Gastroenterology

Question 0

Vitamin deficiencies:
1 vitamin A
2 vitamin D
3 vitamin E
4 vitamin K
5 vitamin B1
6 vitamin B6
7 vitamin B12
8 Vitamin C
9 niacin
10 zinc

Answer 0

1. Night blindness, dry conjunctiva/cornea
2. Ricketts/osteomalacia/dental caries, hypophosphatemia, hypocalcemia
3. Anemia/hemolysis, neurologic Deficits, altered prostaglandin synthesis
4. Coagulopathy, abnormal bone matrix synthesis
5. Beriberi (high output cardiac failure, peripheral neuropathy, hoarseness, Wernecke’s)
6. Dermatitis, chelosis, glossitis, microcytic anemia, peripheral neuritis
7. Demyelination, megaloblastic anemia
8. Scurvy
9. Pellagra – diarrhea, dermatitis, dementia,
10. Skin lesions, poor wound healing, diarrhea, immune dysfunction

Question 1

Marasmus versus Kwashiorkor?

Answer 1

Energy depleted state with very thin patient versus protein deficient state (edema, Abdominal distention, alterations in skin pigmentation)

Question 2

carbohydrate malabsorption – Causes? Findings?

Answer 2

1. Congenital enzyme deficiency (lactase deficiency)
2. Mucosal atrophy
3. Acidic (below 5.6) stool
4. Positive Clinitest – Non-glucose reducing substances

Question 3

Causes of protein malabsorption? Test?

Answer 3

1. Congenital enterokinase deficiency – hypoproteinemia with edema, massive nitrogen loss in stool
2. Protein-losing enteropathies – inflamed intestinal mucosa cannot absorb protein
3. Inflammatory disorders – Crohn’s disease etc.

Fecal alpha-1-antitrypsin levels

Question 4

Causes of fat malabsorption?

Answer 4

1. Exocrine pancreatic insufficiency – cystic fibrosis, chronic pancreatitis, Schwachman-Diamond
2. Intestinal mucosal atrophy
3. Bile acid deficiency
4. Abetalipoproteinemia

Question 5

Blood finding in abetalipoproteinemia?

Answer 5

Acanthocytosis of erythrocytes

Question 6

Schwachman-Diamond syndrome?

Answer 6

1. Pancreatic exocrine insufficiency
2. Neutropenia or pancytopenia
3. Failure to thrive/short stature

Question 7

protein intolerance – Main cause? Clinical features? Management?

Answer 7

Cows milk greater than sign soy/egg

1. Enteropathy – diarrhea, vomiting, irritability,
2. Enterocolitis – diarrhea, rectal bleeding, irritability

Avoidance of dietary protein. Usually resolves by 1 to 2 years of age

Question 8

Celiac disease – presents when? Gold standard for diagnosis? Serum antibodies?

Answer 8

6 months to 2 years of age

Small bowel biopsy

Tissue transglutaminase antibody, antigliadin (in IGA deficient patients)

Question 9

Short bowel disease – causes? Complications (5)? Management?

Answer 9

1. Congenital lesions – gastroschisis, volvulus, intestinal atresia
2. Surgery for necrotizing internal colitis, Crohn’s disease, radiation
3. Carbohydrates/fat malabsorption with stearrhea
4. Secretory diarrhea, dehydration, hyponatremia, hypokalemia
5. If distal bowel involved – decreased B12, bile acid absorption
6. Intestinal bacterial overgrowth
7. Poor bone mineralization, renal stones
8. TPN
9. Currently enteral feedings to ensure Adaptic growth of rest of bowel
10. Transplantation

Question 10

GERD – predominant cause during childhood? Clinical features of physiologic reflux? Physiologic reflux resolves by?

Answer 10

Inappropriate LES relaxation

Physiologic – “happy spitters” (Resolved by 6-12 months)

Question 11

GERD – clinical features of pathologic reflux? Unlikely to have spontaneous resolution if?

Answer 11

1. Emesis
2. esophagitis - Feeding refusal, constant hunger
3. Sandifer syndrome – torticollis caused by painful esophagitis
4. Nausea and weakening, hoarseness, halitosis, wheezing

Symptomatic over one year of age

Question 12

GERD – complications?

Answer 12

1. Airway disease – laryngitis, hoarseness, wheezing, subglottic stenosis
2. G.I. – esophageal strictures, Barrett’s

Question 13

GERD – gold standard for diagnosis? Other methods? Management? Type of surgery?

Answer 13

1. Gold standard: pH probe (number of acidification episodes)
2. Scintigraphy for aspiration
3. Bronchoscopy with alveolar lavage if aspiration strongly suspected
4. Endoscopy when uncertain diagnosis
5. Barium swallow – poor test for diagnosis
6. Positioning, frequent small meals,
7. antacids/H2-blockers/PPI,
8. metoclopramide
9. Surgery – Nisen fundoplication (wraps fundus of stomach around esophagus), gastric antroplasty, G-tube

Question 14

Intestinal anatomic obstructions that result in vomiting?

