GI Flashcards

Question

What is the recommended vit D supplementation for a 6 month old baby living above the 55th latitude during winter months? A. 200 IU B. 400 IU C. 600 IU D. 800 IU

Answer 1

B. Zinc Acrodermatitis enteropathica - AR cannot absorb zinc. Symptoms first month of life after weaning from breast milk to cow’s milk.

Answer 2

B. Zinc level

Answer 3

A. Amox and clarithromycin - would also need PPI Treatment options 1. Amox + clarithromycin + PPI 2. Amox + metronidazole + PPI 3. Clarithromycin + metronidazole + PPI Abx each x 14d and PPI x 1 month

Answer 4

B. Cow’s milk allergy A. Fissure - seems kind of young and blood would be on surface of stool

Answer 5

Answer A: NPO and IV fluids Pancreatitis

Answer 6

A. Celiac disease Dermatitis herpetiformis

Answer 7

B- upper scope and biopsy Other possibility was A looking for stricture but scope better as can dx stricture and eosinophilic esophagitis

Answer 8

Controversial A- acute onset lethargy Vs B- acute liver volume loss - sick kids answer Nelson’s says acute liver volume loss is a bad sign Hepatic encephalopathy- initially minor disturbances in of consciousness or motor functio . Irritability, poor feeding and a change in sleep rhythm may be the only findings in infants. Asterisks May be demonstrable in older children. Pts can rapidly progress to deeper stages of coma Age <1y.o, stage 4 encephalopathy, and INR >4 and the need for dialysis before transplantation are a/w increased mortality.

Answer 9

A. Cyclic vomiting

Answer 10

B. Dvlp of asterixis Although sudden decrease in liver size is an ominous sign, signs of encephalopathy indicate severe liver failure

Answer 11

B. Stool alpha 1 antitrypsin Protein losing enteropathy

Answer 12

B. Colonoscopy Hx concerning for IBD Nocturnal bowel movements common in UC

Answer 13

A. 2 weeks of hypoallergenic milk.

Answer 14

A. Renal colic Azathioprine - immunomodulatory drug used in IBD. No specific renal side effect. Most common side effect: malaise, n/v/d, leukopenia, thrombocytopenia, black box warning for malignancy, hepatotoxicity, infection, myalgia, fever Flank pain likely secondary to renal stone: chronic steatorrhea >> fat binds to calcium, leaving oxalate free to be absorbed and deposited in the kidney, where it can form into stones. Patients with OBD also get Uric acid stones

Answer 15

A. Anti-TTG Reasons to screen for celiac: FTT, persistent diarrhea, chronic constipation, recurrent abdominal pain, iron deficiency anemia not responsive to supplementation, ideopahtic short stature, significant pubertal delay, dermatitis herpetiformis, arthritis/arthralgia.

Answer 16

A. Peutz- Jegher

Answer 17

C. Autoimmune hepatitis

Answer 18

INR Indications for liver function - PTT/INR, albumin, bilirubin Progression of liver dysfunction Decreased PLTs > INR increased > alb decreased > bilirubin increased Pancytopenia results from hypersplenism- PLTs first then WBC then hemoglobin

Answer 19

B. Posterior embryotoxin Alagille syndrome

Answer 20

A. Rectal biopsy Hirschsprung disease Marked as controversial because can also be sweat chloride or TSH

Answer 21

D. pH probe GERD

Answer 22

A. Low intake of nutrients

Answer 23

A. Rectal biopsy This question was debated during review - B and C are possible answers but if they describe a rectal exam that is consistent with Hirschsprung’s than A is definitely right

Answer 24

C. Anal manometry Best answer would be biopsy Hirschsprungs

Answer 25

A. Yersinia

Answer 26

D. Yersinia Great mimicker of IBD

Answer 27

B. Autoimmune hepatitis Normal alpha 1 antitrypsin level Low is 0.8 and high 2.0 g/L Therefore not deficient

Answer 28

A. Decrease risk of perforation

Answer 29

Answer: Do nothing vs blood smear. I feel like they are getting at Gilbert but you can’t officially rule out hemolytic anemia with the info we have In the first question, the LFTs are normal, which would not be seen in acute viral hepatitis. Therefore, the patient may have Gilbert’s

Answer 30

C. Check for CF and C. Sweat chloride test Rectal prolapse is rare if no underlying predisposing condition

Answer 31

A. pH probe

Answer 32

A. Jaundice

Answer 33

A. Colonoscopy - would need upper and lower scopes and MRE Suggests a possible dx of Crohn’s disease given presence of peri-anal disease and constitutional sx.

Answer 34

B. Small bowel biopsy Celiac disease

Answer 35

Answer: what?? This sounds like it could be celiac disease but proper investigations not available in answers given

Answer 36

C. Slow motility with increased visceral pain response

Answer 37

C. Yersinia Things to know that cause terminal ileum thickening = salmonella, c.diff, Yersinia and histoplasmosis Yersinia can mimic IBD Infections a/w being on a farm: anthrax (bacillus anthracis), brucellosis, campylobacter, E.coli, influenza, leptospirosis, listeria, MRSA, coxiella, rabies, ringworm, salmonella, TB, vesicular stomatitis

Answer 38

Answer C. Neonatal hepatitis A- BF jaundice presents with unconjugated hyperbilirubinemia B.- Hemolysis also presents primarily with unconjugated hyperbili (exception: A history of severe ABO incompatibility May explain a conjugated hyperbili; in about 3% of infants, this is a benign complication which resolved on its own accord within a month. D. Galactosemia - presents with conjugated hyperbili but is far less common than neonatal hepatitis and tend to be unwell infants.

