis
  9. epilepsy with occipital lobe calcifications
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4
Q

Conditions associated with Celiac Disease

A
  1. Down syndrome
  2. Turner syndrome
  3. Williams syndrome
  4. IgA deficiency
  5. Other autoimmune disorders (thyroid, arthritis, liver)
  6. DM I
  7. first degree relative with celiac (1:20)
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5
Q

What 3 foods contain gluten protein

A

“WE REMOVE BREAD”
wheat
rye
barley

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6
Q

What is the first line screening test for celiac disease

A

TTG-IGA
must measure serum IgA as well
patients with low serum IgA require endoscopic biopsy for diagnosis
2nd line- EMA-IGA

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7
Q

In children less than 2 what test must you order to test for celiac disease

A

DGP (deamidated gliadin peptide)

TTG-IgA is poor in children <2

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8
Q

What are FODMAPS

A 
carbohydrates that tend to be highly fermentable
F- fermentable
O- oligosaccharides
D- disaccharides
M- monosaccharides
P- polyols
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9
Q

What would you see on intestinal biopsy for celiac disease?

A

villous atrophy (duodenum or jejunum)

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10
Q

What is the treatment for celiac disease

A

Life-long gluten free diet

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11
Q

How do we diagnose celiac disease

A
  1. first line screening test- TTG-IgA

2. Intestinal biopsy (jejunum, duodenum)- villous atrophy

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12
Q

Differential diagnosis of terminal ileitis (7)

A
  1. Crohn’s disease
  2. yersinia infection
  3. severe eosinophilic gastroenteropathy
  4. lymphoma
  5. tuberculosis
  6. chronic granulomatous disease
  7. lymphonodular hyperplasia (normal finding)
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13
Q 
Which of the following is not in the differential for terminal ileitis?
Crohn's disease
lymphoma
tuberculosis
yersinia infection
celiac disease
A

celiac disease is NOT on the differential for terminal ileitis

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14
Q

UC:

  • rectum
  • distribution
  • terminal ileum
  • serosa
  • bowel wall
  • mucosa
  • stricture
  • fistula
  • erythema nodosum
  • uveitis
  • PSC
A
  • rectum= YES
  • distribution= Diffuse
  • terminal ileum= NOT INVOLVED**
  • serosa- Usually normal
  • bowel wall- NORMAL
  • mucosa- Hemorrhagic
  • stricture- RARE
  • fistula- RARE
  • erythema nodosum- RARE
  • uveitis- COMMON
  • PSC- COMMON
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15
Q

Crohn’s:

  • rectum
  • distribution
  • terminal ileum
  • serosa
  • bowel wall
  • mucosa
  • stricture
  • fistula
  • erythema nodosum
  • uveitis
  • PSC
A
  • rectum- variable
  • distribution- segmental/diffuse
  • terminal ileum- YES
  • serosa- creeping fat
  • bowel wall- THICKENED
  • mucosa- cobblestone/linear
  • stricture- COMMON
  • fistula- COMMON
  • erythema nodosum- COMMON
  • uveitis- COMMON
  • PSC- RARE
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16
Q

What are the treatment options for Crohn’s/ UC to induce remission (4)

A
  1. tube feeds (common; Crohn’s only)
  2. corticosteroids (common)
  3. 5-ASA (mild)
  4. Biologics (severe)
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17
Q

What are the treatments options for Chron’s/UC to maintain remission (5)

A 
Tube feeds (Crohn's only)
5-ASA (mild, UC only)
Azathioprine (moderate)
MTX (moderate)
Biologics (severe)
** NOT STEROIDS**
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18
Q

What percentage of chronic constipation is functional? organic?

A

90% functional

10% organic

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19
Q

What are the organic causes of constipation? (11)

A 
hypothyroidism
lead poisoning
celiac disease
medications
cystic fibrosis
hirshprungs
idiopathic
CP
neural tube defects
hypercalcemia
hypokalemia
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20
Q

Name 4 osmotic laxatives

A

PEG 3350
lactulose
docusate (colace)
magnesium citrate

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21
Q

Name 4 stimulant laxatives

A 
bisacodyl (docolax)
picosalax
glycerin suppository
phosphate enema
senokot
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22
Q

What is the treamtent for GER

A

8 weeks of acid blockade (H2RB or PPI)

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23
Q

What is the next step if there is no resolution of GER after 8 weeks of acid blockade or recurrence after weaning the medication (2)

A
  1. upper endoscopy to look for eosinophilic gastritis, hiatal hernia, gastritis
  2. 24 hour PH/impedance probe- physiologic, hiatal hernia, medications, dysmotility
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24
Q

