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GI Board Review

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.

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GI Board Review

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  1. GI Board Review December 16, 2010

  2. 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

  3. 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

  4. Malnutrition • Explore diet and eating habits • Formula • Type, quantity, how it is mixed • Older Children • Food intake, preferences, avoidances • Plot BMI

  5. Extreme Malnutrition • Marasmus • Caloric deficiency • Emaciation • Hypothermia and bradycardia late • Kwashiorkor • Protein deficiency • Edema • Hepatomegaly, AMS • Marasmic-kwashiorkor

  6. Question 2 Which of the following electrolyte abnormalities may be seen in refeeding syndrome? A. Hyperkalemia B. Hypercalcemia C. Hypophosphatemia D. Hypoglycemia E. Hypermagnesemia

  7. 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

  8. Vitamin deficiencies

  9. B1 (Thiamine) • BeriBeri • Mental confusion • Peripheral paralysis • Muscle weakness • Tachycardia • Cardiomegaly

  10. B2 (Riboflavin) • Stomatitis (angular) • Anemia • Dermatitis (seborrheic) • Infants on prolonged phototherapy at risk

  11. B3 (Niacin) • 3D’s of B3 • Dermatitis • Diarrhea • Dementia • Glossitis • Toxicity results in vasodilation

  12. B9 (Folate) • Large tongue and macrocytic anemia • Neural tube defects • When folate given for macrocytic anemia, may mask B12 deficiency

  13. B12 (Cyanocobalamin) • Macrocytic anemia • Pernicious anemia • Poor absorption (decreased intrinsic factor)

  14. Vit C (ascorbic acid) • Scurvy • Bleeding gums • Leg tenderness • Poor wound healing • Toxicity • Nephrocalcinosis • Hemolysis in G6PD

  15. Fat soluble vitamins ADEK

  16. 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 • Pseudotumorcerebri

  17. Vit E (tocopherol) • Hemolytic anemia in preemies • Neuro changes • Neuropathies • Absent DTRs • Ataxia • Weakness

  18. Vit K (phylloquinone) • Hemorrhagic disease of the newborn • Breast fed babies • Factors 2,7,9,10 • Prolonged PT

  19. gastroenterology

  20. 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

  21. 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

  22. 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%

  23. 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

  24. 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. Rectal suction biopsy B. Unprepped barium enema C. Prepped barium enema D. Endoscopy E. Upper GI with small bowel follow through

  25. Hirschsprung disease • Constipation from early infancy • Unprepped barium enema • Transition zone • Rectal bx for ganglion cells

  26. Vomiting

  27. 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 • Unconjugatedhyperbili

  28. Pyloric stenosis • Physical Exam • Peristaltic wave • Olive • Lab finding • Hypokalemic, hypochloremic metabolic alkalosis • Diagnosis • US • Near 100% sensitivity and specificity

  29. Pyloric stenosis • Diagnosis • US • Near 100% sensitivity and specificity • UGI • “string sign” • Treatment • Pyloromyotomy

  30. Question 4 The diagnostic approach to a child with symptoms typical of uncomplicated GER is: A. Barium swallow and pH probe B. Barium swallow C. No investigation D. pH probe E. Subspecialty consultation

  31. 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

  32. reflux • GER • Common • Usually self-limited • Disappears by 1 to 2 years of age • GERD • Growth failure • Aspiration • Esophagitis • Hemorrhage • Apnea • Sandifer syndrome • RARE

  33. reflux • Diagnosis • Based clinically • UGI • Does not diagnose reflux! • Anatomic abnormalities • pH probe • Correlates symptoms with episodes • Esophagoscopy • Assess esophageal injury

  34. reflux • Therapy • Frequent small feedings • Upright position? • Prone?? • Thickened feeds • 1 tablespoon/ounce • H2 blockers • PPIs • Prokinetics • Controversial • Nissen

  35. 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

  36. 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

  37. Diarrhea

  38. 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

  39. 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

  40. 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

  41. E.Coli Diarrhea • EnterotoxigenicE.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

  42. E.Coli Diarrhea • EnteroinvasiveE.coli • Closely related to Shigella • Clinical course nearly identical to Shigella

  43. E.Coli Diarrhea • EnterohemorrhagicE.coli (O157:H7) • Undercooked ground beef • Reported in apple cider/ raw vegetables • Summer months • Shiga toxin-positive • Bloody diarrhea • Hemolytic uremic syndrome

  44. Pathogenesis Person-to-person transmission Incubation up to 7 days Carrier state up to 4wks Shigella salmonella • Killed rapidly by acidity • Animal transmission • Common source outbreaks • Eggs/poultry • Incubation 24hrs • Longer carrier state

  45. Clinical Manifestations Leukemoid reaction Neuro symptoms HUS Shigella 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

  46. Treatment • Treat with antibiotics • Ceftriaxone • Cipro • Decreased carrier state Shigella salmonella • Treat ONLY high risk • Infants <3mos • Immune compromised • Bacteremia • Ceftriaxone or ampicillin • Beware resistance!! • Increased carrier state

  47. Rose Spots of Typhoid Fever

  48. Campylobacter • Undercooked poultry, unpasteurized milk • Second most common documented foodborneillnesss in US • Watery or hemorrhagic • Sequelae • Reactive arthritis • Guillian-barre

  49. Yersiniaenterocolitica • 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 • Erythemanodosum

  50. Vibrocholerae • 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

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