Answer 39

B. IBD Oral lesions are reported in at least 10% of children with Crohn’s disease; when evaluated by a dentist, oral involvement was noted in 42% - oral manifestations include: mucogingivitis, mucosal tags, deep ulceration, cobblestoning, lip swelling - no oral lesions in eosinophilic gastritis

Answer 40

C. Protein hydrolysate formula Protein losing enteropathy (unclear underlying etiology). And you trea any protein losing enteropathy with a protein hydrolysate formula

Answer 41

Answer A,D observe

Answer 42

B. Carbohydrate intolerance is common at this age Functional Diarrhea - increased intake of hyperosmolar fluids, such as fruit juices in toddlers and young children may cause diarrhea as a result of increased osmotic load - also called Toddler’s diarrhea

Answer 43

B, B colonoscopy IBD- crohn’s

Answer 44

A. Hep A IgM HAV is the most prevalent hepatotropic virus, responsible for most forms of acute and benign hepatitis. EBV and CMV would have other symptoms too (liver is one manifestation of multiorgan disease) - Hep B unlikely as no risk factors

Answer 45

Answer C.reassess in one week Breast milk jaundice Typically presents after the first 3 to 5 days of life, peeking within two weeks after birth, and progressively declines to normal levels over 3 to 12 weeks. The hyperbilirubinaemia is generally mild but should be monitored to ensure that it remains unconjugated and does not increase. Breast-feeding can continue with the expectation of resolution by 12 weeks of age. Appears to be due to a factor in human milk that promotes an increase in intestinal absorption of bilirubin

Answer 46

Answer B.Meckel’s diverticulum. The only issue with the question is bright red as it is described more as dark red in Meckel’s diverticulum. Most common congenital anomaly of the G.I. tract. Rule of twos. Occurs in 2% of population, male to female ratio of 2 to 1, located within 2 feet of the ileocecal valve, can be 2 inches in length, two types of heterotopic mucosa presentation before two years old. Symptoms, painless lower G.I. bleeding, intussusception which can lead to bowel obstruction, diverticulitis.

Answer 47

Answer A. Celiac disease Clinical presentation of coeliac disease. Infants and young children with malabsorption and failure to thrive. Kids age 6 to 24 months after introduction of gluten into the diet, includes symptoms of chronic diarrhea, anorexia, abdominal distention, pain, failure to thrive, vomiting. Older children have constipation or diarrhea. P.cystic fibrosis. I think they would have to give you more information, like stay at to Ria or watery diarrhoea or respiratory infections. C.cows milk allergy. If it’s IGE mediated then presents like a classic allergy with urticaria, and angioedema, Wheezing, vomiting, anaphylaxis. If it’s non-IGA median baby looks well with bloody stools

Answer 48

C. Pharmacologic and behavioral. Definition: the voluntary or involuntary passage of feces Into inappropriate places at least once a month for three months consecutive once a chronological or developmental level of four years has been reached. Treatment: clearance of impact material and short term laxatives to prevent further constipation. Behavioural modifications including change in diet, Regular post prandial toilet sitting. CPS statement on managing functional constipation and children. Includes behavioural management should be used in conjunction with medication therapy

Answer 49

A. Jaundice

Answer 50

Answer B. Jejunal biopsy

Answer 51

Answer C. pH probe Gerd

Answer 52

A. Cirrhosis Steve’s group had a question like this where cirrhosis and jaundice we’re both answers. The lecture said that is not fair. And said that if we did have that question a younger (infant) would present as jaundice/cholestasis and an older kid would present as cirrhosis.

Answer 53

B. Cystic Fibrosis 99% of newborns will pass meconium by 48h. - 15-20% of newborns with CF, meconium will cause Complete obstruction of the ileum. The first 24 to 48 hours of life you get abdominal distension and no meconium and vomiting. On abdominal x-ray you see diluted loops of bowel with air fluid levels and collection of granular, ground glass material in lower abdomen. May get meconium peritonitis which is rare and you see in utero rupture of the bowel wall. On abdominal x-ray you see calcifications in the scrotum or peritoneum due to the inflammatory response to the perforated bowel that sealed off. Meconium plug syndrome which is delayed passage of meconium and comes at 48 hours is less specific for cystic fibrosis then meconium ileus pancreatic calcifications are possible

Answer 54

C. Nuclear med scan for ectopic gastric tissue Meckel’s diverticulum Stools are red so this is lower GI process. The other two answers don’t make sense (even if you don’t know the answer).

Answer 55

D.wait and do nothing

Answer 56

C. Carbohydrate intolerance is a common cause Chronic nonspecific diarrhoea of childhood infancy. The most common form of persistent diarrhoea in the first three years after birth. Potential pathophysiologic mechanism is increased intestinal motility and osmotic affects of intraluminal solutes i.e.; carbohydrates. The rule of ingested carbohydrates has been emphasized in light of a typical toddler‘s affection for fruit juices. A.maybe but why would Rash be in the diaper? B. CM PA. No would have been introduced to it earlier D.allergy E.no

Answer 57

E. Abdominal ultrasound Differential diagnosis of postprandial abdominal pain: 1. gastric ulcer 2. chronic pancreatitis 3. gallstones 4. Abdominal ischemia 5. Functional disorder’s for example IBS, gastroparesis, functional dyspepsia. Cholelithiasis with right upper quadrant pain, might worsen with meals and Key evaluation is the ultrasound of gallbladder A. To diagnose SCD B. To diagnose H. Pylori - abdominal pain worse on empty stomach C. Gastroscopy with biopsy - eosinophilic esophagitis D. UGI/SBFT - difficulty swallowing

