GI-Lecture part 5 Flashcards
(58 cards)
1
Q
What is IBS?
A
Dysregulated immune response of intestinal mucosa to microbes in genetically susceptible persons
- Crohn disease (CD)
- Ulcerative colitis (UC)
- Unclassified IBD (IBDU)
2
Q
Crohn disease
A
- Any part of GI tract; terminal ileum/colon most common
- Esophageal disease in 20%; perianal disease common
- Inflammation usually transmural – fissures and fistulas occur
- “Skip” areas are unaffected areas of intestine
- Environmental exposure may trigger abnormal immune reaction in genetically susceptible individual
3
Q
What condition has “Skip” areas are unaffected areas of intestine?
A
Chrons
4
Q
What should be included in the history of Chron’s disease?
A
- Fever, weigh loss
- Delayed growth velocity, short stature, delayed bone age
- Arthralgias/arthritis in large joints
- Obstructive symptoms associated with meals
- Pain in umbilical region and RLQ
- Anorexia
- Malabsorption/lactose intolerance
- Diarrhea, pain with stooling
- Jaundice
- Oral aphthous ulcers
5
Q
What should be included on physical exam of Chron’s Disease?
A
- Growth parameters
- Abdominal exam – RLQ tenderness, inflammation
- Perianal skin tags, deep anal fissures, perianal fistulas
- Clubbing of digits may be present
- Erythema nodosum common
6
Q
Diagnostic studies – Chron Disease?
A
- Inflammatory markers
- Nutritional labs
- CBC, liver enzymes
- Stool O&P, culture, fecal alpha 1-antitrypsin, fecal calprotectin assay
- Bone age, bone density, abdominal films
- Ileocolonoscopy, esophagoscopy
7
Q
Differential diagnosis- Chron Disease?
A
- RA, SLE, hypopituitarism, appendicitis, PUD, obstruction, lymphoma, anorexia, chronic granulomatous disease, sarcoidosis, growth failure
8
Q
Management – Chron Disease?
A
- Control disease
- Prevent relapse
- Achieve normal nutrition, growth, lifestyle
- Pharmacologic, nutritional, surgical, psychosocial
- Refer to pediatric gastroenterologist for colonoscopy, endoscopy, diagnosis, consultation
- Corticosteroid management most common in U.S
9
Q
Management – Crohn Disease (Cont.)
A
- Medications – prescribed by Pediatric GI
- Corticosteroids
- 5-Aminosalicylates
- Immunomodulator agents
- Biologic agents
- Antibiotics for acute infections
- Adjunctive therapy – growth hormone
- Hospitalization, TPN, surgery when severe
- Monitor growth, pubertal changes
- Ophthalmologic exam
- Nutritional counseling
- Encourage participation in social activities
10
Q
What are the complications of Crohn Disease?
A
- Intestinal obstruction/scarring
- Growth failure
- Fistula/abscess
- Primary sclerosing cholangitis, pancreatitis, pericarditis, arthritis, peripheral neuropathy
- Increased risk of lymphoma/colon cancer
- Increased risk for opportunistic infections
11
Q
Prevention and prognosis – Chron Disease
A
- Follow therapy to prevent sequelae
- Progressive; no cure, with remissions
- Child-onset disease more severe
12
Q
Ulcerative Colitis?
A
- Chronic disease; diffuse inflammation of rectal/colonic mucosa
- Involves rectum in 95% of cases
- Multifactorial basis – heredity, diet, environment, immunologic, ineffective mucosal integrity
- Incidence increased in developing nations
13
Q
History – Ulcerative colitis?
A
- Fever
- Anorexia / Weight loss
- Delayed growth/sexual maturation
- Diarrhea
- Lower abdominal cramping
- Pain increased before stooling/flatus
- Bright red blood/mucus in stool
- Nocturnal stooling
- Oral aphthous ulcers
- Skin lesions – erythema nodosum, pyoderma gangrenosum, diffuse papulonecrotic eruptions
14
Q
Physical examination - Ulcerative Colitis
A
- Growth parameters
- Complete physical exam
- Abdominal rebound tenderness if severe
15
Q
Diagnostic studies – Ulcerative colitis?
