November 21, 2007. Malabsorption Cystic Fibrosis- poor exocrine function Celiac Disease Milk Allergy Short Gut Syndrome- previous GI surgery.

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ORAL, GI, AND NUTRITION

November 21, 2007

GET FIRED UP!!! RAPID FIRE Q AND

A

Malabsorption

Cystic Fibrosis- poor exocrine function Celiac Disease Milk Allergy Short Gut Syndrome- previous GI

surgery

Malabsorption

A 15 mo male presents with 3 month history of diarrhea and weight loss. It is also hard to stop bleeding from minor trauma. His labs show a sodium of 129.

Most likely diagnosis is………………. Cystic Fibrosis

Cystic Fibrosis Meconium ileus/plug Chronic cough and chronic diarrhea FTT Clubbing Steatorrhea

OK sure…. BUT don’t forget Edema Recurrent wheezing Hyponatremia- lost through sweat Fat soluble vitamin deficiency Hepatobiliary disease Rectal prolapse

Malabsorption

A 2 year old child has pale foul-smelling stools, abdominal distension and proximal muscle wasting. Diagnosis?Cystic Fibrosis?Celiac?Giardia?Toddler’s Diarrhea?

How do you confirm the diagnosis?

Celiac Disease

Diagnosis depends on characteristic small intestine histopatholgic findings and response to a gluten-free diet

Gluten is found in foods that contain wheat or rye

Malabsorption

A child with Crohn’s disease has an H/H of 9/27 with an MCV of 106. What is the treatment?

VITAMIN B12 Absorbed in the terminal ileum Deficiency leads to macrocytic anemia

Rectal Prolapse A 27 month old male with a history of

constipation presents with rectal prolapse. He is well- appearing and growth parameters are within normal limits. He has had two episodes of otitis media and two episodes of pneumonia.

What is the most likely cause of his rectal prolapse?CF?Chronic constipation?**Parasitic infection?

Rectal Prolapse

Causes in the USConstipation 28%Neuromotor disorders 24%Acute diarrhea 20%CF 11%Other 16%

Vomiting

A 4 week old male presents with forceful, non-bilious emesis that “looks like a fountain.” What is his most likely electrolyte imbalance?

Hypochloremia Hypokalemia Metabolic Alkalosis

What is the initial step in management? Correct the electrolyte abnormality

Vomiting

A 3 mo infant with h/o low birth weight and polyhydramnios presents with nonbilious emesis. Upper GI series shows a radiolucent filling defect in the prepyloric region. What’s the diagnosis?Antral Web?**Chronic intestinal pseudo-obstruction?Duodenal stenosis?Hirschsprung disease?Pyloric stenosis?

Vomiting

Bilious emesis in an infant with abdominal distension and tenderness

Malrotation Decreased intestinal air and “corkscrew

appearance” of duodenum Volvulus NEC can occur in full term infant.

True**False

Vomiting 6 yr old female whose parents are going

through a divorce has episodes of intermittent vomiting that last 48 hours. She is asymptomatic between episodes. Obstruction and reflux has been ruled out. She also misses school because of abdominal pain and headaches. Diagnosis?

Cyclic Vomiting She takes Ondanestron during these episodes.

Mechanism of action? Serotonin receptor antagonist

Reflux The “gold standard” study for GER is pH probe study Anterior or true vocal cord polyps with

granulation tissue in the tracheal mucosa and bronchial washings revealing lipid-laden macrophages are suggestive of:Respiratory allergies with chronic postnasal drip?Laryngeal webs, cysts, or clefts?Gastroesophageal reflux?**Vocal Cord paralysis?Tumors?

Diarrhea

Child who attends daycare has h/o diarrhea x three weeks with abdominal distension, increased flatulance and four pound weight loss. She has been afebrile. Diagnosis?

Giardiasis Child with diarrhea and seizures. CBC

with left shift. Stool with WBCs. Diagnosis?

Shigella

Diarrhea

Patient who ate contaminated food and now has diarrhea. Diagnosis?

Salmonella 4mo child with C. diff toxin in stool.

Treatment? None Healthy child paying in a lake with

chronic diarrhea. Diagnosis? Cryptosporidium

Diarrhea 2 year old child with 3 week h/o diarrhea. Has

formed stool in the am, progressively loose throughout day. Normal growth and development.

Diagnosis? Toddler’s diarrhea (Chronic nonspecific diarrhea) Treatment? Limit CHO and juice, increase dietary fat and

fruits and veggies Poor growth, fever, and melena not part of this

diagnosis

Diarrhea

16 yo cheerleader with 2 month h/o chronic diarrhea. What should you consider as a diagnosis?

Laxative abuse

Abdominal Pain

Patient has a 3 day h/o lower abdominal pain and coughing. What test seals the diagnosis?

CXR- Pneumonia- Referred Pain Child with JRA develops epigastric pain.

Most likely etiology of pain? NSAID induced dyspepsia

Abdominal Pain 2 yo child with lethargy and poor distal

perfusion. Afebrile. Diagnosis and imaging study?

Intusussception Air Contrast Enema Less than 1/3 have colicky pain, currant jelly

stools, and abdominal mass The most common cause of acute abdominal

pain in 5-24 months is intussusception Assoc with enterovirus and rotavirus

Abdominal Pain

12 yo with chronic periumbilical pain with positive H. pylori IgG. What’s the next step?