Answer 58

B. Cholecystitis. Debated question with Fitz- Hugh - Curtis

Answer 59

B. A/w splenomegaly A. Classically, in EHPVO cases liver is normal and the architectural pattern is preserved B. EHPVO in child it is most often chronic and presents with features of variceal bleeding and splenomegaly, where as an adult it could be either acute or chronic. D. Mcc is splenic vein thrombosis - no it’s obstruction in the portal vein

Answer 60

Answer D. The natural history of Gerd is associated disappearance of symptoms and 98% by 15 months. Yes peaks at four months and then 88% resolved by 12 months in nearly all by 24 months A. Prevalence by PH monitoring is 10% in 1st year - likely higher B. One episode of regurgitation a day in 10-12 months - probably not at all C. The natural history of Gerd is improvement with introduction of the solid food. Not always, usually peaks at four months

Answer 61

Controversial question C. peptic ulcer disease versus D. ulcerative colitis. I don’t think this child is unwell enough to have UC, especially if it’s been going on for 2 years- they also don’t describe any extra intestinal manifestations A. going on too long B.Meckel’s diverticulum occurs in first or second year of life typically mechanic her in for a decade. Painless bleeding. C.peptic ulcer’s due to H pylori D.ulcerated colitis but it seems like blood not evident.

Answer 62

C. Omeprazole - PPI is first line Used to be ranitidine. H2RAs are considered safe for use in children and are used commonly as first line therapy in infants

Answer 63

B.Amoxicillin, clarithromycin, and proton pump inhibitor

Answer 64

D. TG require hydrolysis to FFA. Nonesterified FFAs are metabolically active lipids derived from lipolysis of TG stored in adipose tissue blind to albumin for circulation in the plasma

Answer 65

A. Liver abnormalities Wilson disease

Answer 66

C. The colon has a large caliber. A.usually in the morning. Not true can be at any time of the day, often happen throughout the day B.most common preschool children. Not true, functional ENCOPRESIS does not begin until age 4 D.stool softeners cure the problem. Need laxatives to disimpact, the maintenance dose to clear stools and also need behavioural therapy with regular toilet sitting and high fibre diet. No laxatives are a cure

Answer 67

D. Bowel washouts

Answer 68

E. No investigations. Constipation with overflow

Answer 69

B false but also isn’t C false ? A- decreased conjugation - true B- increased uptake by hepatocytes - false it’s decreased hepatic bilirubin uptake C- increased excretion - should be false because you get decreased bilirubin conjugation and this decreased excretion ? D-increased enterohepatic circulation - true E- increased breakdown of Hb - true

Answer 70

A. | Chronic constipation

Answer 71

E. Milk challenge

Answer 72

B. Sucrose Can test stool for reducing substances and if present suggest carbohydrate malabsorption. Glucose, lactose and fructose are reducing sugars, but sucrose is not. However, malabsorbed sucrose can also be degraded by colonic bacteria to glucose and fructose, resulting in a positive test for reducing substances. Lactose breaks down into glucose and galactose. A reducing sugar is any sugar that is capable of acting as a reducing agent because it has a free aldehyde group or a free keto group. All monosaccharides are reducing sugars along with some disaccharides, Oligosaccharides, and polysaccharides. ``` Monosaccharides = glucose, fructose, galactose Disaccharides = sucrose (glucose + fructose), lactose (glucose + galactose), maltose (glucose + glucose). Sucrose is not one. ``` Would do this in galactosemia.

Answer 73

D. Introduce to solids For infants who have not yet begun solid foods, acute constipation can be treated by the addition of undigestible osmotically active carbohydrates to the formula titrating the dose to induce a daily bowel movement. One such option is addition of sorbitol containing juices for example Apple, prune or pear. For infants 4 months and older 2 to 4 ounces of 100% fruit juice per day is a reasonable starting dose. For infants who have just begun solid foods, sorbitol containing food Can be used. Can use glycerine suppositories if there’s hard stool and rectum. Can use laxatives like Peg if you’ve tried dietary changes. Avoid stimulants like Senna mineral oil and enemas in infants because of potential adverse side effects.

Answer 74

B. Try avoiding milk Confirm by eliminating milk from diet African Americans and Asians are more likely to have decrease in lactase as they age compared to white people who are much less. So they should not do the breath test, better to do a clinical challenge. According to lecture, we basically never do breath hydrogen test. White kids can do a breath test as less likely to have lactase deficiency.

Answer 75

A. UGI and small bowel follow- through Likely crohn’s but scopes would be better !!!

Answer 76

Answer A. Autoimmune hepatitis - high transaminases, liver assosiated serum auto Ab and hypergammaglobulinemia - hepatocytes get injured B. Not hep C C. Wilson’s- no neurological changes, KF rings, low ceruloplasmin levels, increased free copper and urine copper D. Sclerosing cholangitis - autoimmune process where I RTA and extra hepatic bile ducts are injured - often with IBD, asymptomatic Eli Er disease, with high ALP and GGT E. Alpha-1- antitrypsin- Normal level of AAT. AAT is an anti-protease and the natural inhibitor of the serine proteases released by activated neutrophils. In patients with AAT liver disease, the abnormal protein accumulates within the endoplasmic reticulum, resulting in liver injury in a subset of patients by unclear mechanism. Affected individuals typically have decreased plasma ATT concentration because of impaired hepatic production.

