GIT Flashcards
(194 cards)
1
Q
What are some common causes of sudden onset acute abdominal pain in children and young adults?
A
🔹 Midgut volvulus
🔹 Intussuscpetion
🔹 Ovarian torsion
🔹 Testicular torsion
2
Q
What are two common causes of acute abdominal pain associated with bilious vomiting?
A
🔹Volvulus
🔹 intussusception
▪️both of them associated with bilious vomiting, indicating possible bowel obstruction or ischemia that requires urgent evaluation.
3
Q
On examination, a patient has localized abdominal tenderness with involuntary guarding. Which two inflammatory conditions of the abdomen should be high on your differential?
A
🔹Acute appendicitis
🔹 acute cholecystitis.
4
Q
A patient complains of upper abdominal pain but also has a productive cough and fever. Chest auscultation reveals crackles at the right base. What non‑intra‑abdominal cause can mimic an acute abdomen in this area?
A
🔹Right lower lobe pneumonia.
5
Q
patient reports epigastric pain that reliably worsens shortly after meals. Which two peptic conditions are most likely?
A
🔹 Gastritis
🔹 peptic ulcer disease.
6
Q
patient on chronic NSAIDs develops dyspeptic symptoms and epigastric discomfort without overt ulceration on endoscopy. What medication‑related cause should you consider?
A
🔹 NSAID‑induced dyspepsia.
7
Q
What’s volvulus ??
A
twisting of a bowel segment around its mesenteric axis, causing acute obstruction and compromised blood flow.
8
Q
Why is volvulus considered a surgical emergency?
A
🔹 Because the twisting of the bowel rapidly cuts off its blood supply, leading to ischemia and necrosis. Without prompt surgery, this can result in massive bowel loss (short gut syndrome) or death.
9
Q
At what age does volvulus typically present, and can it occur outside this window?
A
It most commonly presents in infants—usually before 1 year of age—but malrotation and volvulus can occur at any age, including adulthood.
10
Q
What are the consequences of delaying surgical intervention for volvulus?
A
A5: Delay can lead to irreversible bowel necrosis, requiring extensive resection (short gut syndrome), severe sepsis, or death.
11
Q
What might a plain abdominal radiograph show in a patient with midgut volvulus?
A
It may show a dilated stomach and proximal duodenum, suggesting obstruction.
12
Q
What is the primary imaging study used to diagnose midgut volvulus?
A
An upper gastrointestinal (GI) series with contrast.
13
Q
: What characteristic finding on an upper GI contrast study suggests midgut volvulus?
A
A “corkscrew” appearance of the twisted small bowel.
14
Q
Signs of volvulus on plain abdominal X-ray include:
A
▪️Dilated stomach and proximal duodenum (midgut. volvulus)
▪️ Double bubble sign (neonates)
▪️ Coffee bean sign (sigmoid volvulus)
15
Q
What is intussusception?
A
🔹 the invagination of a proximal segment of the intestine into a distal segment, leading to intestinal obstruction and possible ischemia.
▪️▪️▪️▪️
✨Intussusception occurs when a segment of the bowel (the intussusceptum) is pulled into a distal segment (the intussuscipiens), resulting in compression of the mesentery, impaired venous return, bowel wall edema, and potential ischemic injury.
16
Q
Why is intussusception clinically important in pediatrics?
A
🔹It is the most frequent cause of intestinal obstruction in children.
17
Q
What is the typical direction of bowel movement in intussusception?
A
The proximal segment is pulled antegrade into the distal segment.
18
Q
In which age group is intussusception most common?
A
It is more common in infants than in older children.
19
Q
What is the most common site of intussusception?
A
The ileocolic junction, where the ileum is pulled into the colon.
21
Q
How does abdominal pain in intussusception differ from that in appendicitis?
A
A: Intussusception pain is intermittent, whereas appendicitis pain is continuous.
22
Q
What unusual symptom may appear out of proportion to abdominal pain in intussusception?
A
Lethargy
▪️disproportionate to the degree of abdominal pain.
23
Q
What type of vomiting is seen in intussusception?
A
May be ,,, Bilious vomiting ( green)
▪️▪️▪️▪️
🔹can happen when the bowel is blocked and bile can’t pass through. This is common in intussusception if the blockage is low in the bowel.
24
Q
What are two signs of prolonged obstruction in intussusception?
A
🔹Abdominal distention and red currant jelly stools (blood and mucus).
▪️▪️▪️
‼️ red currant jelly stools , Why ?
➡️It’s due to bowel wall bleeding and mucus from poor blood flow in the trapped segment
25
Q
What is a classic palpable finding in intussusception?
A
🔹. A sausage-shaped mass in the right upper quadrant.
26
What is the nature of abdominal pain in intussusception?
🔹 It is intermittent and colicky.
27
Where is abdominal pain typically located in intussusception?
🔹In the periumbilical area or right lower quadrant.
28
What is the most common cause of intussusception in infants?
🔹The cause is usually unknown (idiopathic).
29
What congenital abnormality can act as a lead point for intussusception?
🔹 Meckel’s diverticulum.
▪️ Meckel’s diverticulum acts as a lead point—a fixed area in the bowel that can pull the surrounding intestine into itself, starting the telescoping motion that leads to intussusception.
30
What is a common cause of intussusception in older children?
🔹Tumors, especially lymphoma
31
What common trigger is thought to cause intussusception in children?
