GI Board Review - LSU School of Medicine
Download
Report
Transcript GI Board Review - LSU School of Medicine
GI BOARD REVIEW
December 16, 2010
INFANT NUTRITION
Breast milk ideal
Supplements:
Vitamin D
400IU/day
Fluoride
(exclusive breast feeding may require Fe supplements after
several months of age)
VLBW infants
Higher Ca, Phos, vitamin requirements
QUESTION 1
You are seeing a healthy 6 month old infant for a
well visit. The mother is concerned that the baby
is not taking in enough calories. What is the
required cal/kg/day for this child?
A. 70
B. 100
C. 50
D. 125
E. 80
MALNUTRITION
Explore diet and eating habits
Formula
Type, quantity, how it is mixed
Older Children
Food intake, preferences, avoidances
Plot BMI
EXTREME MALNUTRITION
Marasmus
Caloric deficiency
Emaciation
Hypothermia and bradycardia late
Kwashiorkor
Protein deficiency
Edema
Hepatomegaly, AMS
Marasmic-kwashiorkor
QUESTION 2
Which of the following electrolyte abnormalities
may be seen in refeeding syndrome?
A.
B.
C.
D.
E.
Hyperkalemia
Hypercalcemia
Hypophosphatemia
Hypoglycemia
Hypermagnesemia
NUTRITION
Low weight for height
Diminished height (and wt) for age
Acute Failure to Thrive
Chronic undernutrition
Refeeding syndrome
Hypophosphatemia
Hypokalemia
Hypomagnesemia
Hypocalcemia
Glucose intolerance
VITAMIN DEFICIENCIES
B1 (THIAMINE)
Beri Beri
Mental confusion
Peripheral paralysis
Muscle weakness
Tachycardia
Cardiomegaly
B2 (RIBOFLAVIN)
Stomatitis (angular)
Anemia
Dermatitis (seborrheic)
Infants on prolonged
phototherapy at risk
B3 (NIACIN)
3D’s of B3
Dermatitis
Diarrhea
Dementia
Glossitis
Toxicity results in
vasodilation
B9 (FOLATE)
Large tongue and macrocytic anemia
Neural tube defects
When folate given for macrocytic anemia, may
mask B12 deficiency
B12 (CYANOCOBALAMIN)
Macrocytic anemia
Pernicious anemia
Poor absorption (decreased intrinsic factor)
VIT C (ASCORBIC ACID)
Scurvy
Bleeding gums
Leg tenderness
Poor wound healing
Toxicity
Nephrocalcinosis
Hemolysis in G6PD
FAT SOLUBLE VITAMINS
ADEK
VIT A (RETINOL)
Most common cause of
childhood blindness worldwide
Eye Findings
Dry eyes (xerophthalmia)
Night blindness
Bitot spots (shiny gray
triangular conjunctival lesions)
Follicular hyperkeratosis
Intoxication
Pseudotumor cerebri
VIT E (TOCOPHEROL)
Hemolytic anemia in preemies
Neuro changes
Neuropathies
Absent DTRs
Ataxia
Weakness
VIT K (PHYLLOQUINONE)
Hemorrhagic disease of the newborn
Breast fed babies
Factors 2,7,9,10
Prolonged PT
GASTROENTEROLOGY
HELICOBACTER PYLORI
Endoscopic findings
Antral gastritis
Nodularity of antrum
Duodenal ulcers
Treatment: “Triple Therapy”
Antibiotics X2wks, PPI X4wks
Amoxicillin, clarithromycin, PPI
Amoxicillin, metronidazole, PPI
Clarithromycin, metronidazole, PPI
PANCREATITIS
Causes:
Gallstones in adults
Trauma and systemic diseases (HUS) in children
Biliary tract disease
Congenital anomalies
Drugs
Organ transplantation
Idiopathic
Infectious
Metabolic
Post-op
Malignancy
INTUSSUSCEPTION
Age 3mos – 5yrs
Older children usually have lead point
Meckel’s
HSP (ileo-ileal)
Classic Triad: colicky abd pain, vomiting, current
jelly stools: 30%
May present with lethargy or seizure
Air contrast or barium enema
Recurrence in 10%
CONSTIPATION
Delay or difficulty passing stool for >2wks
resulting in discomfort to patient
Usually functional
Overflow incontenence or encopresis
Chronic distal fecal impaction
Stretching of rectal wall
Relaxation of internal anal sphincter
Bladder dysfunction with UTI
QUESTION 3
You are seeing a 2 year old child that has had
chronic constipation since infancy. You suspect
Hirschprung disease. Which of the following
tests is necessary for the confirmation of
diagnosis?
A.
B.
C.
D.
E.
Rectal suction biopsy
Unprepped barium enema
Prepped barium enema
Endoscopy
Upper GI with small bowel follow through
HIRSCHSPRUNG DISEASE
Constipation from early infancy
Unprepped barium enema
Transition zone
Rectal bx for ganglion cells
VOMITING
PYLORIC STENOSIS
Narrowing of pyloric channel
Unknown etiology
Secondary to hypertrophy of
musculature
Erythromycin
Presentation
3-5 weeks
Forceful, projectile, nonbilious
vomiting
Persistent hunger
Constipation
Dehydration
Unconjugated hyperbili
PYLORIC STENOSIS
Physical Exam
Peristaltic wave
Olive
Lab finding
Hypokalemic,
hypochloremic metabolic
alkalosis
Diagnosis
US
Near 100% sensitivity and
specificity
PYLORIC STENOSIS
Diagnosis
US
UGI
Near 100% sensitivity
and specificity
“string sign”
Treatment
Pyloromyotomy
QUESTION 4
The diagnostic approach to a child with symptoms
typical of uncomplicated GER is:
A.
B.
C.
D.
E.