Answer 77

A. Two most important components of your physical exam 1. Rectal exam 2. Abdominal exam 3. Neurological exam B. Confirmed fecoloma. What are 3 management strategies ? 1. Bowel clean out with Peg 3350 or peglyte 2. Long term maintenance therapy with PEG 3350 3. Conservative management including increased fiber and fluid intake, avoid constipating foods including bananas, cheese; increased physical activity; bowel training 4. Behavioural training

Answer 78

A. X-ray findings of coin concerning 1. Double halo sign and step off sign suggesting button battery 2. Diameter > 25mm and length > 6cm B. Anticipatory guidance and next step 1. Watch for signs of drooling, dysphagia and respiratory compromise 2. Esophageal coins should be removed within 24h in ingestion your reduce the risk of significant esophageal injury or erosion into neighbouring structures Next steps 1. Admit patient 2. NPO 3. Consult GI for endoscopic removal within 24h

Answer 79

A. Diagnosis - Meckel’s Diverticulum B. Two other conditions it could be ? 1. Anal fissure 2. Polyps C. Investigation - Meckel’s scan

Answer 80

A. Screening investigations 1. TTG and IgA 2. Deamidated gliadin peptide (DPG IgA and IgG) - what about biopsy - I guess that is not a screening tool B. 5 extra intestinal manifestations 1. Abnormal liver enzymes 2. Arthralgia/arthritis 3. Dermatitis Herpetiformis 4. Alopecia 5. Fatigue 6. Headache 7. Anemia 8. Stomatitis 9. Myalgias 10. Psychiatric disorders 11. Rashes 12. Seizures 13. Neuropathy 14. Short stature 15. Delayed puberty 16. Osteoporosis 17. Infertility

Answer 81

A. How soon for NPO ? - 8h A light meal or non-human milk may be ingested for up to six hours before elective procedures requiring general anesthesia, regional anaesthesia or procedural sedation and analgesia. Additional fasting time for example 8 hours or more maybe need in cases of patient intake of fried foods, fatty foods or meet. Consider both the amount and type of foods ingested when determining appropriate fasting period. Since non-human milk is similar to solids and gastric emptying time consider the amount ingested when determining appropriate fasting period. B. 3 indications for urgent removal of an esophageal foreign body ? 1. Sharp, long >6cm, or a super absorbent polymer and is in the esophagus or stomach 2. High powered magnet or magnets 3. Disk/ button battery in the esophagus 4. Patient shows signs of airway compromise 5. Evidence of near complete esophageal obstruction (ie; patient can’t swallow secretions ) 6. Symptoms suggesting inflammation or intestinal obstruction (fever, abdo pain, or vomiting)

Answer 82

A. Type of stone - calcium oxalate Complications of inflammatory bowel disease include kidney stones due to malabsorption of calcium and increased absorption of oxalate. When less calcium is available in the intestinal lumen to bind oxalate, oxalate absorption and therefore urinary Oxalate excretion increases. B. 2 indications for surgical removal: 1. Severe debilitating pain refractory to parenteral analgesic therapy 2. Significant urinary obstruction 3. Solitary kidney with partial or total obstruction 4. Renal insufficiency 5. Signs of infection 6. Struvite stones 7. >5mm in diameter C. What are 3 recommendations you could give her to avoid future stone formation ? 1. Increase fluid intake 2. Limiting dietary sodium (low sodium diet can enhance proximal sodium and calcium reabsorption, leading to a reduction of calcium excretion) 3. Recommended daily allowance of calcium 4. Avoiding excess animal protein in the diet (oxalate) 5. Increased dietary potassium intake 6. Moderate intake of high oxalate foods 7. Avoidance of excess vit C 8. Low fat diet The greatest risk factors for calcium kidney stone formation are low fluid and high sodium intake.

Answer 83

1. Hashimoto hypotheyroidis 2. Type 1 DM 3. Autoimmune hepatitis 4. IBD Celiac disease is associated with dermatitis herpetiformis, down syndrome, selective IGA deficiency, and other conditions which have auto immune features such as type 1 diabetes mellitus, thyroid disease, and liver disease. Patient with coeliac disease and their families may also be more likely to have atopic dermatitis compared with the general population.

