pathophys of NSAIDs on GI tract
inhibit PG synthesis; PGE normally stimulates gastric mucous production and helps maintain the protective mucin glycoprotein-bicarbonate layer (without which the gastric mucosa is exposed to deleterious effects of gastric acid and proteolytic effects of pepsin)
stress ulcerations
usually in severly ill, post op pts in ICU setting - lesions are single or multiple, non-inflammatory and occur in stomach and duodenum - due to epithelial cell ischemia
causes of gastric acid hypersecretion
- disorders with hypergastrinemia and hyperhistaminemia (Zollinger Ellison) 2. rebound hypersecretion after PPIs 3. cysteamine treatment in children with cytinosis
protein-induced allergic proctocolitis
- clinical features
- cause
- treatment
- bloody-streaked stools +/- mucous, may be assoc. with anal fissure in 50%; otherwise, health infant with healthy weight gain
- anal fissure in infants (first few months) not likely assoc with constipation
- cow milk protein allergy: caseins make 80% but are less immunogenic than whey proteins (esp. lactoglobulin)
- if formula fed –> switch to protein hydrolysate formula
- do not switch to soy –> approx 30% shared immunogenicity
- if breast fed, mom should avoid cows milk and soy products
Use of Medium Chain Fatty Acyl Triglycerides as supplements
- shorter FA chains = soluble in aqueous environment, therefore do NOT require bile salts for luminal absorption; they do however, require hydrolysis by pancreatic lipase
- can be used in:
- cholestatic conditions - decreased bile salt delivery
- short bowel syndrome - ileal resection removes site of bile salt absorption
Common medications causing pill-induced esophagitis
- Non-steroidal anti-inflammatory drugs (NSAIDs), 41%
- Tetracyclines, 22%
- Potassium chloride tablets, 10%
- Alendronate, 9%
- Other drugs, 18%
Uses of alendronate (and other bisphosphonates)
- prevent pathologic fx 2/2 postmenopausal and steroid-induced osteoporosis
- pediatric patients: osteogenesis imperfecta
- preventing secondary osteopenia in young pts on chronic steroid therapy for Crohn’s dz and rheumatic dz
Tx. pill induced esophagitis
- remove offending agent.
- proper medication instruction - taken in upright position with copious water, not before bedtime
a neonate in term nursery is having bilious emesis after every feed, what does your work-up include and what must you rule out?
- Work-up:
- AXR - may show obstruction but may be normal
- definitive study: Upper GI series
- Rule-out: Malrotation –> surgical emergency!
- If UGI in infant with bilious emesis is normal:*
- if it resolves, ok to just observe*
- if continues, obtain barium enema to r/o Hirschsprung*
Risk Factors for developing C. difficile
- antimicrobial therapy - B-lactams, clindamycin, FQs, clindamycin
- underlying bowel disease (IBD)
- GI tract surgery
- prolonged NG tube insertion
- repeated enemas
- renal insufficiency
- prolonged hospitalization -> nosocomial infxn
Diagnosis: C. Difficile
- testing stool for the presence of C difficile toxins (A and B) via enzyme immunoassay –> degrades rapidly, therefore test promptly or store at 4 C.
other diagnostic supportive findings:
- endoscopy: pseudomembranes, friable colorectal mucosa
- USG: nonspecific findings; thickened bowel wall or ascites; non-diagnostic
Treatment: C. difficile
- PO Metronidazole, 30 mg/kg/day divided Q6hr, max 2 g/day
- PO Vancomycin, 40 mg/kg/day divided Q6hr, max 125 mg QID
- can be used w/ or w/o metronidazole in pts with severe disease, or alone in patients who failed therapy w/ metronidazole
Duration: 10 days
11 yr old boy p/w acute onset jaundice, abdominal pain and palpable RUQ mass
- diagnosis?
- etiology?
- diagnostic approach?
- choledochal cyst
- Etiology - multifactorial; see pdf with subtypes
- Diagnostic approach:
- abdominal USG - definitive test
- abdominal CT or MRI may help delineate anatomy, appearance of surrounding structures and aid in determining extent of intrahepatic ductal involvement
Treatment: Choledochal cyst
complete surgical excision
- patient’s with Type 1 lesions may require Kasai procedure