🔹 Enlarged mesenteric lymph nodes, often after a viral infection.
32
How accurate is ultrasound in diagnosing intussusception?
🔹It is very accurate—with a sensitivity and specificity of around 97.9%.
33
What is the first-line treatment for intussusception?
🔹 Air contrast enema (pneumatic or hydrostatic reduction).
34
Q: Is the air contrast enema both diagnostic and therapeutic?
Yes, it can both confirm the diagnosis and treat the condition.
35
What is the recurrence rate of intussusception after reduction?
🔹 About 10%.
36
When do most recurrences of intussusception happen?
🔹Within 72 hours after treatment.
37
What’s is a Esophageal atresia ?
congenital malformation in which the esophagus ends in a blind pouch and does not connect to the stomach.
38
What is a Tracheoesophageal fistula (TEF) ?
🔹abnormal connection between the trachea and esophagus.
▪️They most often occur together (Type C), with a blind upper esophageal segment and a fistula from the distal esophagus into the trachea.
39
What is the most common type of esophageal atresia with TEF?
🔹 A blind-ending (upper) esophageal pouch with a fistula connecting the distal esophagus to the trachea (Type C).
40
How is the most common type of TEF anatomically configured?
🔹 The proximal esophageal segment ends blindly, and the distal segment forms a fistulous connection to the trachea.
41
Which type of TEF is most often missed in infancy, and why?
🔹The H‑type TEF (isolated fistula without atresia), because it may present later with chronic respiratory symptoms rather than feeding obstruction.
42
What proportion of esophageal atresia/TEF cases are non‑syndromic?
A: Approximately 50%
43
Which syndromic association includes esophageal atresia and TEF, and what does the acronym stand for?
VACTERL association:
• Vertebral anomalies
• Anal atresia
• Cardiac defects
• Tracheo-Esophageal fistula
• Renal anomalies
• Limb abnormalities
44
What is the earliest sign of esophageal atresia/TEF in a neonate during feeding?
🔹 Frothing and bubbling at the mouth.
45
Which respiratory symptoms suggest esophageal atresia/TEF?
🔹Cyanosis,
🔹 respiratory distress,
🔹 coughing especially with attempted feeds.
46
What antenatal history is commonly associated with esophageal atresia/TEF?
🔹 Maternal polyhydramnios (due to the fetus’s inability to swallow amniotic fluid).
47
What bedside maneuver helps diagnose esophageal atresia/TEF immediately after birth?
🔹 Inability to pass a nasogastric tube into the stomach.
48
What finding on a plain chest/abdominal radiograph confirms the diagnosis?
🔹 A coiled nasogastric tube in the upper esophageal pouch.
49
What is the definitive management for esophageal atresia/TEF?
🔹 Surgical repair of the atresia and fistula.
50
What is gastroesophageal reflux (GER) in children?
🔹The effortless passage of gastric contents into the esophagus—seen as “spitting up” or regurgitation—in an otherwise healthy child without troublesome symptoms or complications.
51
How do you distinguish physiologic GER from GERD in children?
GERD involves reflux that causes troublesome symptoms or complications (esophagitis, failure to thrive, respiratory problems), whereas GER is benign and self‑limiting.
52
Which symptoms or complications are absent in physiologic GER?
🔹No pain or irritability
🔹no feeding difficulties
🔹 poor weight gain
🔹no respiratory issues (e.g., aspiration pneumonia, chronic cough).
53
When does GER typically occur in infants?
🔹Usually after feeds, especially in the first few months of life.
54
What are signs of normal (physiologic) GER in infants?
🔹The infant is healthy, happy, and gaining weight despite spitting up.
55
When does GER typically resolve in infants?
▪️80% resolve by 6 months
▪️90% by 12 months of age.
56
What are some possible symptoms that may occur with GER?
🔹Irritability
🔹arching (Sandifer syndrome)
🔹 choking
🔹gagging.
****
Clarification for you ‼️
▪️Sandifer syndrome: Typically seen in infants with gastroesophageal reflux (GER), it involves head tilting and body arching as a response to acid reflux. These movements are often temporary and resolve with treatment for GERD.
57
What complications may suggest progression from GER to GERD?
🔹 Failure to thrive
🔹aspiration pneumonitis
🔹 obstructive apnea.
58
Define Eosinophilic Esophagitis (EE)?
🔹 a chronic allergic inflammatory condition of the esophagus, marked by eosinophil infiltration of the esophageal lining, most often due to food allergies.
59
What is the pathological hallmark of Eosinophilic Esophagitis (EE)?
▪️ Infiltration of the esophageal epithelium with eosinophils.
60
What is the most common cause of Eosinophilic Esophagitis (EE)?
🔹 Food allergy.
61
What are the common clinical symptoms of EE?
▪️ Vomiting
▪️ Chest pain
▪️ Epigastric pain
▪️ Dysphagia
▪️ Food impaction (due to strictures)
▪️ Poor response to anti-reflux therapy
62
What is the main diagnostic method for Eosinophilic Esophagitis (EE)?
🔹Endoscopy with biopsies
▪️showing at least 15 eosinophils per high-power field (eos/hpf) in at least one field.
63
What diagnostic findings can support the diagnosis of EE?
**other than biopsy
▪️ Peripheral eosinophilia
▪️ Elevated IgE levels
64
What is the standard treatment for Eosinophilic Esophagitis (EE)?