Answer 84

``` A. Gilbert syndrome B. Invites jaundice 2 things 1. Inter current illness 2. Dehydration 3. Fasting 4. Alcohol 5. Exercise ``` C. How would you treat her ? 1. Reassurance - no treatment needed. 2. Encourage hydration

Answer 85

NASPGHAN suggest the following diagnostic criteria all of which need to be met. These recommendations apply to children and adolescents: 1. At least five attacks in any interval, or a minimum of three attacks during a six-month period. 2. episodic attacks of intense nausea and vomiting lasting 1 hour to 10 days and occurring at least one week apart. 3. Stereotypical pattern and symptoms in the individual patient 4. Vomiting during attacks occurs at least four times per hour for at least one hour. 5. return to baseline health between episodes 6. Not attributed to another disorder

Answer 86

A. Dumping syndrome Occurs when food, especially sugar, moves too fast from the stomach to the doudenum in the upper gastrointestinal tract. It could be happening because the patient is taking foods very high in sugar content or the NG moved to NJ. B. - Early dumping syndrome = rapid emptying of food into small bowel with a sympathetic nervous system response. - late dumping syndrome = result of hyperglycaemia and the subsequent insulin response leading to hypoglycaemia that occurs 2-3h after a meal. Or According to lecturer If this is an NG the most likely cause for dumping would be an infection. B. The pathophysiologic mechanism would be: 1) osmotic load (rapid emptying of hyperosmolar fluid into the the small intestine) 2) high rate of administration of feed 3) dysmotility 4) small bowel bacterial overgrowth (no?) 5) late dumping due to hypoglycaemia following postprandial insulin peak But if question was not remembered correctly and the child had a G-tube then: A. Most likely reason for dumping would be either post-op for recent G-tube insertion or migration of G-tube to GJ tube. B. Possible pathophysiological mechanisms include: 1). Osmotic load 2) post op ileus 3) small bowel bacterial overgrowth For NJ tube - can get dumping shortly after insertion. If NG has migrated to NJ, more likely to cause vomiting than the above symptoms

Answer 87

A. 2 most likely causes of dysphagia 1. Eosinophilic esophagitis 2. GERD Esophagitis B. 3 additional possible causes of dysphagia 1. GERD 2. Achalasia 3. Esophageal spasm 4. Scleroderma 5. Intrinsic lesions 6. Foreign bodies including pills 7. Esophagitis: GERD, eosinophilic esophagitis 8. Stricture: corrosive injury, pill induced, peptic 9. Esophageal webs 10. Esophageal rings 11. Esophageal diverticula 12. Neoplasm 13. Extrinsic lesions 14. Vascular compression 15. Mediastinal lesion 16. Cervical osteochondritis 17. Vertebral abnormalities

Answer 88

3 sequelae of short gut syndrome 1. Sepsis or line infection 2. Hepatic cholestasis (due to parenteral nutrition ) + cirrhosis 3. Renal stones 4. Thrombosis 5. Gallstones

Answer 89

4 complications of indwelling enteral tubes 1. Gastric outlet obstruction 2. Infection at site - local ostomy site infection/irritation 3. Dislodged G-tube 4. G-tube malfunction ie; clogged, leaky, rupture balloon 5. Disruption of ostomy tract 6. Peritonitis and Septicemia 7. Pneumoperitoneum

Answer 90

A. 2 risk factors for refeeding syndrome 1. Quick refeeding 2. Rapid weight loss with weight less than 70% ideal body weight 3. Low baseline PO4, Mg, K B. List 2 electrolyte abnormalities 1. Hypophosphatemia 2. Hypokalemia 3. Hypomagnesemia

Answer 91

A. Chances of successful reduction ? - 80-95% as per Nelson’s B. Chances of perforation? - 0.1-0.2% C. Chances of recurrence ? - 10% (2-5% after surgical correction) D. Two contraindications 1. Prolonged intussusception 2. Signs of shock, peritoneal irritation, intestinal perforation or pneumatosis intestinalis

Answer 92

5 conditions of neonatal cholestasis and diagnostic tests 1. Biliary atresia - biopsy 2. Neonatal hepatitis - serologies 3. Alagille syndrome - genetic testing 4. Alpha-1- antitrypsin deficiency - a1 level 5. Choledochal cyst - U/S

Answer 93

3 non-renal cause of abdominal mass 1. Constipation 2. Neuroblastoma 3. Intussusception

Answer 94

1. Erythema nodosum; painful raised red lesions 1 to 3 cm in diameter, seen most commonly on the shins 2. pyoderma gangrenosum; a severe ulcerating rash that responds to immunosuppression, is rare in children and is seen more often in patients with long-standing ulcerated colitis and patients with Crohn’s disease. 3. cutaneous vasculitis; cutaneous small vessel vasculitis and cutaneous polyarteritis nodosa 4. Metastatic Crohn’s disease; metastatic Crohn’s disease is characterized by cutaneous ulcerating nodules and violaceous plaques that demonstrate histologic similarity to the underlying Crohn’s disease and have noncaseating granulomas on biopsy. 5. epidermolysis bullosa acquisita; epidermolysis bullosa acquisita is a rare subepithelial blistering disorder that has been associated with Crohn’s disease. 6. Sweet syndrome; sweet syndrome is an acute inflammatory dermatitis characterized by tender papules, plates, and nodules distributed on the face, arms and trunk. 7. psoriasis

Answer 95

A. 5 vitamins/micronutrients that could be deficient 1. Vit B12 2. Vit D 3. Calcium 4. Iron 5. Zinc B. Why do they need more protein ? - because the amino acid composition and digestibility is less from non animal sources - Animal foods are considered complete or high quality proteins because they contain all nine essential amino acids. Plant-based foods are usually incomplete, meaning they are deficient in one or more of the essential amino acids. C. Risk of so much fiber ? - can compromise dietary energy intake and reduce the bioavailability of minerals such as iron, calcium, zinc.

Answer 96

A. EBV Most common transplant related infections are CMV and EBV B. What are three non-infectious complications that can be seen post liver transplant? 1. Primary non-function of the graft (rare and Peds) 2. Hepatic artery thrombosis (most frequent and early vascular complication; can have devastating consequences on the graft and may require transplantation 3. Portal vein or hepatic vein strictures/occlusions (rare and usually later finding) 4. Biliary strictures (most frequent surgical complication around 10 to 30%) 5. Rejection - usually after the first two weeks after transplant and peaks within the first 90 days; abnormal liver function 6. Chronic rejection rejection (progressive damage presenting as cholestasis) 7. PTLD (post transplant lymphoproliferative disease)

Answer 97

Warning signals of underlying pathology: the presence of warning signals suggest that an infant’s reflux may be related to an underlying gastrointestinal systemic disease that may be associated with regurgitation of vomiting. These findings should prompt for the evaluation. Warning signals include: Symptoms of gastrointestinal obstruction or disease 1. Bilious vomiting 2. Gastrointestinal bleeding: hematemesis, hematochezia* 3. Consistently forceful vomiting 4. Onset of vomiting after six months of life * 5. Constipation 6. Diarrhea 7. Abdominal tenderness, distention 8. Recurrent pneumonia raises possibility of tracheoesophageal fistula Symptoms or signs suggesting systemic or neurologic disease 1. Hepatosplenomegaly 2. Bulging fontanelle 3. Microcephaly or microcephaly 4. Seizures 5. Hypotonia or hypertonia for example cerebral palsy 6. Stigmata of genetic disorders for example trisomy 21 7. Chronic infections for example HIV Nonspecific symptoms 1. Fever 2. Pneumonia* 3. Lethargy 4. Failure to thrive* * May also be a consequence of Gerd

Answer 98