A
- CBC, iron-binding capacity, total protein, albumin, ESR, CRP
- Stool for WBC, blood, culture
- Bone age
- Colonoscopy
- Perinuclear neutrophil cytoplasmic antigen
- Fecal calprotectin assay
16
Q
Differential diagnosis – Ulcerative Colitis?
A
- Shigella, Salmonella, Yersinia, Campylobacter, E. coli, C. difficile, IBS, self-limited colitis, Crohn disease
17
Q
Management – Ulcerative Colitis?
A
- Control disease
- Prevent relapses
- Achieve normal nutrition, growth, lifestyle
- Refer for colonoscopy
18
Q
Pharmacologic treatment options – individualized –
Ulcerative Colitis?
A
- Mild-moderate: topical mesalamine, oral 5-ASAs, or topical steroids
- Moderate-severe: systemic steroids
- Thiopurines -immunosuppressive drugs; fight inflammation
- Biologic agents
- Hydrocortisone rectal for tenesmus (cramping rectal pain)
- Cyclosporin monotherapy
- Probiotics as adjunctive therapy
- Curcumin to maintain inactive disease – Antioxidant/ anti-inflammatory
- Iron supplementation to correct anemia
19
Q
A
20
Q
A
21
Q
A
22
Q
A
23
Q
Management – Ulcerative Colitis
A
- Nutrition
- High in protein/carbohydrate, normal fat, decreased roughage
- Lactose poorly tolerated
- Parenteral/enteral supplements
- Refer for nutritional therapy
- Monitor growth
- Surgery – complete proctocolectomy curative
- Ophthalmologic examination
- Psychosocial therapy
- Immunization status
23
Q
Complications – Ulcerative colitis
A
- Growth failure, toxic megacolon, intestinal perforation, liver disease, sepsis, colon cancer
- Arthritis, uveitis, malnutrition, behavior problems
23
Causes of Failure to
Thrive
Endo/Metabolic
* Hypothyroidism
* Diabetes mellitus
* Adrenal insufficiency or excess
* Parathyroid disorders
* Pituitary disorders
* Growth hormone deficiency
* Inborn errors of metabolism
23
Prevention and prognosis – Ulcerative Colitis
* Follow therapy to optimize remission
* Prognosis good - mild disease/those responding well to initial therapy
23
Failure to Thrive
* Lack of weight gain proportional to age
* Disruptions in biologic, psychosocial, environmental factors contributing to growth and development
Three basic causes:
1. Inadequate caloric intake
2. Inadequate caloric absorption
3. Excessive caloric expenditure
* Onset between 2-4 months – usually congenital disorders
* Onset between 4-8 months – associated with feeding problems
23
Causes of Failure to
Thrive
Gastrointestinal
* GER
* Crohn disease
* Pyloric stenosis
* Cleft palate / lip
* Lactose intolerance
* Hirschsprung disease
* Hepatitis
* Cirrhosis
* Pancreatic insufficiency
* Biliary disease
* IBD
* Malabsorption
23
Pulmonary Failure to Thrive
* Asthma
* Bronchopulmonary dysplasia
* CF
* anatomic abnormalities of upper airway
* OSA
* Recurrent infected adenoids and tonsils
23
Neurologic failure to thrive?
* Mental retardation
* Cerebral hemorrhage
* Degenerative disorders
* Cerebral palsy
24
Cardiac failure to thrive?