🔹 Elimination diet based on proven allergies or elemental diet
(e.g., six-food elimination diet (SFED): wheat, milk, eggs, soy, nuts, fish/shellfish)
🔹 Inhaled and systemic steroids
🔹 Montelukast (a leukotriene receptor antagonist)
65
What can happen if Eosinophilic Esophagitis (EE) is left untreated ?
** after elimination of diet and medical ttt !
🔹Esophageal stricture may develop.
****
How ‼️
Chronic eosinophilic inflammation causes tissue remodeling and fibrosis, which can narrow the esophageal lumen that leads to dysphagia and don’t respond to ttt for EE !
66
A 10-year-old boy presents with chronic dysphagia, especially to solid foods, and a history of food impaction. He has not improved despite proton pump inhibitor therapy. Endoscopy reveals a narrowed esophagus with mucosal rings, and biopsy shows >15 eosinophils per high-power field. What is the most likely diagnosis?
A. Gastroesophageal reflux disease (GERD)
B. Achalasia
C. Eosinophilic esophagitis (EE)
D. Esophageal candidiasis
Correct Answer: ✅ C. Eosinophilic esophagitis (EE)
Clues in the case 🔎🕵🏻♂️
🗝️ Dysphagia to solids ➡️ suggests structural or inf causes
🗝️ Food impaction
🗝️ No response to PPIs ➡️ exclude GERD
🗝️ Endoscopy shows narrowed esophagus
🗝️ >15 eosinophils/hpf on biopsy ➡️ Diagnostic for EE.
67
What is Achalasia?
🔹A primary esophageal motility disorder caused by failure of the lower esophageal sphincter (LES) to relax, leading to difficulty swallowing and esophageal dilation.
🔹characterized by loss of lower esophageal sphincter relaxation and absent peristalsis.
68
What are the key symptoms of Achalasia?
▪️ Dysphagia to both solids and liquids
▪️ Vomiting undigested food
▪️ Weight loss
69
What does barium swallow show in Achalasia?
🐦“Bird’s beak”
▪️ smooth tapering at the lower esophageal sphincter .
70
What is the preferred treatment for Achalasia in children?
🔹Heller myotomy (surgical) is the treatment of choice in children, often combined with fundoplication to prevent reflux.
71
A 4-year-old patient presents with progressive dysphagia to both solids and liquids, regurgitation of undigested food, and weight loss. Barium swallow shows a smooth tapering at the lower end of the esophagus resembling a bird’s beak. What is the most likely diagnosis?
A. Eosinophilic esophagitis
B. Gastroesophageal reflux disease (GERD)
C. Achalasia
D. Esophageal stricture
Correct Answer: 👏🏻✅ C. Achalasia
Clues in the case 🔎🕵🏻♂️
🗝️Dysphagia to liquids & solids➡️ suggests a motility. disorder
🗝️Undigested food regurgitation➡️ food is not reaching the stomach
🗝️Weight loss
🗝️ Bird’s beak on barium➡️ classic radiologic sign
🗝️ Manometry ➡️ diagonistic test
72
Define foreign body in the esophagus.?
🔹The impaction of an ingested object within the esophagus, most commonly affecting young children (6 months to 3 years) and requiring prompt evaluation to prevent complications
73
What is the most common age group for esophageal foreign body ingestion?
🔹 6 months to 3 years
74
What are the most common types of foreign bodies ingested by children?
🔹 Coins and small toys
75
What is the most common site of foreign body impaction in the esophagus?
🔹 Upper esophageal sphincter (below cricopharyngeus) 70%
76
Other common impaction sites for esophageal foreign bodies?
▪️ Mid-esophagus – 20%
▪️ Lower esophageal sphincter (just above diaphragm) – 10%
****
🧠The commonest site is !?
77
What percentage of esophageal foreign body cases are asymptomatic?
🔹 Around 30%
78
What are common symptoms of foreign body ingestion in the esophagus?
▪️ History of choking, gagging, coughing
▪️ Salivation
▪️ Dysphagia
▪️ Refusal to eat
79
What is the most sensitive diagnostic test in achalasia?
🔹 Esophageal manometry
## Footnote
▪️most sensitive diagnostic test ➡️Esophageal manometry
▪️Primary screening test ➡️Barium fluoroscopy
80
What is the primary diagnostic tool for foreign bodies in the esophagus?
🩻 Radiography ➡️Plain film AP and lateral
81
What are examples of radiolucent foreign bodies?
▪️ Most foods
▪️ Wood
▪️ Splinters
▪️ Thorns
▪️ Fish bones
▪️ Plastics
82
What are examples of radiopaque foreign bodies?
▪️Glass
▪️ Metal except aluminum
▪️ Some food
▪️ Medications
83
What is the typical appearance of a coin lodged in the esophagus on X-ray?
🔹 AP/PA view: Coin shows its face (circular, flat side).
🔹 Lateral view: Coin appears as an edge (thin line)
🪄🪄🪄🪄
🧠 Quick Memory Aid
🔎FACE in Front = Food pipe (Esophagus)
84
What is the typical appearance of a coin in the trachea on X-ray?
🔹 AP/PA view: Coin shows its edge (thin line).
🔹 Lateral view: Coin shows its face (circular).
🪄🪄🪄🪄🪄
🧠 Quick Memory Aid :
🔎Thin in Front = Trachea
Or
🔎 T = Trachea, Thin, Turned = Sagittal
85
What is the recommended management for a button battery in the esophagus?