``` Ovarian torsion Ectopic pregnancy Incarcerated inguinal hernia Pelvic inflammatory disease Ruptured ovarian cyst Appendicitis Nephrolithiasis ```

Answer 99

Eosinophilic esophagitis Esophagitis from Gerd Esophageal webs rings Achalasia Dysphasia and Odynodysphagia 1. GERD 2. Eosinophilic esophagitis 3. Crohn’s disease with esophageal involvement 4. Infectious pharyngitis (ie; due to GAS, EBV) 5. Retropharyngeal abscess 6. Infectious epiglottitis 7. Stomatitis (ie; enterovirus auch as cox’s a lie A; herpetic gingivostomatitis) 8. Medication- induced esophagitis (ie; tetracycline: but this is not with solids ) Dysphagia (but no odynophagia) 1. Neuromuscular disorders: cerebral palsy, brain tumor, CVA, MS, dermatomyositis, myasthenia gravis, muscular dystrophies 2. Hypothyroidism, goiter 3. Achalasia 4. Scleroderma 5. Esophageal webs, esophageal rings, esophageal diverticula 6. Esophageal neoplasm

Answer 100

Two diagnosis ? 1. Pancreatitis - from azathioprine toxicity 2. Cholelithiasis - complication from Crohn’s 3. Dyspepsia or gastric ulcer 4. Crohn’s exacerbation or flare 5. Crohn’s disease involving the esophagus Other side effects of azathioprine 1. Bone marrow suppression 2. Liver dysfunction/hepatotoxicity 3. Drug fever 4. Arthritis, rash 5. Nausea 6. Pneumonitis 7. Increased risk of lymphoma Regular monitoring recommended: CBC, serum aminotransferases , bilirubin, amylase

Answer 101

Indications to investigate abdominal pain 1. Weight loss 2. Decreased growth velocity 3. Nocturnal symptoms 4. Severe chronic diarrhea 5. Bloody stool 6. Hematemesis/bilious emesis 7. Jaundice/stigmata of liver disease/HSM

Answer 102

Counselling methods: 1. Relaxation techniques (deep breathing exercises, progressive muscle relaxation) 2. Cognitive behavioural therapy 3. Guided imagery/hypnotherapy, distraction technique through which child enters a state of engagement and imagery and relaxation, which distracts attention from painful stimuli 4. Biofeedback - Technique that provides a visual or auditory despite other physiologic response to pain/anxiety (for example heart rate, Skin temperature, so the effects of relaxation techniques can be externally validated) 5. For separation anxiety parent child interaction therapy (PCIT) = therapists teach caregivers to reinforce desired behaviours and extinguish unwanted behaviours and coach them to apply them while interacting with her child I do wonder though if the question really was how do you manage counsel the family? 1. Therapeutic relationship between clinician and patient and the family is important. The family and patient should believe their concerns are taken seriously. 2. Reassurance and education; reassurance that there is no evidence of a serious underlying disorder 3. Acknowledge that the pain is real and has affected important activities in a child’s life. Functional abdominal pain thought to be caused by heightened sensitivity to the normal function of the stomach and bowel; it can be triggered and exasperated by environmental and psychosocial factors including stress, anxiety, and social reinforcement. 4. The pain is not life-threatening and does not require activity restriction. Thus treatment should focus on return to normal activity despite discomfort. A plan to return to school is crucial. Plan ahead for pain episodes at school, provide parents with guidelines about when the child is too sick to go to school, identifying and addressing school related sources of stress for example bullying. If the child also has IBS with diarrhoea provide a note to school requesting that child be allowed to use the bathroom whenever necessary. 5. Management of pain should include avoiding triggers and improving coping skills. 6. Reinforcement of well behaviours - praising/rewarding the child for attending school or extracurricular activities (for example sticker chart) 7. Improve coping through relaxation techniques, distraction, guided imagery and hypnotherapy, cognitive behavioural therapy and bio feedback 8. Screen for coexisting anxiety disorder 9. Medical interventions: probiotics, increased water soluble fiber, peppermint oil none of these are well-established but they have low risk of harm so short term trial is reasonable.

Answer 103

Rectal prolapse underlying etiology . According to lecturer idiopathic is most likely but probably the question asks what is the most important thing to rule out? Answer would be cystic fibrosis. According to lecture with rectal prolapse need to rule out chronic constipation, cystic fibrosis, inflammatory bowel disease, and repaired Hirschsprung’s.

