GI Board Review

GI BOARD REVIEWDecember 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 1You 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. 70B. 100C. 50D. 125E. 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 2Which of the following electrolyte

abnormalities may be seen in refeeding syndrome?

A. HyperkalemiaB. HypercalcemiaC. HypophosphatemiaD. Hypoglycemia E. Hypermagnesemia

NUTRITION Low weight for height

Acute Failure to Thrive Diminished height (and wt) for age

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 VITAMINSADEK

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 3You 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. Rectal suction biopsyB. Unprepped barium enemaC. Prepped barium enemaD. EndoscopyE. 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

Secondary to hypertrophy of musculature

Unknown etiology 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 Near 100%

sensitivity and specificity

UGI “string sign”

Treatment Pyloromyotomy

QUESTION 4The diagnostic approach to a child with

symptoms typical of uncomplicated GER is:

A. Barium swallow and pH probeB. Barium swallowC. No investigationD. pH probeE. Subspecialty consultation

REFLUX GER

Passage of contents into the esophagus GERD

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 5The 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 vegetablesB. Avoid all lactose-containing dairy productsC. Begin a high-fat, low-carbohydrate dietD. Keep a food diaryE. 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 Unabsorbed sugar

Stool pH Low (<5) in carbohydrate

maldigestion and malabsorption Fat

Malabsorption Fecal leukocytes

Infection or inflammation Ova and parasites

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

PATHOGENESISShigella

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 MANIFESTATIONSShigella

Leukemoid reaction Neuro symptoms HUS

salmonella

Mild leukocytosis Focal infections

Osteo in Sickle Cell Dz Reactive arthritis

HLA-B27 Typhoid fever

Salmonella typhi Fever, H/A, abd pain,

muscle aches, rose spots

TREATMENTShigella

Treat with antibiotics Ceftriaxone Cipro

Decreased carrier state

salmonella

Treat ONLY high risk Infants <3mos Immune

compromised Bacteremia

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