🚨 Immediate removal
*******
▪️due to the risk of mucosal injury, perforation, and chemical burns.
86
How should an asymptomatic child with a blunt foreign body (e.g., coin) in the esophagus be managed?
🔹Observe for up to 24 hours—many pass spontaneously
87
What is the next step if a patient with an esophageal foreign body becomes symptomatic (e.g., drooling, pain, vomiting)?
🚨 Urgent removal of the foreign body is indicated.
88
A 3-year-old presents with sudden onset coughing, wheezing, and stridor after playing with coins. X-ray shows a coin in the lateral view, appearing as a full circle, but only the edge is seen in the AP view. What is the most likely diagnosis?
A. Coin in esophagus
B. Coin in stomach
C. Coin in trachea
D. Laryngeal edema
Answer: 👏🏻✅ C. Coin in trachea
🪄🪄🪄🪄🪄
Don’t forget our mnemonic 🧠
🔎Thin in Front = Trachea
As mentioned in the case “but only the edge is seen in the AP view”
89
A 2-year-old child is brought in after swallowing a coin. X-ray (AP view) shows a full circular disc. What is the most likely location of the coin?
A. Stomach
B. Trachea
C. Bronchus
D. Esophagus
Answer: 👏🏻✅ D. Esophagus
🪄🪄🪄🪄
Don’t forget our mnemonic 🧠
🔎FACE in Front = Food pipe (Esophagus)
▪️As mentioned in the case “X-ray (AP view) shows a full circular disc. “
90
A child presents with vomiting, drooling, and chest discomfort after swallowing an unknown object. X-ray confirms a radiopaque object in the esophagus. What is the next step?
A. Repeat X-ray after 24 hours
B. Induce vomiting
C. Must be removed
D. Oral fluids and discharge
Answer: 👏🏻✅ C.must be removed
✨✨✨✨
🕵🏻♂️🪄Explanation:
🔹symptomatic patient with esophageal foreign body always must be removed .
🕵🏻♂️🪄 clues in the case
🔹 "Vomiting, drooling, and chest discomfort”
▪️ These are red flag symptoms suggesting esophageal obstruction or irritation.
▪️ They indicate the child is symptomatic, not just a passive ingester
91
A child has vomiting with fever (with or without abdominal pain). What are the possible causes?
▪️ Gastroenteritis
▪️ UTI
▪️ Systemic infection
▪️ Appendicitis
92
A child has projectile vomiting without bile. What should you suspect?
🔹 Pyloric stenosis
93
Vomiting of undigested food suggests what condition?
🔹 Achalasia
94
A vomiting infant has a bulging fontanelle. What are two serious causes to consider?
🔹Meningitis
🔹 Intracranial tumor
95
What is pyloric stenosis?
🔹 It is an acquired condition in infants where the pyloric muscle hypertrophies, causing gastric outlet obstruction.
96
What is another name for pyloric stenosis?
🔹Infantile hypertrophic pyloric stenosis (IHPS)
97
Is the cause of pyloric stenosis known?
🔹No – the exact etiology is unknown.
98
Is pyloric stenosis more common in boys or girls?
🔹 Boys – it is 4 times more common in males than females.
99
At what age does pyloric stenosis typically present?
🔹Anytime between birth and 5 months of age (most commonly around 2–8 weeks old).
100
What type of vomiting is seen in pyloric stenosis?
🔹 Non-bilious vomiting, typically immediately after feeding, and often becomes progressively projectile.
101
What is the infant’s behavior after vomiting in pyloric stenosis?
🔹 The infant is usually hungry and eager to feed again (“hungry vomiter”).
102
What physical sign may be found on examination in pyloric stenosis?
🔹 A palpable, olive-shaped mass in the right upper quadrant (RUQ) of the abdomen.
103
What laboratory abnormality is classically associated with pyloric stenosis?
🔹 Hypokalemic, hypochloremic metabolic alkalosis
104
What ultrasound findings are diagnostic for pyloric stenosis?
▪️ Pyloric muscle thickness > 4 mm
▪️ Pyloric channel length > 14 mm
105
: What is the definitive treatment for pyloric stenosis?
Surgical pyloromyotomy (Ramstedt operation)
106
Summarize pyloric stenosis in a memorable way ‼️
🧠🪄Mnemonic: “PYLORIC”
🪄P – Projectile vomiting (progressive, non-bilious, after feeding)
🪄Y – Young infant (typically 2–8 weeks old)
🪄L – Lump in RUQ (olive-shaped palpable mass)
🪄O – On labs: Hypochloremic, hypokalemic metabolic alkalosis
🪄R – Refeeds hungrily (hungry vomiter)
🪄I – Imaging (Ultrasound): Thickness >4 mm, Length >14 mm
🪄C – Corrected with surgery (Ramstedt pyloromyotomy)
107
A 4-week-old male infant presents with progressive non-bilious projectile vomiting. On examination, you find a small, firm, olive-shaped mass in the right upper quadrant. The baby is irritable but hungry after vomiting.
What is the most likely diagnosis?