Cardiac: Cardiac diseases leading to CHF
24
Failure to Thrive
Clinical findings and risk factors
* Poor weight gain associated with poor intake
* Vomiting, food refusal, food fixation, abnormal feeding practices, anticipatory gagging, irritability
* Chronic physical problems, psychosocial problems
* Distinguish non-organic from organic etiology
* Prenatal – maternal health, obstetric complications
* Perinatal – birth weight, congenital anomalies, neurologic insults, NB screening results, weight for gestational age
* Neonatal –intraventricular hemorrhage ( IVH), seizures, hypoxia, extreme hyperbilirubinemia, infection
* Postnatal health – illness, hospitalization, chronic health, stooling/voiding history,
ROS
* Developmental trajectory/temperament
* Family/psychosocial history
24
Renal: failure to thrive?
* UTI
* Renal tubular acidosis
* Diabetes insipidus
* CKD
24
Failure to Thrive
Diagnostic studies
* Basic metabolic profile, vitamin D (calcidiol), lead, zinc, iron screening, albumin for protein status (severe FTT)
* CBC/ESR, BMP, serum electrolytes (include total CO2 to rule out renal tubular acidosis), UA and culture, sweat test, stool studies for fat, reducing substances, O&P, and culture
* Review of newborn metabolic screening tests
* Extremity radiographs if indicated (e.g., rickets)
* TSH, Chest radiograph, Renal ultrasound and voiding cystourethrography
* HIV screening, Karyotype (especially in small girls for Turner syndrome), Bone age, Developmental testing, Growth hormone (expensive, often done later in workup)
24
Causes of Failure to
Thrive
Infectious
* GI parasitic or bacterial infections
* TB
* HIV
Congenital - Many genetic abnormalities
Malignancy/immune
* Cancers of childhood
* Collagen-vascular disease
* JIRA
Nutritional - Lack of calories/micronutrients: Vit A, Zn, Fe
24
Causes of Failure to
Thrive
Hematologic - Sickle cell disease and others
Prenatal - Small for gestational age, perinatal infection
Psychosocial
* Depression
* Anorexia nervosa, bulimia
* Maternal depression
* Child abuse or neglect
* ADHD
* Autism
* Chronic pain
Environmental - toxins
24
Failure to Thrive
Physical examination
* Weight, height, BMI, head circumference
* Skinfold measurements
* Vital signs
* Hydration status
* Dysmorphic features
* Skin, hair, nails, mucous membranes
* Evidence of abuse/neglect
* Oral findings
* Respiratory, cardiovascular, abdominal, endocrine, neurologic exam
24
Failure to Thrive
Diagnostic studies
* Feeding assessment
* Developmental assessment
* Laboratory/imaging
* Failure to Thrive Evaluation
* Complete dietary history
* Complete psychosocial evaluation
24
Failure to Thrive
Management??
* Interdisciplinary team
* Manage treatable causes
* Restore nutritional intake
* Provide nutritional rehabilitation
* Parent education/support
* Treat underlying chronic condition
* Evaluate for weight gain every 1-3 weeks
* Hospitalize if needed
25
Failure to Thrive
Prognosis?
* Most achieve expected growth/development
* Severe effects on development and social/emotional health because of effects on brain in first 6 months
26
Acute-Chronic Diarrhea
* Altered intestinal mechanisms as result of:
* Nonabsorbable solutes in GI tract; fluids exceed transport capacity
* Invasion, inflammation, release of toxins by bacteria/viruses
* Mutations in ion transport proteins
* Altered anatomy of intestinal surface
* Change in intestinal motility
* Altered immune function
27
Acute Diarrhea
* Disruption of normal intestinal net absorption versus secretory mechanisms
* Excessive loss of fluids into intestinal lumen
* Dehydration, electrolyte imbalance, death may occur
* Viruses, viral enterotoxin (rotavirus)
* Bacteria, parasites, bacterial endotoxins, cytotoxins
* 20% of child deaths worldwide
28
Acute Diarrhea Organisms
* Nontyphoidal Salmonella, Shigella, Campylobacter, E. coli, rotavirus, norovirus, enteric adenovirus, Giardia, Cryptosporidium, Strongyloides cause most disease
* Dysentery – specific strains of Salmonella, Shigella
* Cryptosporidium, E. coli O157:H7, Giardia, Listeria, Salmonella, Shigella, V. cholerae must be reported to CDC
29
Acute Diarrhea
History
* Pattern of diarrhea: onset, volume, frequency
* Appearance of stool
* Associated symptoms: pain, fever, vomiting
* Number of wet diapers/voids in past 24 hours
* Diet/changes in diet
* Response to ORT
* Food allergies
30
Acute Diarrhea
History continued:
* Family members/friends with similar symptoms
* Day care, school, other exposure
* Travel history, picnics
* Recent weight/growth
* Medications
* Chemotherapy
* Surgeries
31
Acute Diarrhea
Physical examination?