Answer 104

Answer: swallows maternal blood. We confirmed this with the lecturer and confirmed that the blood would be red. The rectal blood should be tested to determine whether it comes from the infant or whether it represents maternal blood which may have been swallowed doing delivery or ingested during breast-feeding from cracked nipples. APT test for brown yellow colour looking for adult Hb, pink colour = fetal Hb Neonatal period. The most common diagnosis to consider in newborns with LGIB are: 1. Swallowed maternal Blood 2. Anorectal fissures 3. Necrotizing enterocolitis 4. Malrotation with midgut volvulus 5. Hirschsprung’s disease with enterocolitis 6. Coagulopathy 7. Brisk upper G.I. bleeding 8. Vascular malformations 9. Gastric or duodenal ulcer 10. Gastrointestinal duplication cyst ** FPIAP/CMPA - usually starts at 2 weeks ** Infants and toddlers, the most common causes bleeding in infants and toddlers one month to two years includes: 1. Anal fissures especially around the introduction of solid food or cows milk 2. Milk or soy protein induced colitis (allergic colitis) 3. Intussusception, 4. Infectious colitis 5. Meckel’s diverticulum 6. Lymphonodular hyperplasia 7. Gastrointestinal duplication cyst 8. Coagulopathy

Answer 105

Gilbert syndrome

Answer 106

1. Intestinal malrotation with volvulus 2. Upper GI contrast series Intestinal malrotation in older children most common symptom is abdominal pain and vomiting which may or may not be Bilious. Intestinal malrotation can lead to volvulus. Evaluation begins with plain radiographs to exclude obvious perforation for example a pneumoperitoneum. Then do an upper G.I. contrast series which shows clearly misplaced duodenum with the ligament of Treitz on the right side of the abdomen. They duodenum appears as a corkscrew appearance. With your duodenal obstruction you may have a “beak” appearance of volvulus is present. Treatment is the LADD procedure to minimize future risk of volvulus by widening the base of the mesentery and placing the bowel in a position of non-rotation.

Answer 107

A. Pouchitis - inflammation of the ileal pouch (an artificial rectum surgically created of ileal gut tissue in patients who have undergone a colectomy) B. Treatment: Pouchitis =PO ciprofloxacin (other option: metronidazole) Vs Cuffitis is a mild presentation with some blood loss but is not a/w pain or significant bloody diarrhea. This occurs if colonic mucosa has been left behind. This presentation sounds more like pouchitis which is also more common to see. Also in the text they say total colectomy (not subtotal) which may be another hint. Cuffitis - treatment is steroid/mesalamine Based on uTD, I think pouchitis but based on Nelson’s, I think pouchitis UTD Pouchitis - among patients who have undergone an ileal PICU- anal anastomosis, reported incidence of pouchitis ranges from 23-59% - ulcerative colitis is the most important risk factor for pouchitis -clinical presentation: increased stool frequency, urgency, abdominal cramps, tenesmus, Night time fecal seepage, incontinence Vs Cuffitis - symptoms of hematochezia are rare in patients with pouchitis and are suggestive of inflammation of the rectal cuff (cuffitis) - cuffitis typically presents with urgency and hematochezia - cuffitis is considered a recurrence of ulcerative colitis in the residual cuff of rectal mucosa - pouchitis and cuffitis can co-exist - Treated with steroids/mesalamine Nelson’s The ileostomy is usually closed within several months, restoring bowel continuity. At that time, stool frequency is often increased but may be improved with loperamide. The major complication of this operation is pouchitis, which is a chronic inflammatory reaction in the pouch, leading to bloody diarrhea, abdominal pain, and, occasionally, low grade fever. The cause of this complication is unknown, although it is more common when the ileal pouch has been constructed for ulcerative colitis than for other indications. It 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 abx therapy.

Answer 108

4 strategies for GERD in baby. Non pharmacological 1. Prone when awake, avoid supine/side positions 2. Upright x 20 min after feeds 3. Thickened feeds 4. Can try hypoallergenic diet - exclude milk or soy protein 5. Normalize feeding volumes - smaller volumes more frequently 6. Avoid exposure to tobacco smoke

Answer 109

4 steps in management 1. Disempaction - daily enemas x 6days or PEG 1.0-1.5g/kg/daily divided TID (max 100g/day) - if severe, admit to hospital and give NG PEG until rectal effluent clear 2. Maintenance therapy with PEG 3350 - start at 0.4-0.8g/kg/day as single daily dose or twice daily and can tailor dose 3. Behaviour modification. - toileting regime - routine, scheduled toilet sitting for 3-10min 1-2x a day - make sure they have a foot stool to make valsalva more effective - praise for stooling and sitting - no punishment for not stooling 4. Dietary modification - balanced diet - diet with prunes, Apple or pear juice is good for retaining water in stool - adequate fiber (AAP: 0.5 mg/kg/day to max of 35g/day). - no evidence for giving more than this - no real evidence for milk elimination, but can try this if constipation Is not improve with medical and behavioural management as intolerance to cows milk in atopic children has been associate with chronic constipation. - No evidence of probiotic

Answer 110

4 steps for supportive management in acute fulminant hepatitis 1. Transferred to Centre with ICU and that can do a liver transplant if required 2. Intubation to prevent aspiration, reduce cerebral edema by hyperventilation 3. Glucose containing fluids to maintain normal serum glucose 4. Treat for coagulopathy with vitamin K times one 5. If actively bleeding can give FFP, cryoprecipitate, platelets 6. IV PPI due to high-risk of G.I. bleeding 7. Volume to correct and avoid hypovolemia 8. Frequent monitoring of electrolytes 9. Protein restriction or elimination based on encephalopathy 10. Regular neural vitals and can use lactulose if encephalopathy 11. Dialysis fluid overload acute renal failure 12. Administer antibiotics/acyclovir if unclear etiology

Answer 111

1. Toxic megacolon 2. Bowel perforation Other colon cancer Toxic megacolon happens in 5% of people with severe ulcerative colitis. It can be triggered by hypokalaemia or opiate use. Think about this in patients with severe abdominal pain and distention. Symptoms may be masked in patients on steroids. Transverse colon > 4 cm in diameter, if age less than 10, (if age <10), may see loss of Haustral folds. Be worried about fever abdominal pain, distension not associated with bowel movements.