A. Duodenal atresia
B. Gastroesophageal reflux
C. Pyloric stenosis
D. Intussusception
✅ Answer: C. Pyloric stenosis
Clues:
• Age: classic age (2–8 weeks)
• Non-bilious projectile vomiting
• Olive-like mass in RUQ
• Hungry after vomiting (“hungry vomiter”)
108
A 6-week-old infant presents with repeated vomiting. Blood work shows:
• Na⁺: 132 mmol/L
• K⁺: 2.8 mmol/L
• Cl⁻: 88 mmol/L
• ABG: metabolic alkalosis
What is the most likely underlying diagnosis?
A. Gastroenteritis
B. Adrenal insufficiency
C. Pyloric stenosis
D. Congenital chloride diarrhea
✅ Answer: C. Pyloric stenosis
Clues:
• Electrolytes: low K⁺, low Cl⁻
• Metabolic alkalosis
• Matches classic electrolyte pattern of persistent vomiting in pyloric stenosis
109
Which of the following ultrasound findings confirms the diagnosis of pyloric stenosis?
A. Pyloric muscle thickness of 2 mm, length 10 mm
B. Pyloric muscle thickness of 5 mm, length 16 mm
C. Pyloric channel width of 1 mm
D. Normal pyloric morphology
✅ Answer: B. Pyloric muscle thickness of 5 mm, length 16 mm
Clues:
• Diagnostic criteria:
• Thickness > 4 mm
• Length > 14 mm
110
What is Duodenal Atresia?
A: Duodenal atresia is a congenital condition where the duodenum is abnormally closed or narrowed, leading to intestinal obstruction. It results in bilious vomiting and is often associated with other congenital anomalies, including Down syndrome.
111
What is the most common associated syndrome with Duodenal Atresia?
A: Down syndrome (20-30% of cases)
112
What are the common associated congenital anomalies with Duodenal Atresia?
Esophageal atresia, congenital heart disease, anorectal anomalies, and renal anomalies.
113
What is the characteristic clinical presentation of Duodenal Atresia?
• Bilious vomiting in the first day of life
• No abdominal distension
• Jaundice
• History of polyhydramnios during pregnancy
114
What diagnostic test is used for Duodenal Atresia, and what is the classic sign seen?
A: KUB X-ray, which shows the double-bubble sign.
115
A newborn presents with bilious vomiting within the first 24 hours of life, along with a history of polyhydramnios. The baby has no abdominal distension. What is the most likely diagnosis?
A. Malrotation with volvulus
B. Duodenal atresia
C. Pyloric stenosis
D. Hirschsprung disease
✅ Answer: B. Duodenal atresia
Clues:
• Bilious vomiting within the first 24 hours of life is highly suggestive of intestinal obstruction.
• Polyhydramnios is commonly associated with duodenal atresia.
• No abdominal distension makes pyloric stenosis less likely.
116
An infant presents with bilious vomiting, abdominal distension, and a double-bubble sign on X-ray. What is the most likely diagnosis?
A. Duodenal atresia
B. Necrotizing enterocolitis
C. Malrotation with volvulus
D. Gastroesophageal reflux disease (GERD)
✅ Answer: A. Duodenal atresia
Clues:
• The double-bubble sign on X-ray is characteristic of duodenal atresia.
• Bilious vomiting and abdominal distension are common findings in duodenal atresia.
117
Summarize HIRSCHSPRUNG dis in a memorable way ‼️
🧠🪄Mnemonic 1:
🕵🏻♂️HIRSCHSPRUNG
🪄 H – High anal tone
🪄 I – Infant (presents in neonatal period)
🪄 R – Retained meconium >48 hrs
🪄 S – Stool ribbon-like
🪄 C – Congenital (aganglionic colon)
🪄 H – Hypoganglionosis (or absent ganglia)
🪄 S – Squirt sign (explosive stool on rectal exam)
🪄 P – Proximal dilation (on imaging)
🪄 R – Rectal biopsy = gold standard
🪄 U – Underlying syndromes (Down, Waardenburg)
🪄 N – No peristalsis
🪄 G – Ganglion cells absent
🧠🪄 Mnemonic 2:
“ME-CON-NO-GO”
🪄ME – Meconium
🪄CON – Constipation (chronic)
🪄NO GO – No ganglion cells = No motility
🔹 To remember delayed meconium passage and absence of ganglia
118
What is Hirschsprung disease?
A congenital condition caused by the absence of ganglion cells in the distal colon, leading to functional obstruction and megacolon.
119
What is a red flag for suspecting Hirschsprung disease in a newborn?
A:
Delayed passage of meconium beyond 48 hours after birth.
(Normal full-term infants pass meconium within 48 hours in 99% of cases.)
120
By what age do 99% of normal full-term infants pass meconium?
🔹Within the first 48 hours after birth
121
What is the typical gastrointestinal symptom of Hirschsprung disease in infants and children?
A: Chronic constipation due to functional bowel obstruction from aganglionic bowel segment
122
How does enterocolitis occur in Hirschsprung disease?
Failure to pass stool causes proximal bowel dilation → fecal stasis → bacterial overgrowth (e.g. C. difficile, Staph, anaerobic coliforms) → risk of life-threatening enterocolitis
123
What are signs of enterocolitis in Hirschsprung disease?
• Abdominal distension
• Fever
• Explosive, foul-smelling diarrhea
• Signs of sepsis
124
What are key rectal exam findings in Hirschsprung disease?
• Elevated anal sphincter tone
• Empty rectal vault
• Explosive release of foul-smelling stool and gas after exam
125
What is the diagnostic procedure of choice for Hirschsprung disease?
A: Rectal suction biopsy
126
What does the rectal suction biopsy show in Hirschsprung disease?
