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Week 9: GI, endo Flashcards

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1
Q

What is the definition of diarrhea?

A

WHO: 3+ loose or liquid stools/day OR more frequent than normal

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2
Q

DIARRHEA

what is the most common cause of infectious diarrhea worldwide?
-what is the most common cause of acute gastro (medically attended)?

A

Rotavirus most common worldwide

norovirus #1 for gastro

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3
Q

what is timeline for:

  • acute diarrhea
  • persistent diarrhea
  • chronic diarrhea
A

acute: sudden onset and resolution within 2 weeks
persistent: acute onset lasting >2 weeks, <1 month
chronic: lasts 30 days or more, associated with specific cause eg IBD

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4
Q

Common causes of acute diarrhea

A
  • viral gastro (esp rotavirus): preceding URTI symptoms, vomiting, diarrhea no blood or mucous
    bacterial: usually unwell, high fever , mucus or blood in stool (campylobacter, shigella, salmonella)

parasites usually last long time

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5
Q

what are some signs of Hirschsprung (congenital megacolon)

A

small watery stools
abdo distention
poor appetite
poor growth

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6
Q

common causes of persistent diarrhea?

risk factors

A

no cause detected for most causes

-caloric and protein malnutrition, vit A and zinc deficiency, prior infection, male, young age (6-24 months old), young maternal age

consider shigella, E coli, HIV, starvation

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7
Q

common causes of chronic diarrhea

A

IBD
IBS
high consumption of fruit/carbonated beverages
antibiotic/NSAID use

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8
Q

describe diarrhea associated with IBS

A

• No diarrhea at night (compared with infectious/secretory diarrhea)
• Usually partially formed/liquid first stool in AM, worse throughout the day
• BM after each meal, 3-10 stools with mucus/day
• Alternate with constipation
• Remember ABCD (abdo pain, bloating, constipation, diarrhea)
Systemically well: no weight loss, stunted growth, fever, etc. Good appetite

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9
Q

diet recommendations for diarrhea

A

-hydration +++
ORS if needed

full resumption of normal diet

  • high fat low carb diet accelerates improvement
  • avoid lactose
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10
Q

Constipation

Rome IV criteria

A
  • defecation frequency 2x or less per week
  • fecal incontinence 1x/week for toilet trained kids
  • retentive posturing
  • pain with defection
  • large diameter stools that obstruct toilet
  • palpable rectal fecal mass

2 or more criteria for one month

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11
Q

Risk factors for chronic constipation

A

think GU

hydronephrosis, UTIs, enuresis

also family hx constipation, genetic predisposition

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12
Q

Describe the vicious cycle of constipation

A

Vicious Cycle of Constipation
• If ongoing suppression of urge to defecate: rectosigmoid and entire colon becomes dilated and impacted
• Contractions are weaker, less effective
• Positive feedback loop: withholding stool worsens constipation –> stretch receptors accommodate distended rectum, contractile forces fail to cause complete evacuation
• Child becomes desensitized to rectal distention
• Delayed defecation –> hard bulky stool –> painful
• Child learns to tighten external anal sphincter and gluteal muscles
• Results in intentional and prolonged suppression of defecation

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13
Q

What DDX should you consider if “explosive” passage of stool after DRE?

what are the red flags?

A

Hirschsprung (congenital megacolon)
-rectal exam induces gush of air

Risk of toxic megacolon and enterocolitis
-lethargy, signs of sepsis, peritoneal signs, bloody diarrhea

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14
Q

What DDx would you consider with delayed passage of meconium (>24 hours after birth)?

A

Hirschsprung

cystic fibrosis

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15
Q

What are some causes of functional constipation?

A
  • poor diet and fluid intake
  • stool withholding
  • high consumption (>24 oz/day) of cow’s milk, cheese, sugary fruit juice
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16
Q

Potential causes of constipation

A
  • functional
  • stool withholding (acute stressors)
  • intestinal malrotation
  • Hirschsprung
  • hypothyroidism
  • anorectal malformation
  • side effect of medications
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17
Q

What is the goal of treatment for constipation?

A

1 to 2 soft painless stools/day

-no less than every other day

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18
Q

What is the 3 pronged approach to constipation management?