Name 3 extensively hydrolyzed formulas

A
  1. Nutramigen
  2. Alimentum
  3. Progestimil
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25
Name 2 amino acid based formulas
Neocate | Puramino
26
Treatment of BF baby with CMPA
remove milk protein in mothers milk | refer mother to dietician for ca supplementation (1000mg Ca2+)
27
What is the most common cause of LGI bleeding in infants?
``` CMPA -2-3% of formula feeders will develop - 0.5% breastfeeders will develop cross reactivity in 10-15% receiving soy-formula colitis may take 2-4 weeks to resolve ```
28
What are Meckel's rule of 2's?
``` age <2 most common age 2 feet from ileocecal valve 2:1 male:female 2% develop bleeding 2 types of mucosa in diverticulum: native + heterotypic gastric/pancreatic/colonic ```
29
What is first line treatment for pinworms
Mebendazole | albendazole
30
Name the GI infections that present with bloody diarrhea (5)
``` salmonella shigella yersinia campylobacter e.coli ```
31
A patient is diagnosed with dientamoeba fragilis. Metronidazole fails to clear the infection. What is the next antibiotic choice?
paromomycin
32
What is the Rome IV criteria for infantile colic
infant <5 months of age when symptoms start and stop recurrent and prolonged episodes of crying, fussing or irritability without obvious cause, cannot prevent or resolve no history of FTT, fever or illness episodes lasting >3h/day for 3 days per week for at least 1 week
33
Rome IV criteria for Functional diarrhea
``` daily, painless, >4 large unformed stools >4 weeks onset 6-60 months of age (5 years) occurs during waking hours no FTT if caloric intake adequate ```
34
Infant regurgitation Rome IV criteria
``` age 2-12 months >2 episodes per day for > 3 weeks Characterized by features that are NOT SEEN: - retching - hematemesis - aspiration - apnea - FTT - feeding or swallowing difficulties - abnormal posturing ```
35
Rome IV criteria for infant dyschezia
discoordination between relaxation of external anal sphincter and contraction of pelvic muscles <9 months old >10 minutes of straining and crying before successful passage of soft stool otherwise healthy
36
Rome IV criteria cyclic vomiting syndrome
At least five attacks in any interval or a minimum of three attacks during a six-month period Episodic attacks of intense nausea and vomiting lasting one hour to 10 days and occurring at least one week apart Stereotypical pattern and symptoms in the individual patient Vomiting during attacks occurs at least four times per hour for at least one hour Return to baseline health between episodes Not attributed to another disorder
37
Rome IV rumination syndrome
repeated or painless regurgitation and reviewing or expulsion of food that: - begins soon after ingestion of a meal - does not occur during sleep No retching No organic explanation Eating disorder must be ruled out
38
Rome IV criteria for Irritable bowel syndrome
abdominal pain >4x per month with >1 of the following symptoms: 1. timing related to defecation 2. change in frequency of stool 3. change in form of stool
39
Rome IV criteria for abdominal migraine
``` must occur >2x: - paroxysmal episodes of intense acute, periumbilical pain for >= 1 hour -healthy for weeks to months between episodes -interferes with normal activities sterotypical pattern >= 2 of the following symptoms: headache pallor nausea vomiting photophobia anorexia ```
40
Rome IV criteria for functional constipation
2 or more of the following at least once per week for more than one month not IBS 1. <=2 bowel movements/weeks in a child developmentally >= 4 yo 2. >= 1 episode of focal incontinence/week 3. retentive posturing 4. painful or hard bowel movements 5. large fecal mass in rectum 6. large diameter stools that may block the toilet symptoms not fully explained by another medical condition
41
Nonretentive fecal incontinence
at least 1 month of episodes >=1/month defecation in places inappropriate to social context - no fecal retention - not attributable to another condition
42
What are some red flags for organic causes of abdominal pain
``` weight loss hematemesis hematochezia nocturnal symptoms delayed puberty arthritis oral ulcers chronic diarrhea unexplained rashes bilious emesis dysphagia anemia/pallor decreased linear growth velocity ```
43
What is the gold standard for diagnosing hirschsprungs disease?
rectal biopsy
44
what is a screening test for hirschprungs disease?
barium enema
45
Empty rectal vault and "blast sign" on DRE is suggestive of what?