A: Absence of ganglion cells in the submucosal and myenteric plexus
127
What is the classic finding on barium enema in Hirschsprung disease?
A: Narrow distal rectum (aganglionic segment) with proximal colonic dilation (transition zone)
128
What is the definitive treatment for Hirschsprung disease?
A: Surgical resection of the aganglionic bowel segment
129
When is definitive surgery typically performed in Hirschsprung disease?
A: Between 6–12 months of age, often after a temporary colostomy in severe cases
130
A 2-day-old full-term infant has not passed meconium. He has abdominal distension and bilious vomiting. On rectal exam, the vault is empty but there is an explosive release of stool. What is the most likely diagnosis?
A. Meconium ileus
B. Intestinal atresia
C. Hirschsprung disease
D. Pyloric stenosis
E. Functional constipation
Answer: C. Hirschsprung disease
Clues:
• Delayed meconium >48 hours
• Abdominal distension
• Explosive stool on rectal exam
• Classic for Hirschsprung
131
On barium enema, which finding is most suggestive of Hirschsprung disease?
A. Dilated entire colon
B. Narrow rectum with proximal dilation (transition zone)
C. Microcolon
D. Corkscrew appearance
E. Double bubble sign
Answer: B. Narrow rectum with proximal dilation (transition zone)
Clues:
• Narrow aganglionic segment
• Transition to dilated ganglionic colon
• Classic radiologic finding
132
Which of the following statements best distinguishes Hirschsprung disease from functional constipation in a 3-year-old child?
A. Presence of fecal soiling (encopresis)
B. Onset in infancy
C. Hard stools
D. Large-caliber stools
E. Dietary cause
Answer: A. Presence of fecal soiling (encopresis)
Clues:
• Encopresis = common in functional constipation
• Rare in Hirschsprung
• Functional constipation also typically shows large stools and history of dietary/lifestyle cause
133
How does passage of meconium differ between Hirschsprung disease and functional constipation?
A:
• Hirschsprung: Delayed passage >48 hours after birth
• Functional constipation: Normal meconium passage within 24–48 hours
134
What is the rectal exam finding in Hirschsprung disease vs functional constipation?
• Hirschsprung: Empty rectum with explosive stool release after withdrawal
• Functional constipation: Rectum full of stool
135
How does stool appearance differ between Hirschsprung disease and functional constipation?
A:
• Hirschsprung: Small, ribbon-like stools
• Functional constipation: Large-caliber stools
136
Is encopresis (fecal soiling) more common in Hirschsprung disease or functional constipation?
A:
• Hirschsprung: Rare
• Functional constipation: Common
137
What are clinical presentations of Hirchispring dis ?
🔹constipation
🔹Enterocolitis
🔹rectal examination
138
Why does constipation occur in HIRSCHSPRUNG disease?
🔹Absence of ganglion cells ➡️ functional obstruction
➡️ failure to pass stool ➡️ chronic constipation and proximal bowel dilatation.
139
What causes proximal bowel dilatation in Hirschsprung disease?
🔹Stool accumulation above the aganglionic segment.
140
What causes enterocolitis in Hirschsprung disease?
🔹Stasis of stool leads to bacterial overgrowth (C. diff, Staph, anaerobic coliforms).
141
What are the rectal exam findings in Hirschsprung disease?
🔹Elevated anal tone
🔹 Empty rectal vault
🔹 Explosive foul smelling feces and gas
142
A newborn has not passed meconium for 72 hours. Abdominal distension is noted. Rectal exam reveals explosive passage of stool. What is the most likely diagnosis?
A. Meconium ileus
B. Hirschsprung disease
C. Imperforate anus
D. Small left colon syndrome
Answer: ✅ 👏🏻B. Hirschsprung disease
🕵🏾♀️🗝️Clues:
🔎Think “delayed meconium + explosive stool on DRE.”
143
Hirschsprung disease is most commonly associated with which of the following genetic conditions?
A. Marfan syndrome
B. Down syndrome
C. Turner syndrome
D. Prader-Willi syndrome
Answer: ✅ 👏🏻B. Down syndrome
144
Other name for Hirchsprung dis :
🔹Congenital aganglionicpn megacolon.
145
What is the definition of Recurrent Abdominal Pain (RAP) in children?
For you 🩺
🔹At least 3 episodes of abdominal pain over a period of 3 months, severe enough to interfere with the child’s normal activities, in the absence of an obvious identifiable cause.
146
the prevalence of Recurrent Abdominal Pain (RAP) in children?
🔹It affects about 15–35% of the pediatric population worldwide.
147
What percentage of RAP cases are due to organic causes?
🔹Around 1/3 of cases are found to have an organic cause.
148
What is Functional Recurrent abd pain ?
🔹 RAP with no identifiable organic cause; most likely related to functional GI disorders.
149
What are the “red flags” 🚨 that suggest an organic cause of RAP?