A
  • diet
  • behavioural modification
  • medications
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19
Q

Describe diet and behaviour modification for constipation

A

Diet:
• decrease intake of simple carbs (sugar), refined/processed carbs, saturated fat, processed meat, dairy (milk and cheese)
• Increase fruits, vegetables, whole grains, legumes, tree nuts
• Prune juice, pear/peach/apricot nectar
• Dried fruit (raisins, cranberries): rich in sorbitol and helpful
• Increase fibre, whole grain breads, brown rice
• Continually introduce new food items

Behaviour modifications:
• Consistent toilet hygiene: sticker/star reward chart
• Sit on toilet 1-2x/day for 8-10 min each time, preferably after a meal
• Discourage longer toilet sitting

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20
Q

Describe use of PEG 3350 for constipation

  • starting dose
  • titration
  • common side effects
A

PEG 3350
• Better tolerated than other oral laxatives, tested +++ in kids and safely used
• Tasteless, odourless, dissolve in any beverage
• Not systemically absorbed, stress to parents that PEG does not lead to dependence
• Starting dose 0.4-1 g/kg/day
• Titrate up or down every 2-3 days
• High dose PEG for disimpaction: 1-1.5 g/kg/day max 100 g/day
• Most common lack of response to PEG: inadequate dosing
Side effects: gas, abdo pain, loose stools

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21
Q

Treatment of chronic constipation

-duration of treatment?

A

can take up to 6-12 months

-treat minimum 2 months until having 1-2 BMs/day without difficulty for minimum 1 month, then gradual wean

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22
Q

what is the typical presentation of appendicitis?

A
  • periumbilical pain migrating to RLQ
  • pain BEFORE nausea/vomiting
  • fever, tachycardia
  • low grade fever in first 24 hours
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23
Q

what would labwork for appendicitis typically show?

A

CBC:

  • leukocytosis (elevated WBC) = perforation
  • shift to left (immature white blood cells)
    urinalysis: pyuria
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24
Q

what is the imaging of choice for appendicitis?