Hirschprungs disease Blast sign (explosive stool output upon DRE) Barium (contrast) enema: transition zone
46
What would you see on rectal biopsy for Hirschsprungs disease (3 things)?
absent ganglion cells hypertrophic nerve fibres increased cholinesterase staining
47
Young child with 2 episodes of rectal | prolapse. What test should you do? what are you looking for?
sweat chloride | have to rule out CF
48
What is the definitive test for celiac disease?
endoscopic biopsy (small bowel biopsy)
49
List 4 causes of intestinal flat villi besides Celiac disease
1. rotavirus 2. sprue 3. CMPA 4. eosinophilic gastroenteritis
50
What vitamin deficiency can you have if the terminal ileum is resected?
Vit B12
51
What are 2 skin manifestations of Crohn's disease?
erythema nodosum pyoderma gangrenosum metastatic Crohn's
52
What is the differential for erythema nodosum (7)
``` IBD sarcoid TB fungal infection strep infection Bechett's meds (OCP, sulpha drugs) ```
53
why do patients with IBD lose weight?
inadequate nutrient intake | they don't feel well therefore they don't eat
54
Ecoli UTI + jaundice=
galactosemia
55
What tests would you order if you suspect biliary atresia and what is the diagnostic test?
1. AUS 2. HIDA scan 3. Cholangiogram + biopsy= diagnostic test
56
What is the treatment for biliary atresia?
kasai
57
What is the leading indication for liver transplant in peds?
biliary atresia
58
What is a key feature of biliary atresia on history?
pale (acholic) stools
59
What are the "BIG 5" things to investigate for hyperbilirubinemia
1. biliary atresia- abdo ultrasound 2. Thyroid- TSH/free T4 3. Galactosemia- urine for reducing substances/ RBC GALT (The demonstration of nearly complete absence of galactose-1-phosphate uridyl transferase (GALT) activity in RBCs is the gold standard for diagnosis) 4. Tyrosinemia- urine succinylacetone 5. TORCH- ucx +/- other culture, TORCH w/u including urine CMV
60
what investigations would you do for autoimmune hepatitis
immunoglobulins, anti-SMA, anti-LKM, ANA
61
what investigations would you do for Wilson's disease (3)
serum copper, ceruloplasmin, 24 hour urinary cu
62
what investigations would you do for acute liver failure?
cbc, lytes, bun, cre, lfts, ggt Liver function tests: albumin, inr, glucose, ammonia, albumin, bilirubin acetaminophen, tox screen Infectious- Hep A, B, C, EBV, CMV alpha 1 antitrypsin AIH- immunoglobulins, anti- SMA, anti- LKM, ANA Wilsons- ceruloplasmin, serum copper, 24 h urinary cu ferritin (HLH)
63
what are the vitamin k dependent factors?
``` 1972 10 9 7 2 ```
64
what is the only factor that is made outside of the liver?
factor 8 | normal if liver if the cause of coagulopathy and abnormal if DIC
65
Name 2 signs of portal hypertension on physical exam in a child with liver disease
hepatosplenomegaly ascites caput medusae
66
what IBD is associated with PSC
UC | 60-80% of patients with PSC have IBD
67
what would you see on MRCP with PSC
"beading" (alternating dilated and narrowed segments on MRCP, “beading”)
68
what liver enzyme is particularly elevated with PSC
GGT
69
What would you see on slit lamp for Wilsons disease?
kayser fleischer ring
70
what is the treatment for Wilsons disease?
copper chelation (penicillamine)
71
Wilsons disease does not usually present in children less than?
wilsons disease does not usually present in children less than 3
72
what is acrodermatitis enteropathica
Autosomal recessive disorder caused by inability to absorb sufficient zinc
73
where is the characteristic rash found for acrodermatitis enteropathica
mouth | perianal
74
what is the classic finding for kwashiorkor
edema enlarged abdomen due to low protein intake normal caloric intake
75
What is the classic finding for marasmus
emaciation low protein intake and low caloric intake <70% ideal weight
76
vit A deficiency results in what
night blindness | bitot spots
77
vit D deficiency
ricketts (dichotic rosary) | cupping of metaphysis
78
vit e deficiency
hemolytic anemia | neurologic deficit
79
vit k deficiency
coagulopathy | abnormal bone matrix synthesis
80
vit B1 (thiamine) deficiency
Beriberi
81
Niacin deficiency (Pellagra)
``` 4D's dermatitis (necklace rash) **photosensitive! diarrhea dementia death ```
82
what is the treatment for acrodermatitis enteropathica
zinc 1mg/kg/day for life
83
what does a folate deficiency in the mother cause for a baby
NTD
84
Vit B12 deficiency
megaloblastic anemia | paresthesias
85
vit C deficiency
scurvy- bleeding gums, petechia, anemia
86
if they say vegan think what vitamin deficiency
B12
87