Barium swallow and pH probe
Barium swallow
No investigation
pH probe
Subspecialty consultation
REFLUX
GER
GERD
Passage of contents into the esophagus
Symptoms and complications
Symptoms
Vomiting
Poor weight gain
Substernal chest pain
Abdominal pain
Dysphagia
Esophagitis
Respiratory disorders
REFLUX
GER
Common
Usually self-limited
Disappears by 1 to 2 years of age
GERD
Growth failure
Aspiration
Esophagitis
Hemorrhage
Apnea
Sandifer syndrome
RARE
REFLUX
Diagnosis
Based clinically
UGI
Does not diagnose reflux!
Anatomic abnormalities
pH probe
Correlates symptoms with
episodes
Esophagoscopy
Assess esophageal injury
REFLUX
Therapy
Frequent small feedings
Upright position?
Prone??
Thickened feeds
1 tablespoon/ounce
H2 blockers
PPIs
Prokinetics
Controversial
Nissen
INTESTINAL MALROTATION AND VOLVULUS
Incomplete rotation of
the intestine during
embryonic life
Presentation
Sudden onset
Bilious emesis
Abdominal pain
Bilious emesis is a
surgical emergency until
proven otherwise
INTESTINAL MALROTATION AND VOLVULUS
Studies
Plain film
Paucity of air in lower
abdomen
UGI
Gold standard
“corkscrew”
Small intestine on right
C-loop does not cross
midline
Treatment
Surgical Emergency
DIARRHEA
QUESTION 5
The mother of a 2-year-old complains that her son has
frequent, watery, foul-smelling stools with visible food
particles that has been occurring for >2 weeks. The
child appears well on physical exam and his weight is
at the 50%ile. Stool analysis reveals a pH of 5 and no
evidence of fat malabsorption. Of the following the
MOST appropriate management plan for this infant
is to:
A. Avoid all fresh fruits and vegetables
B. Avoid all lactose-containing dairy products
C. Begin a high-fat, low-carbohydrate diet
D. Keep a food diary
E. Increase the total daily fluid intake
DIARRHEA
Usually acute and infectious
Chronic
>2 weeks
Most commonly postinfectious or dietary
History
Small bowel
Watery and free of mucus
Infectious or inflammatory
Blood and/or mucus
DIARRHEA
Stool Examination
Reducing substances
Stool pH
Infection or inflammation
Ova and parasites
Malabsorption
Fecal leukocytes
Low (<5) in carbohydrate
maldigestion and malabsorption
Fat
Unabsorbed sugar
Parasitic pathogens
Stool culture
Bacterial pathogens
E.COLI DIARRHEA
Enterotoxigenic E.coli
Traveler’s diarrhea
Thrives in environment (food and water)
Incubation 1-3 days
Large outbreaks in US
Watery diarrhea, voluminous, may resemble cholera
Self limited
Fluid therapy
Prophylaxis not necessary in healthy children
If asked to choose: Bactrim
E.COLI DIARRHEA
Enteroinvasive E.coli
Closely related to Shigella
Clinical course nearly identical to Shigella
E.COLI DIARRHEA
Enterohemorrhagic E.coli (O157:H7)
Undercooked ground beef
Reported in apple cider/ raw vegetables
Summer months
Shiga toxin-positive
Bloody diarrhea
Hemolytic uremic syndrome
PATHOGENESIS
Shigella
Person-to-person
transmission
Incubation up to 7
days
Carrier state up to
4wks
salmonella
Killed rapidly by
acidity
Animal transmission
Common source
outbreaks
Eggs/poultry
Incubation 24hrs
Longer carrier state
CLINICAL MANIFESTATIONS
Shigella
salmonella
Leukemoid reaction
Neuro symptoms
HUS
Mild leukocytosis
Focal infections
Reactive arthritis
Osteo in Sickle Cell Dz
HLA-B27
Typhoid fever
Salmonella typhi
Fever, H/A, abd pain,
muscle aches, rose
spots
TREATMENT
Shigella
Treat with antibiotics
salmonella
Ceftriaxone
Cipro
Infants <3mos
Immune compromised
Bacteremia
Decreased carrier
state
Treat ONLY high risk
Ceftriaxone or
ampicillin
Beware resistance!!
Increased carrier state
ROSE SPOTS OF TYPHOID FEVER
CAMPYLOBACTER
Undercooked poultry, unpasteurized milk
Second most common documented foodborne illnesss
in US
Watery or hemorrhagic
Sequelae
Reactive arthritis
Guillian-barre
YERSINIA ENTEROCOLITICA
Mimics appendicitis
Peak in winter
Contaminated food and water
Undercooked pork (chitterlings)
May have insidious onset
May last up to 3 wks
Prolonged shedding 2-3 mos
Low mortality
Sequelae
Reactive arthritis
Erythema nodosum
VIBRO CHOLERAE
Most common Asia, Africa,
S.America
Endemic along gulf coast
Contaminated seafood
Reports following Katrina and Rita
Incubation 1-3 days
Sudden and severe dehydration
Rice water stools
If untreated, 50-70%mortality
within 1-2 days
Treatment
Aggressive rehydration
Abx as adjunct
DIARRHEA
Acute infectious
Bacterial
C. Diff
Bloody diarrhea
Abdominal pain
Vomiting
Test for toxin
Recent antibiotics
Treat with flagyl unless <6 months
Viral
Rotavirus is leading cause worldwide
Low grade fever, vomiting, large loose watery stools
Adeno is second
DIARRHEA AND FEEDING
AAP Recs…
Continue age appropriate diet
Pedialyte if dehydrated
2% glucose and 90mEq NaCl
Avoid ONLY foods high in fat and simple sugars
NO BRAT: “unnecessary starvation”
Do not use antidiarrheal medications