A

ultrasound (gold standard)
85% sensitive, 90% specific

CT if US did not confirm/exclude appendicitis

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25
what is non-surgical management of uncomplicated apppendicitis?
-if symptom duration is <5-7 days then unlikely perforation IV abx followed by 10 days of po abx -90-95% success rate with 20% recurrence rate at one year
26
what is the most accurate way to assess degree of dehydration?
-compare current weight with recent pre-illness weight
27
what is the most useful sign to detect dehydration of 5% or more? what about dehydration at 3-5%?
>5%: cap refill 3-5%: skin turgor, resp disturbance
28
``` For kids under age 5: % of body weight loss for: -mild dehydration -moderate dehydration -severe dehydration ```
mild: 5% or less moderate: 6-9% severe: 10% or more
29
For kids 5 and older: % of body weight loss for: - mild dehydration - moderate dehydration - severe dehydration
mild: 3% moderate: 6% severe: 9%
30
what is the treatment for mild dehydration in kids? when is IV hydration needed?
ORS preferred *also preferred if moderate dehydration IVF if severe dehydration, intractable vomiting, shock, anatomical defect
31
What are some parent education points for ORT?
• Need to add on additional fluid for replacement of losses (see third column in table 80.5) • Relate mL to common household measures ○ Eg 5 mL = 1 tsp, 15 mL = 1 TBSP • Small frequent feeds: volumes of 5-15 mL via syringe or teaspoon every 2-5 min better tolerated ○ Labor intensive for parent but can successfully deliver 150-300 mL/hour • Diarrhea often increases (frequency and amount) during initial treatment with ORT • Primary goal of ORT is to rehydrate, not to stop diarrhea • Diarrhea will resolve spontaneously • No longer recommend "gut rest" --> early refeeding with return to formula/milk and solids is a priority Red flag signs etc.
32
how is emesis categorized?
bilious vs non-bilious time (acute vs chronic vs cyclic) bilious - think obstruction
33
what is a complication of severe vomiting?
dehydration failure to thrive, starvation esophageal tears and hematemesis (Mallory-Weiss)
34
DDx for vomiting in newborns and infants?
- overfeeding (more likely to be regurgitation) - food allergies - GERD - UTI - OM - pyloric stenosis
35
Pyloric stenosis - age group? - risk factors? - symptoms?
• Pyloric stenosis: most common surgical condition associated with vomiting in infancy ○ M>F ages 2 weeks to 2 months ○ Risk factors: firstborn, male, high birthweight, early exposure to erythromycin ○ Non-bilious projectile emesis, often has curdled milk ○ Appetite intact, eager to eat ○ May have fewer bowel movements and constipation or mucous-laden stools
36
DDx for vomiting in children
-gastro -acute infection (UTI, OM, strep) -labyrinthitis -DM CNS: tumour, infection -cyclic vomiting -appendicitis -cholecytitis
37
describe pattern of cyclic vomiting
- recurrent episode of vomiting, completely well in between - assoc with family hx migraines - triggered by emotions, fatigue, infection - resolves in late childhood/early adolescence
38
DDx for bilious vomiting
- obstruction - pancreatitis - paralytic ileus
39
signs and symptoms of intussception
- intermittent abdo pain/irritability - palpable abdo mass - red currant jelly stool (mixed blood and mucous) - vomiting (bile think obstruction) - lethargy - looks well in between
40
what is the definition of colic (rule of 3's) symptoms of colic?
>3 hours/day >3 days/week >3 weeks duration starts at age 2-3 weeks, ends by 3 months - prolonged fussiness - symptoms usually start after feeding, late in the day - responds to rhythmic motion (bouncing) - otherwsie well
41
hep D: common co-infection with which type of hepatitis?
hep B hep D needs HBsAg for replication
42
What are some acute signs of hepatitis?
- flu-like symptoms (fever, malaise, anorexia, n/v) - diffuse abdo pain - jaundice (not always in peds) - DARK URINE and LIGHT STOOL - pain over liver - hepatomegaly
43
complication of hepatitis A?
- does not become chronic | - can have fulminant hepatitis
44
how is hep B transmitted?
-bodily fluids - only serum, sexual fluids (semen and vaginal), saliva are contagious - vertical transmission
45
how is hep E spread?
water, fecal oral *esp monsoon in endemic areas - most common viral hepatitis in the world - acute infection is self-limiting - high risk of fetal loss for pregnant women
46
what is Fitz-Hugh-Curtis syndrome?
-liver inflammation associated with PELVIC infections - RUQ pain, perihepatitis - usually from chlamydia or gonorrhea
47
Hepatitis A IgM suggests _____ infection Hepatitis A IgG suggests ______ infection
IgM: acute IgG: vaccination or previous infection
48
Functional abdominal pain: diagnostic criteria: -must have ____ per month for minimum of _____ months
FAP-NOS: functional abdominal pain not otherwise specified: 4x/month for a min of 2 months PLUS ALL OF THE FOLLOWING: • Episodic or continuous that does not occur solely with physiological events (eating, menses) • Does not match IBS, functional dyspepsia, or abdominal migraine Cannot be explained with another medical condition
49
visceral pain is caused by _____ fibres -well or poorly localized? somatic pain is caused by _____ fibres -well or poorly localized?
visceral pain: - slow unmyelinated C fibres - poorly localized - kids are RESTLESS somatic pain - rapid myelinated A fibres - well localized, sharp - kids are lying STILL
50
how is functional abdominal pain different from acute/chronic pain?