Cheilosis is a sign of what?
iron deficiency
88
Glossitis is a sign of what?
B2 (Riboflavin) deficiency
89
``` Question: A child is currently on goat’s milk. What do you recommend supplementing with? A. Folic acid B. Iron C. Multivitamin C. Vitamin B12 ```
goat's milk= deficient in folate
90
perioral/bum rash + diarrhea=
zinc deficiency/acrodermatitis enteropathica
91
Dark skin baby, bow-legged, metaphyseal cupping/flaring, rachitic rosary, Harrison groove, delayed walking
Ricket’s, check a 25OHD level
92
Phytoestrogens in soy milk are contraindicated in what condition?
congenital hypothyroidism | phytoestrogens can inhibit thyroid peroxidase, potentially lowering free thyroxine concentrations
93
what is the whey to casein ratio in breastmilk
70 whey: 30 casein | Whey fraction promotes gastric emptying, more easily absorbed
94
what are the maternal contraindications to breastfeeding?
HIV infection chemotherapy/cytotoxic drugs radioactive isotopes/radiation therapy active TB or brucellosis Human T-cell lymphotrophic virus types I and II (HTLV type I and II) Some drugs (eg. Primaquine, quinine, high dose metronidazole)
95
what are the baby contraindications to breastfeeding?
galactosemia
96
what percentage of weight loss is expected in the first week
lose 7-10% birth weight in first week | should be back to birth weight by 2 weeks
97
what are some advantages to breastfeeding
``` Decreases: Bacterial meningitis Bacteremia Diarrhea Respiratory tract infections OM UTIs Negative effects of 2nd hand smoke decreases SIDS ``` Increases: Neurocognitive testing Postpartum weight loss Protection for mom from Breast cancer & Ovarian cancer Faster gastric emptying Less GERD Stimulates intestinal growth, differentiation
98
what is the current recommendation for breastfeeding
babies should be exclusively breastfeed for 6 months Beyond 6 months = increased risk for iron def. continue with complementary foods until ≥ 2 years - first complementary foods should be iron rich
99
what two findings are associated with Peutz–Jeghers syndrome
Autosomal dominant condition associated with: benign polyps in the GI tract hyper pigmented macules on the lips and oral mucosa They are at increased lifetime risk of GI malignancies
100
Peutz-Jeghers syndrome is associated with _________ due to small bowel polyps
intussusception
101
A button battery in the stomach should be removed when?
within 48 hours
102
a button battery in the esophagus should be removed when?
emergently! | worry about aorto-enteric fistula
103
what are the electrolyte abnormalities associated with pyloric stenosis
hypochloremic, hypokalemic metabolic alkalosis
104
gastroschesis is associated with higher rates of what 3 things?
malrotation, intestinal atresia and NEC
105
Describe some of the findings for Alagille syndrome
- pointed chin - paucity of bile ducts - posterior embrytoxin - butterfly vertebrae - deep set eyes - heart things (pulmonary stenosis mostly but can be TOF)
106
what would you see on ultrasound for biliary atresia
unable to visualize the gallbladder | triangular cord sign
107
what is the most common pathological lead point for intussusception?
meckel's diverticulum
108
what is the most specific test for pancreatitis?
lipase
109
what is Eosinophilic esophagitis
esophageal dysfunction and infiltration of esophageal epithelium by >15 eosinophils per high power field
110
what are the treatment options for eosinophilic esophagitis
PPI elimination diet Topically acting swallowed corticosteroids (fluticasone)
111
Palpable olive in the abdomen
pyloric stenosis
112
what is the best test of hepatic synthetic function?
INR
113
what is an example of a non-reducing sugar?
sucrose
114
HAV infected patients are contagious for ??
HAV infected patients are contagious for 2 wk before and 7 days after onset of jaundice
115
how do you treat pouchitis?
Pouchitis commonly responds to treatment with Oral metronidazole or ciprofloxacin Probiotics have also been shown to decrease the rate of pouchitis as well as the recurrence of pouchitis following antibiotics
116
what is the worst complication of Vitamin B12 deficiency
neurological signs (hypotonia, irritability, regression, involuntary movements)
117
Name 3 dermatological manifestations of a kid with IBD features
``` erythema nodosum pyoderma gangrenosum oral ulcers metastic crohn's perianal skin tags ```
118
name 2 ways to diagnose pinworms
direct visualization of adult worm in perianal area (usually best 2-3h after going to bed) transparent adhesive tape to perianal area to collect eggs, look under low-power microscopy