Answer 112

1. Disease extent 2. Disease duration The risk for development of colorectal cancer and patience with ulcerated colitis increases with Disease extent and duration

Answer 113

2 signs of ports HTN 1. Splenomegaly 2. Caput Medusa (distended periumbilical veins) 3. Hemorrhoids 4. Ascites 5. Varices (but not visible on exam)

Answer 114

Causes of hypoalbuminemia 1. Decreased production - protein malnutrition - defective synthesis 2. Increased loss - protein-losing enteropathy - nephrotic syndrome - excessive burns 3. Redistribution - inflammation of vasculature (ie; sepsis) - hemodilution

Answer 115

4 things that increase neonates incidence of cholestasis on TPN 1. Low birthweight < 1000g 2. Duration of TPN = usually after >2weeks 3.+ 4Complicated medical courses, including those affected by respiratory distress , hypoxia, acidosis, NEC, sepsis, and short bowel syndrome

Answer 116

4 screening tests 1. IgA endomyseal antibodies (EMA) 2. IgA tissue transglutaminase (TTG) 3. Total IgA level of (1 and 2 are negative but IgA level is low, then celiac disease strongly suspected) 4. Intestinal biopsy

Answer 117

A. IBD Crohn’s disease -generally don’t have abdo pain in UC and height isn’t affected B. 2 skin manifestations 1. Erythema nodosum 2. Pyoderma gangrenosum 3. Aphorism ulcers 4. Vesiculopustular eruption 5. Necrotizing vasculitis 6. Metastatic Crohn’s disease

Answer 118

2 dx 1. Vascular ring 2. Esophageal stricture 3. Esophageal web 4. Eosinophilic esophagitis

Answer 119

4 other cause of flat villi 1. Tropical sprue 2. Giardiasis 3. Crohn’s disease 4. HIV enteropathy 5. Bacterial overgrowth 6. Autoimmune enteropathy 7. Eosinophilic gastroenteritis 8. Cow’s milk enteropathy 9. Soy protein enteropathy 10. Primary immunodeficiency 11. GVHD 12. Chemo and radiation 13. Lymphoma 14. Protein energy malnutrition 15. Non-gluten food intolerance

Answer 120

A. Atypical form: 1. Absence or few gastrointestinal symptoms 2. Presence of atypical symptoms, such as anemia due to iron deficiency, osteoporosis or osteopenia, infertility, low stature B. List 2 conditions that are a/w celiac disease 1. Thyroid disease - hashimoto’s 2. Type 1 DM 3. Multiple sclerosis 4. Autoimmune hepatitis 5. Addison disease 6. Arthritis 7. Snogged ‘s syndrome 8. Idiopathic dilated cardiomyopathy 9. IgA nephropathy

Answer 121

A. Crohn’s disease RLQ mass = inflamed terminal ileum. B. List 2 diagnostic tests to confirm diagnosis 1. Upper and lower endoscopy with biopsy 2. Abdominal MRI- enterography (to see terminal ileum which you can’t really see on scope) C. List 3 acute complications of this disease 1. Toxic megacolon 2. Bowel perforation 3. Abscess 4. Fistulas 5. Bowel obstruction

Answer 122

1. Protein losing enteropathy 2. Nephrotic syndrome 3. Celiac disease 4. Eosinophilic enteropathy 5. Hypertrophic gastritis (Menetrier’s disease) 6. Milk protein allergy 7. IBD 8. Giardiasis 9. Intestinal lymphangiectasia 10. Structural heart disease

Answer 123

A. IBD, likely Crohn’s B. Conservative management (observation) with sitz bath. May need I &D under local anesthesia if very painful. Pain management. Abx are generally not useful. From Nelson’s: common in children and usually manifests in the first year of life of unknown etiology. Links to congenitally abnormal crypts of Morgagni have been proposed, suggesting that Deeper crypts lead to trapped debris and cryptitis. Strong male predominance in those affected younger than two years of age. Imbalance corrects in older patients where the etiology shifts to associated conditions such as inflammatory bowel disease, leukaemia or Immunocompromised states

Answer 124

Fundoplication is effective therapy for intractable GERD in children, particularly those with refactory esophagitis or strictures and those at risk for significant morbidity from chronic pulmonary disease. It may be combined with a gastrostomy for feeding or venting. Peas and review: fundoplication may be considered in patients with confirmed GERD who experience severe refractory or recurrent symptoms or life-threatening complications of GERD.

Answer 125

A. Endoscopy Gastric bezoar - trichollimania. Need endcosopic removal

Answer 126

B. Silver nitrate

Answer 127

A. Esophagoduodenoscopy and biopsy

Answer 128

Answer A. Familial hypercholesterolemia - increased total cholesterol + increased LDL with Normal TG + family Hx of early CVD death C. Familial combined dyslipidemia = FCH - increased total cholesterol and increased TG

Answer 129

B. Scope and biopsy

Answer 130

A. 2 meds 1. Peg 3350 2. Enemas B. 2 non-pharmacological treatments you would suggest 1. Behaviour modifcation 2. Dietary modification

Answer 131

Name three conditions that predispose you to gallstones in this age range. 1. Obesity 2. Female gender only after puberty 3. Hemolytic disease such as sickle cell disease, hereditary spherocytosis, thalassemias, Wilson’s disease. 4. Reduced bile salt pool for example history of ileal resection, small bowel Crohn’s disease, cystic fibrosis with pancreatic insufficiency 5. TPN 6. Medications such as ceftriaxone, furosemide, octreotide, cyclosporine 7. T21 8. Hypertriglyceridemia 9. Pregnancy 10. Some Native American tribes