Confirm with fecal antigen or urea breath test

Child with symptoms of peptic ulcer disease. She had elevated gastrin levels. Name the syndrome

Zollinger-Ellison Syndrome

Red Flags in Evaluation of Chronic Abdominal Pain Well-localized pain away from the umbilicus Altered bowel pattern (diarrhea, constipation)assoc with the

pain Vomiting Pain awakening the patient from sleep Radiation of pain to back, shoulder, scapula, lower extremities Involuntary weight loss or growth deceleration Rectal bleeding, constitutional symptoms Intermittent fecal incontinence Recurrent isolated episodes of pain that come on suddenly

and last several minutes to a few days Consistent sleepiness following pain attacks FH if PUD, IBD

Pancreatitis

Acute pancreatitis in children usually presents asA. Lethargy

B. Abdominal Pain**

C. Abdominal Mass

D. Chronic diarrhea

E. Shock Abdominal Pain

Pancreatitis T or F Acute pancreatitis in children usually presents as

a palpable mass. FALSE Acute onset epigastric pain with later radiation to

back T or F Pancreatic pseudocyst is a common complication

of acute pancreatitis FALSE Rare complication

Pancreatitis T or F Serum amylase elevation is more specific for

pancreatitis FALSE Serum lipase or trypsinogen level Which test is more sensitive to diagnose

pancreatitis if the amylase and lipase are normal?Amylase isoenzymes?Serum trypsinogen level?**Amylase:Creatinine ratio?

Bloody Stool

Most likely diagnosis in a child with eczema and asthma who has occult blood in stool?

Cow Milk Intolerance

Milk Protein Intolerance

Milk Protein Allergy- IgE -mediatedAnaphylaxisTrigger eczema

Non IgE- mediated MPAMore CommonEnterocolitisVomitingBloody DiarrheaEliminate cow and soy milk first

This question is very hard….

Only on the boards…Seriously..

A patient presents with steatorrhea. The peripheral blood smear show acanthocytosis or RBC’s with porcupine projections (Burr cell). Diagnosis?

Abetalipoproteinemia Retinal Damage Neurological symptoms

WHATEVER!

Bloody Stool 3 yo with painless rectal bleeding. Meckels

scan is negative. Diagnosis? Juvenile polyp Is this associated with adenocarcinoma of

the colon? NO! Name the autosomal dominant syndrome

with intestinal polyps, extra teeth, and osteomas

Gardner syndrome

Inflammatory Bowel Disease Ulcerative

Colitis Rectal Disease Crypt abscesses Inc cancer risk Excision is curative Growth failure

uncommon

Crohn’s Disease Perianal disease

Fistula Fissure Skin Tags

Short stature ** Weight Loss Skip lesions Transmural lesion Noncaseating

granulomas Oral ulcers

Open Wide! A child swallowed drain cleaner. There is no

evidence of burns to the lips or mouth. What is the next step?

Endoscopy A child presents with swollen parotid glands.

Most likely diagnosis? Idiopathic parotitis, NOT Mumps! Swollen parotid glands that are markedly

tender with a high fever. Etiology? Staph parotitis

Open Wide!

You are seeing a male child referred to you for absent teeth and no sweat pores on skin biopsy. What is the name of this disorder?

Ectodermal hypoplasia How is it inherited? X linked

Jaundice A child with hereditary spherocytosis

presents with fever and a RUQ mass. Most likely diagnosis? What study will you order?

Cholecystitis and Ultrasound 14 yo becomes jaundiced following viral

illnesses. His mom also looks yellow when she doesn’t eat for many hours. Diagnosis and Therapy?

Gilbert disease. No treatment. Glucuronyl transferase deficiency

Jaundice

Conjugated hyperbilirubinemiaCholestatic jaundiceElevated alk phosSepsisGalactosemiaEndocrine disordersLiver parenchymal disease

○ Neonatal hepatitis (months)Anatomic Obstruction

○ Biliary atresia, choledochal cyst (weeks)

Jaundice

A patient with biliary atresia s/p Kasai procedure presents for follow up at 2 weeks post-op. Her total bilirubin is 4. Did the Kasai procedure fail?

No! Modest hyperbilrubinemia may persist up to four weeks after relief of a biliary obstruction

Jaundice

Hepatitis AFecal OralIgM ABFlu-like symptoms< 5 yo usually asymptomatic

Jaundice

Hepatitis BHBsAg- earliest indicator of acute infection

○ Present in acute or chronic infectionAnti- HBsAg- prior infection, immunizedHep e Ag- increased infectivityHep C Ag- past infectionHep D needs HepBsAg to replicateHep B positive mom- chronic infection in

infant

Jaundice

A patient with chronic hepatitis C infection has become severely depressed. What medication has likely worsened his depression?

Interferon

Vitamins

A teenager taking a mega doses of vitamins presents with headaches. Work-up?

LP Vitamin A intoxication can result in

increased intracranial pressure- Pseudotumor cerebri

Vitamin A deficiency is blindness

Vitamins

A child with fat malabsorption presents with weakness and ataxia. What is the likely vitamin deficiency?

Vitamin E deficiency Vitamin E deficiency causes hemolytic

anemia in preemies and neurological effects in older children

Vitamin E toxicity= Liver toxicity

Nutrition

What is the carbohydrate in breast milk? Lactose A breastfeeding mom presents with

mastitis. What do you tell her? Reassurance. Continue breastfeeding

Nutrition A 6 yo male with herpangina. Mode of

feeding?NG continuous?NG bolus?TPN?

NG bolus– “If the gut works use it!” A kid with cerebral palsy and h/o

aspiration. Best way to feed? GJ tube– continuously. Cannot bolus

feeds into jejunum.

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