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