-dysregulation of brain-gut interaction and GI nervous system -abnormal response of GI symptoms to physiologic functions (eating etc) VISCERAL HYPERALGESIA hypersensitization of GI tract
51
if abdo pain improves with having BM, think _____ if abdo pain worsens with having BM, think _____
improves with BM: IBS | worse with BM: IBD
52
abdominal migraine symptoms
○ Recurrent paroxysmal episodes of intense, acute periumbilical, midline, or diffuse abd pain ○ Can last 1 to many hours ○ Can be incapacitating ○ Return to normal function for weeks/months between episodes ○ Interferes w/normal activity ○ Pallor, anorexia, photophobia, HA, N/V Association with maternal migraines
53
if pain wakens child from sleep, weight loss, slowed growth, consider DDx
-organic causes | eg IBS, celiac, PUD
54
symptoms of mesenteric adenitis
looks like appendicits, not as unwell nausea and vomiting preceding URTI
55
name some DDX of medical (non surgical) causes of abdo pain in school-aged or adolescent kids
- IBS - functional dyspepsia - epigastric pain syndrome - abdo migraine - organic (celiac, IBD, PUD) - mesenteric adenitis - infection - viral hepatitis - pancreatitis - parasitic infection - pyelonephritis - sickle cell disease - acute intermittent porphyria - dysmenorrhea - PID - gallstones
56
how is functional abdominal pain diagnosed?
- normal physical exam - no red flag findings - negative stool for occult blood
57
functional abdominal pain disorders in child/adolescent top 5
- functional dyspepsia - IBS - abdominal migraine - functional abdo pain NOS - functional constipation
58
red flag signs on history for chronic abdo pain
- weight loss (unintended) - dysphagia - significant vomiting (bilious, projectile) - chronic diarrhea - unexplained fever - back pain - Fam hx IBD, celiac, PUD - bloody diarrhea - melena - rash
59
what are some potential complications of GERD?
- esophagitis - Barrett syndrome - strictures - aspiration
60
what is the common presentation for infants with GER?
recurrent non-forceful small volume emesis - not forceful, bilious or projectile - usually after feeding - a little bit fussy -can also manifest as nighttime cough, wheezing, recurrent pneumonia
61
What are some adverse effects of long term acid suppression:
- headaches - diarrhea - constipation - nausea - increased rates of infections (CAP, gastroenteritis, necrotizing enterocolitis in adults: long term use linked to hip fracture, B12 deficiency
62
hematochezia -definition UGI vs LGIB?
BRBPR | LGIB
63
melena -definition UGI vs LGIB?
dark tarry stool UGIB -can also be blood from nosebleed or side effect of med/food
64
occult blood | -definition
hidden (ie not visible) | usually presents as IDA
65
what are some non-bleeding causes of red-staining of emesis or stool?
- cranberries, cherries, strawberries, beets, tomatoes, candy - amoxicillin, dilantin, rifampin
66
what are some non-bleeding causes of tarry stools/emesis?
- bismuth - activated charcoal - iron - spinach, blueberries, licorice
67
common presentation of UGIB? common presentation of LGIB?
UGIB - hematemesis - melena (not absolute, sometimes can have melena with LGI or hematochezia with massive UGIB) LGIB -hematochezia
68
What differential should be considered in infants and toddlers with bloody diarrhea and diffuse abdo pain?
hemolytic uremic syndrome (HUS) complications: -intussusception, pancreatitis, obstruction, perforation
69
what differential should be considered in children with hematochezia, vomiting, sudden severe abdo pain and purpura to lower extremities?
Henoch schonlein purpura
70
3 C's associated with patho of ulcerative colitis
-autoimmune disease - crypt abscesses - circumferential - continuous (always starts at rectum, extends proximally, no breaks of normal tissue)
71
ulcerative colitis signs and symptoms
abdo pain: moderate to severe LLQ frequent diarrhea with mucous and blood - pain WORSE after defecation - nocturnal diarrhea - anemia - dehydration - cramping - tenesmus - fatigue - weight loss kids may have fecal incontinence
72
how to rank severity of ulcerative colitis - mild - moderate - severe - fulminant
mild: <4 stools/day moderate: 4-6/day severe: >6/day fulminant: >10/day
73
Workup for ulcerative colitis what would tests show?
colonoscopy: ulcers (need biopsy) CT: thickening of intestinal wall Stool studies: N CBC: anemia CRP: elevated
74
Crohn's disease what does it affect? risk factors?
bum to gum (mouth to anus) risk factors: - white - family hx - smoking - OCP - abx - NSAIDs
75
Crohn's disease Patho (TST)
Transmural (ulcers entire depth of wall) - skip lesions (healthy tissue in between) - Thickening, fissures, strictures
76
Crohn's disease signs and symptoms
-Abdo pain moderate to severe -RLQ pain -diarrhea (not grossly bloody) abdo pain WORSE after defecation -weight loss (more than UC) -fatigue -nausea/vomiting -fecal incontinence in peds -anorexia
77
Crohn's disease workup and findings
colonoscopy with biopsy: transmural skip lesions CT: intestinal thickening Stool studies: N CBC: anemia CRP: elevated Fecal calprotectin: 83-100% specific in adults
78
positive fecal calprotectin is indicative of ______
inflammatory bowel disease -helps to differentiate IBD vs IBS -only covered by MSP if already diagnosed with IBD (as marker of progression of disease) otherwise costs $110
79
Risk factors for hyperlipidemia -medications?
thiazide - beta blockers - hormones (specifically progestin) - clozapine - olanzapine - HIV meds
80