▪️ Family history of IBD
▪️ Fever
▪️ Weight loss
▪️ Night-time awakening
▪️ Anemia
▪️ Chronic diarrhea
▪️ Bloody stools
▪️ Localized tenderness
🕵🏻♂️✨ Simple Mnemonic for easy recall”“
🧠🪄”BAD FLAG”
B – Bloody stools
A – Anemia
D – Diarrhea (chronic)
F – Fever
L – Localized tenderness
A – Awakens at night with pain
G – Growth issues / Weight loss
150
Management of Recurrent Abdominal Pain (RAP)
🔹Lifestyle & Behavioral:
▪️ Avoid NSAIDs (gastric irritants)
▪️ Dietary modifications (e.g., fiber, lactose-free if needed)
▪️ Cognitive behavioral therapy (CBT)
🔹Pharmacologic (BLUE):
▪️ Tricyclic antidepressants / SSRIs
(especially for functional pain)
▪️ Trial of acid suppression (short-term only)
🕵🏻♂️🪄Mnemonic:
✨🧠No Diet Causes Trouble Acidically
→ NSAID, Diet, CBT, TCA/SSRI, Acid suppression
151
What is gluten-sensitive enteropathy (celiac disease)?
🔹It’s an autoimmune disorder causing small intestinal mucosal damage after ingestion of gluten in genetically predisposed individuals.
152
Other name for celiac disease?
🔹gluten-sensitive enteropathy
153
What foods trigger celiac disease
🔹Foods containing wheat, rye, and barley
➡️ commonly found in
▪️bread,
▪️pasta,
▪️many processed foods.
154
Which syndromes and diseases are commonly associated with celiac disease?
🔹 Type 1 Diabetes Mellitus
🔹 Down syndrome
🔹 Turner syndrome
🔹 Williams syndrome
🔹 Selective IgA deficiency
155
What is the most common gastrointestinal symptom of celiac disease in children?
🔹 Chronic diarrhea — typically pale, loose, bulky, and offensive due to fat malabsorption.
156
Clinical presentations of celiac disease?
▪️ - Diarrhea (the most common symptom) stool is pale, loose and offensive
▪️ - Abdominal distension
▪️ - Failure to thrive
▪️ - Anorexia
▪️- Constipation
▪️ - iron-deficiency anemia that is unresponsive to iron therapy
157
What type of anemia is commonly associated with celiac disease?
🔹 Iron-deficiency anemia that is often unresponsive to oral iron therapy, due to impaired iron absorption in the damaged duodenal mucosa.
158
What other serologic test is useful in diagnosing celiac disease?
🔹Anti-tissue transglutaminase (anti-tTG) IgA antibody
( the most sensitive and specific test 🦾)
🔹 Anti-endomysial IgA antibodies (EMA) — also highly specific.
159
What is the most sensitive and specific serologic test for diagnosing celiac disease?
🔹 Anti-tissue transglutaminase (anti-tTG) IgA antibody
160
which patients might anti-tTG and EMA tests be falsely negative?
🔹In patients with selective IgA deficiency — a known association with celiac disease.
161
What is the definitive test to confirm the diagnosis of celiac disease?
🔹 Small intestinal biopsy
162
What is the cornerstone of management for celiac disease?
🔹 Lifelong strict gluten-free diet, avoiding wheat, rye, and barley.
163
Which grains must be eliminated from the diet in celiac disease?
🔹 Wheat، Rye, and Barley
— all contain gluten and cause mucosal damage.
164
What blood test is used for follow-up in treated celiac patients, and when should it be checked?
🔹 Anti-tissue transglutaminase IgA levels
▪️▪️ typically rechecked at 6️⃣ months to monitor response to the gluten-free diet
165
Why is dietitian involvement important in celiac disease management?
🔹 To ensure nutritional adequacy, label reading, and avoidance of hidden gluten sources.
166
What are managements plan in children with celiac disease?
▪️Lifelong exclusion of gluten:
▪️ No wheat, barley, and rye in diet
▪️ Follow up with Tissue transglutaminase level 6 months.
▪️ Follow up with dietitian is very important
▪️ Follow up the growth curve
167
What is the clinical definition of diarrhea?
🔹increased stool frequency and liquidity compared to baseline , The passage of three or more loose or watery stools per day .
168
Which bacterial causes of diarrhea are associated with reactive arthritis?
🔹 Salmonella,
🔹Shigella,
🔹Yersinia,
🔹 Clostridium difficile
🕵🏻♂️🪄Mnemonic:
🧠🪄 “Some Sick Young Colon”
(Salmonella, Shigella, Yersinia, C. diff — your colon gets sick, joints hurt!)
✨✨✨✨
MCQ Example
A child with recent diarrhea now presents with joint pain. Which group of organisms is most commonly associated with reactive arthritis?
A. Shigella, Salmonella, Yersinia, C. diff
B. E. coli, Giardia, Entamoeba
C. Rotavirus, Norovirus
D. Vibrio cholerae, Clostridium botulinum
Answer: A.
169
Which diarrheal pathogen is linked with Guillain-Barré Syndrome?
🔹 Campylobacter jejuni
🕵🏻♂️🔎Mnemonic:
🧠🪄“Campy 🟰 Crampy belly ➡️ Can’t walk”
(Campylobacter causes tummy cramps first, then ascending weakness – classic GBS!)
170
Which diarrheal infection may mimic appendicitis?
🔹 Yersinia enterocolitica
171
Which pathogens causing diarrhea are associated with erythema nodosum?
🔹Yersinia,
🔹 Campylobacter,
🔹 Salmonella
🕵🏻♂️🪄Mnemonic
🧠🪄ScY ➡️ SCarY for skin 😉
S 🟰 Salmonella
C 🟰 Campylobacter
Y 🟰 Yersinia
172
Which pathogens are classically associated with Hemolytic Uremic Syndrome (HUS)?