* Complete physical examination
* Assess for dehydration
32
Diagnostic studies for diarrhea?
* Stool examination
* Stool pH, reducing substances
* Stool cultures for bloody/prolonged diarrhea
* Electrolytes if indicated
* CBC for serious disease
33
Acute Diarrhea
Differential diagnosis
* Gastroenteritis, antibiotic use most common
* Systemic infection in infants/children
* Food poisoning in older children/adolescents
* Primary disaccharidase deficiency, Hirschsprung toxic colitis, adrenogenital syndrome, neonate opiate withdrawal, toxins
34
Acute Diarrhea
Management
* Maintain nutrition
* Prescribe antibiotics prudently
* Treat related conditions
* Antidiarrheals – not recommended generally
* Probiotics – treat acute diarrhea and ameliorate the risk of antibiotic-associated diarrhea
* Oral enteric peppermint oil may cause smooth muscle relaxation
35
Acute Diarrhea Complications?
dehydration, electrolyte imbalance, chronic diarrhea, etc
36
Prevention of Diarrhea?
* Good handwashing
* Good sanitation/removal of soiled clothing and diapers
* Avoid contaminated sources
* Exclusive breastfeeding first 6 months
* Vitamin A/zinc (used in developing nations)
* Avoid unnecessary antibiotic usage
* Rotavirus vaccine
37
Chronic Diarrhea?
* Loose stools of >10 mL/kg/day in infants; >200 g/day in older children
* Result of intraluminal/mucosal factors affecting cellular mechanisms of GI tract
38
What is the history for chronic diarrhea?
* >3 watery stools/day > 2 weeks
* “Toddler’s diarrhea” – 10/day
* Dietary history
* Stool consistency, blood, mucus, food particles
* Stool incontinence
* Exposure to illness
* Teething
* Prior treatments for diarrhea
* Recent travel
39
What are the red flags for chronic diarrhea?
hematochezia/melena, persistent fever, weight loss, anemia
40
What is the physical exam for chronic diarrhea?
* Hydration status
* Weight/height/growth retardation
* Skin and hair
* Vital signs
* Thyroid enlargement
* Respiratory symptoms
* Clubbing of fingers
* Abdominal examination/rectal examination
41
Chronic Diarrhea Diagnostic Evaluation?
* Stool – culture, O&P, pH, reducing substances, occult blood, leukocytes, fat/fecal elastase
* CBC, electrolytes, albumin
* UA, culture
* ESR, CRP
* Hormonal studies if secretory tumors suspected
* Breath hydrogen test for lactose intolerance
* Viral serologies
* Sweat chloride test
* Endoscopy, barium studies
42
Chronic Diarrhea
Management
* Treat underlying cause
* Toddler’s diarrhea: normalize diet, remove offending
fluids/foods, eliminate sorbitol, fructose, reduce fluid intake to
<90 mL/kg/day
* Treat carbohydrate malabsorption
* Predigested formula for infants with post-gastroenteritis malabsorption syndrome
* Refer: newborns with diarrhea in first hours of life; patients with growth delay or failure abnormal physical findings, or those with severe illness
43
What are the complications of chronic diarrhea?
* Malnutrition, growth failure