Answer 14

1. Hypertrophic pyloric stenosis
2. Malrotation and midgut volvulus
3. Atresia
4. Intussusception
5. Hirschsprung’s disease

Question 15

Hypertrophic Pyloric stenosis – clinical features? Physical exam? Lab findings? Radiographic sign? Management?

Answer 15

Non-bilious, projectile vomiting immediately after feeding 2-3 weeks after birth

1. Palpable “Olive” mass
2. Visible abdominal peristaltic waves
3. Hypochloremic, hypokalemic metabolic acidosis

Ultrasound showing string sign

Partial pyloromyotomy

Question 16

Malrotation/Midgut volvulus – pathogenesis? Clinical features?

Answer 16

Midgut twist around superior mesenteric vessels due to

1. lack of fixation – Results in peritoneal bands (Ladd’s bands), that compress the duodenum
2. Narrow pedicle which suspends the small bowel that can easily twist

Bilious vomiting and sudden onset abdominal pain with blood tinged stools

Question 17

Malrotation/Midgut volvulus – X-ray shows? Upper contrast imaging shows? Lower contrast imaging? Management?

Answer 17

1. X-ray – distention with little distal bowel gas
2. Upper Contrast imaging – abnormal position of ligament of Treitz, jejunum (Right of midline)
3. Lower contrast studies – cecum and left abdomen or right upper quadrant

Volvulus is surgical emergency

Question 18

Most common cause of obstruction in neonatal period? defect occurs when during gestation? Most typical patient? Clinical features? Impact of gestation? Diagnosis? Management?

Answer 18

Intestinal atresia; 8 to 10 weeks gestation; male with down syndrome.

1. Scaphoid abdomen with epigastric distention
2. Bilious emesis

Polyhydramnios

1. Double bubble sign on AXR
2. Intestinal contrast days
3. Nasogastric decompression
4. Duodenoduodenostomy/surgery resection and anastomosis of atretic segment

Question 19

Most common cause of obstruction within the first two years? peak incidence occurs at what age? Most common location? Causes? Clinical features?

Answer 19

Intussusception; 5-9 months of age; ileocolic region

Lead point (Meckel’s diverticulum, polyp, Pyers patch, lymphoma) may draw intestine inward

1. Seven onset of abdominal pain, with infants drawing legs to chest
2. Vomiting and currant jelly stool (mucosal sloughing)
3. Sausage-shaped mass in right upper quadrant

Question 20

Intussusception – evaluation? Management?

Answer 20

1. Contrast enema is gold standard – “coil spring” sign
2. Radiographs showed dilated loops of bowel
3. Contrast enema – pressure reduces intussusception
4. If contrast enema fails – surgery

Question 21

Physical exam: intestinal obstruction versus peritonitis?

Answer 21

High-pitched bowel sounds, visible peristalsis versus diminished bowel sounds, guarding/rebound

Question 22

Acute pancreatitis – most common cause in children? Physical exam findings? Laboratory findings? Imaging modalities and purpose?

Answer 22

Trauma

1. Gray-Turner sign (bluish discoloration on flank)
2. Cullen Sign (bluish discoloration of paraumbilical area)

Leukocytosis, hyperglycemia, hypocalcemia, elevated transaminases

1. Abdominal ultrasound for diagnosis/management.
2. Abdominal CT for complications (pseudocyst, abscess, necrosis)

Question 23

Cholecystitis – seen in what type of pediatric patients? Acute acalculous cholecystitis caused by? Evaluations?

Answer 23

Sickle cell disease, cystic fibrosis, prolonged TPN

Salmonella, Shigella, E. coli, abdominal trauma, burns

Abdominal ultrasound, scintigraphy

Question 24

Classification of chronic abdominal pain?

Answer 24

1. Epigastric pain – equivalent of nonulcer dyspepsia 2. Periumbilical local pain – classic functional abdominal pain 3. Infraumbilical pain – equivalent of irritable bowel syndrome

Question 25

Laboratory evaluation for functional chronic abdominal pain? Prognosis?

Answer 25

1. Screening labs 2. H. pylori testing if symptoms of dyspepsia 3. Lactose breath hydrogen testing Only 50% have resolution during childhood, 25% continue to have pain as adults

Question 26

Encopresis? Pathophys?

Answer 26

Inappropriate release of stool, almost always associated with severe constipation (liquid stool leaks around hard retained still mass and involuntarily released)

Question 27

Normal stool frequency?

Answer 27

Four times daily during first week of life Two times daily by one year of age Once daily by four years