119
What is the difference radiographically between a coin in the esophagus and a coin in the trachea
coin in the esophagus looks front on in anterior view whereas coin in the trachea looks front on in the lateral view
120
Why is it important to confirm a diagnosis of juvenile polyposis?
the are at increased risk of adenocarcinoma
121
What is the most common cause of encopresis?
functional constipation with overflow incontinence
122
Failure to pass stool within the first _____ hours of life should be considered pathologic until proved otherwise.
48
123
What stool test is most useful for helping diagnose GI protein loss?
Fecal α1-antitrypsin measurement is the most useful stool marker of protein malabsorption. It is important to measure serum α1-antitrypsin to ensure that the patient does not have α1-antitrypsin deficiency
124
How is lactose intolerance diagnosed?
hydrogen breath test
125
What is the role of stool elastase measurement?
screen for pancreatic insufficiency
126
What are the clinical manifestations of typhoid fever?
fever, abdominal pain, nausea, decreased appetite. Diarrhea begins after one week decreased HR despite fever
127
What is the most common cause of travelers’ diarrhea?
Enterotoxigenic E. coli | ETEC
128
12 yo with chronic transaminase elevation and hyperechogenic liver. What is the likely diagnosis?
NAFLD | - consider when BMI >85%
129
what are two things that helps improve NAFLD?
weight loss | exercise
130
what is the acute management of pancreatitis?
1.5-2x maintenance early enteral nutrition ** - if not tolerated then NJ tube feeding, if not tolerated then TPN watch for complications (SIRS response)- due to necrotizing pancreatitis * early nutrition is important for the intestine to rehabilitate
131
AST> ALT think:
``` ethanol myopathies renal syndromes hemolysis (eg capillary blood sample) intestinal inflammation adenovirus infection ```
132
If ALP is abnormally low think...
zinc deficiency
133
If ALP is normal and other enzymes are high think...
Wilsons disease
134
HBsAg - | HBsAb +
hepatitis B immune | cleared infection long ago
135
HBsAg + HBsAb + HBeAg + HbeAb -
chronic active infection
136
What test is required to diagnose H. Pylori?
Esophagoduodenoscopy with biopsy
137
``` Shwachman-Diamond baby. Which vitamin level would be normal? Vit A Vit E Vit B12 Vit D ```
Vit B12 | they have exocrine pancreatic insufficiency therefore affects fat soluble vitamins (ADEK)
138
``` Kid with Alagille syndrome. Classic eye finding: Chorioretinitis Posterior embryotoxin Glaucoma Cataract ```
Posterior embryotoxin
139
What is Fitz-Hugh-Curtis syndrome
Fitz-Hugh-Curtis syndrome, or perihepatitis, is a chronic manifestation of pelvic inflammatory disease (PID). It is described as an inflammation of the liver capsule often due to Chlamydia
140
2 life threatening complications of ulcerative colitis
1. colon cancer | 2. toxic megacolon
141
Neonate on TPN. List four things that will increase his incidence of cholestasis.
1. duration of TPN 2. prematurity 3. sepsis- gram neg sepsis 4. NEC 5. short gut syndrome
142
Surveillance recommendations for Hepatitis B (7)
``` • Measure ALT q6months in children >2yo • Measure HBeAg and HBeAb yearly in patients with normal ALT • Liver biopsy in children >2yo with elevated ALT • Examine for chronic liver disease • Immunize household • Immunize patient against Hepatitis A • Alpha fetoprotein and ultrasound annually ```
143
what are 2 long term risks associated with hepatitis B
1. hepatocellular carcinoma | 2. cirrhosis
144
In a patient with short gut....Of the fat soluble vitamins, which one will not be deficient and why?
vit k- intestinal bacteria primarily synthesize vit k
145
Ddx progressive dysphagia to solids (5)
1. Malignancy 2. esophageal stricture 3. achalasia 4. esophageal ring/web 5. scleroderma
146
what is a common renal complication in IBD
nephrolithiasis (particularly oxalate stones)
147
what are two indications for soy formula
galactosemia | religious/cultural reasons (veganism)
148
what GI complication is seen post Fontan
protein losing enteropathy
149
Name 3 complications of corrective surgery for Hischprung's disease
``` constipation recurrent enterocolitis stricture prolapse perianal abscesses fecal soiling ``` Hirschsprung disease–associated enterocolitis can occur at any time prior to or following surgery and is the leading cause of death in these patients.

Pediatrics- Noelle (28 decks)

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