🔹 Shigella dysenteriae type 1
🔹 E. coli O157:H7
🕵🏻♂️🪄Mnemonic:
🧠🪄“HUS = SHock from E.coli)
(S = Shigella, H = HUS, E = E.coli — shocks kidneys!)
173
What are the contraindications for Oral Rehydration Therapy (ORT)?
1. Severe vomiting
2. Severe dehydration with shock
3. Comatose or unconscious patients
4. Severe malabsorption
5. Intestinal obstruction
6. Severe hypernatremia
7. Severe renal impairment
8. Severe heart failure
174
What is the first step in the management of acute diarrhea in children?
🔹Oral Rehydration Solution (ORS) for hydration.
🩺– always hydrate first
175
Should diet be restricted in acute diarrhea?
No, regular diet should be continued.
176
Why should fruit juices be restricted in diarrhea?
🔹High sugar content can worsen osmotic diarrhea.
Why ‼️
▪️Juices contain fructose and sorbitol—they are poorly absorbed and pull water into the gut, causing osmotic diarrhea.
Mnemonic: “Juicy drinks make stools quick!”
177
Are antidiarrheal medications recommended in children with acute diarrhea?
🔹No, they are contraindicated due to risk of ileus (e.g. Imodium).
Why ‼️
▪️ they traps toxins or pathogens inside the intestines.
▪️Can lead to ileus (stopped gut), bloating, or even toxic megacolon.
178
When are probiotics useful in diarrhea?
🔹 They may shorten duration and improve symptoms.
179
What dietary change may be trialed in diarrhea >2 weeks?
🔹A lactose-free diet.
180
What is the treatment of choice for Shigella?
🔹 Ciprofloxacin,
🔹 TMP-SMX,
🔹 Azithromycin.
🔹 Cephalosporins if severe. ‼️
Third-generation cephalosporin is appropriate empiric therapy in the setting of acute illness
🕵🏻♂️🪄Mnemonic:
🧠✨“Shigella takes a ✨CAT nap!”
▪️ Ciprofloxacin
▪️ Azithromycin
▪️ TMP-SMX
181
When are antibiotics indicated for Salmonella infections?
🔹 In infants <3 months,
🔹 systemic illness,
🔹malignancy,
🔹 immunocompromised.
🕵🏻♂️🪄Mnemonic:
🧠🪄“Small, Sick, Suppressed = Salmonella antibiotics.”
182
What is the antibiotic of choice for Salmonella in indicated patients?
🔹Third-generation cephalosporins.
183
First-line and second-line treatment for Clostridium difficile?
1️⃣ Metronidazole (oral/IV) is first-line
2️⃣ Vancomycin (oral) if no response.
🕵🏻♂️🔎Mnemonic:
🧠🪄“Metro first, Van if worse.”
184
How is Entamoeba histolytica treated?
1️⃣ Metronidazole followed by 2️⃣ Paromomycin (for cyst clearance).
🕵🏻♂️🪄Mnemonic :
🧠✨ To treat Entamena go to the metro 🚇 🚇 then to the Pus🚌
185
What is Chronic Non-Specific Diarrhea (CNSD)?
🔹. A common condition in toddlers causing frequent loose stools without systemic illness. Also called “toddler’s. diarrhea.”common in the 1st year of life ,,
186
What causes CNSD?
🔹Excessive intake of fruit juice or water
187
What are the typical features of CNSD?
▪️ 4–10 loose stools/day
▪️ No blood or mucus
▪️ Occurs only during waking hours
▪️ Stools contain undigested food
188
What is the management of CNSD?
🔹 Reassure parents (child is healthy and growing)
🔹 Restrict fruit juice
🔹 Increase dietary fat
189
What is Microvillous Inclusion Disease
🔹 A rare congenital cause of secretory diarrhea from birth, due to defective enterocyte structure.
🩺Don’t forget ‼️
▪️Microvillous Inclusion Disease➡️ no polyhydraminos
But.
▪️CCD and CSD ➡️ hx of polyhydraminos , diarrhea in utero
190
Why can congenital diarrhea be mistaken for urine?
▪️ Because it’s extremely watery.
191
What are the biopsy findings in Microvillous Inclusion Disease?
🔹 Villous atrophy without inflammation
🔹 Microvillous inclusions seen on electron microscopy
192
How do stool electrolytes differ between congenital chloride and Congenital sodium diarrhea ?
• CCD: High chloride content in stool
But hypchloremia
•CSD: High sodium content in stool
But hyponatremia
193
What metabolic abnormalities are seen in CCD vs CSD?
🔹 CCD: Metabolic alkalosis (due to chloride loss)
So low ph diarrhea (acid)
🔹 CSD: Metabolic acidosis (due to bicarbonate loss with sodium)
So hight pH diarrhea(alkali)
Clarification for you ✨
▪️SALT (Na⁺) loss = Acidosis (Sodium = Strong acid impact)
▪️ Chloride loss = Alkalosis (Chloride = Contracts pH)
194
What clinical clues help differentiate CCD from CSD?
🔹 CCD: Polyhydramnios, distended abdomen, high stool Cl⁻ (>90 mmol/L), metabolic alkalosis
🔹 CSD: Watery diarrhea, high stool Na⁺, acidosis may have associated intestinal epithelial abnormalities on biopsy
195
True or False: Aluminum is considered a radiopaque foreign body.
False👏🏻