Start screening children for hyperlipidemia between age ___ and _____ if risk factors present:
2 to 10 years of age - positive fam hx of dyslipidemia - fam hx of early CVD (<55 male, <65 female) - risk factors for CVD (overweight, obesity, HTN, smoking, DM) Medical conditions: - organ transplant - SLE - nephrotic syndrome - on protease inhibitor for HIV
81
signs and symptoms of malabsorption
- chronic diarrhea - pale, greasy, foul-smelling stools - unintentional weight loss - RARE abdo pain if carb malabsorption: watery diarrhea with ++gas and distention 90 min after eating
82
what are the 3 hormones involved in primary adrenal insufficiency (Addison's)?
DEFICIENCY in - aldosterone - cortisol - androgens
83
symptoms of primary adrenal insufficency?
- cravings for salty food - nausea, vomiting - fatigue - dizziness - weak and tired - altered LOC - hyperpigmentation - loss of pubic and armpit hair - decreased sex drive
84
what are symptoms of adrenal / Addisonian crisis?
pain to abdomen, back, legs - vomiting and diarrhea --> dehydration - HYPOglycemia - HYPOnatremia, hyperkalemia, HYPOtension - LOC - death
85
what is the hormone involved with Cushing's?
cortisol excess
86
what are the symptoms of Cushing's?
- moon-shaped face - buffalo hump - truncal obesity - thin extremities - easy bruising and abdo striae - fractures (osteoporosis) - HYPERglycemia - HYPERtension - HIGHER risk of CVD - HIGHER risk of infections - delayed wound healing - amenorrhea - mental health disturbances
87
Definition of precocious puberty
onset of puberty 2-2.5 SD earlier than population norms - before age 8 (F) - before age 9 (M)
88
patho of precocious puberty central vs peripheral
central: early maturation of hypothalamic-pituitary-gonadal axis - sequential maturation of breasts and pubic hair (F) and penile enlargement and pubic hair (M) -peripheral: excess secretion of sex hormones, exogenous sources of sex hormones, ectopic production of gonadotropin from germ-cell tumor
89
delayed puberty definition
-absence/incomplete development of secondary sex characteristics - absence of breast development by 13 - absence of menarche by 16 or within 5 years of puberty - absence of testicular enlargement by age 13-14
90
delayed puberty potential causes?
``` turner syndrome klinefelter syndrome -nutritional disorder -celiac disease -IBD -anorexia -hepatic disease ```
91
what is the most common cause of hypothyroidism in children?
-autoimmune thyroiditis
92
define subclinical hypothyroid
asymptomatic high TSH, normal fT4
93
define sick euthyroid
Hypothalamic-pituitary-thyroid axis transiently affected by any stress (disease, infection, surgery, fasting) in acute phase: TSH low, then normalizes -reverses spontaneously, does not need treatment
94
what are some risk factors for hypothyroidism
- DM1 or other autoimmune disorders - Down syndrome, Turner syndrome, mitochondrial disease - Family hx - Iodine excess or deficiency - Iatrogenic (neck irradiation, thyroidectomy, radioactive iodine ablation) Medications: Lithium and amiodarone
95
peds specific impact of hypothyroidism?
- decreased mental function (mental disabilities if present before age 2) - slow growth - delayed bone maturation - puberty: delayed or precocious
96
what is the most common cause of hyperthyroidism in children?
Grave's
97
peds specific impact of hyperthyroidism?
- difficulty gaining weight - growth acceleration - advanced bone age - delayed puberty
98
what is the diagnostic test for Grave's disease?
anti-TR antibody
99
what is the risk and benefits associated with thyroid replacement in hypothyroidism for infants?
- CVS: palpitations, tachy, afib, cardiac overload, arrythmias benefit: prevent neurocognitive impairment if treated in first 2-3 years of life
100
congenital hypothyroidism symptoms?
``` jaundice constipation lethargy hypotonia poor feeding ``` if not detected: cognitive outcomes failure to thrive
101
IBS What are the ABCDs
abdominal pain bloating constipation diarrhea
102
Rome Criteria for IBS for children: for adults:
kids: at least 4 days/month for 2 months adults: at least 1 day/week for 3 months
103
signs and symptoms of IBS in children:
○ Change to stool frequency (>4/day or <2/week) and consistency (hard/lumpy or loose/watery) ○ Pain improves w/defecation ○ Straining/urgency/feeling of incomplete evacuation w/BM ○ Passage of mucus ○ bloating/distension (less common in kids compared to adults) ○ Associated w/anxiety and multiple somatic symptoms ○ 30% kids also have dyspepsia (heartburn) ○ Symptoms can be precipitated by school-related problems, overeating or eating problems
104
how would you counsel parents on early introduction of allergens?
• Actively offer common allergens (eg peanuts, cooked eggs) around 6 months old, NOT before 4 months old --> effective in preventing food allergy in some high risk infants • High risk infants: eczema or immediate family member with eczema, food allergy, asthma, allergic rhinitis • Most common allergens: egg, peanut, tree nuts, sesame, soy, wheat • Give allergenic foods for first time at home ○ Give it at a time when they will be awake for 2 hours after ○ Make sure texture and size is age-appropriate to prevent choking ○ Offer small amount on tip of spoon, wait 10 min, then give rest of food at usual pace ○ Do not place food on skin first (can cause irritant effect) • If there is no allergic reaction after first introduction: Keep feeding that food item 2-3x/week to prevent development of food allergy

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