GI/hepatic

Question 1

A CBC confirms an ANC of 200, platelet count of 50,000, and a hemoglobin of
9. During the evaluation in the emergency department, symptoms progress in this child to include worsening abdominal pain, bloody diarrhea, pallor, and hypotension. The most appropriate initial management will be to?
A. Give PRBCs
B. Order antibiotics
C. Obtain surgical consult
D. Consult pain management

Answer 1

C. Obtain surgical consult

Question 2

Acute liver failure is by definition, a progression of jaundice to encephalopathy within 8 weeks from the onset of illness.
True or False

Answer 2

True

Question 3

Which of the following should NOT prompt emergent liver transplantation?
A. Fulminant Wilson disease
*. B. Acetaminophen induced fulminant hepatic failure
C. Rapid decrease in liver size, hepatic failure with fibrinogen level < 1 g/L
D. Fulminant hepatic failure with worsening lactic acidosis and bilirubinemia >23 mg/dl

Answer 3

B. Acetaminophen induced fulminant hepatic failure

Question 4

TPN is the standard of care for patients with intestinal failure who are unable to maintain a normal nutritional fluid balance and electrolyte state by use of the gastrointestinal tract alone.
True or False

Answer 4

True

Question 5

A patient presents with severe, unrelenting diarrhea, and the fluid and electrolyte imbalances one would expect from that. She had been started on an antibiotic recently. Likely diagnosis is antibiotic-associated pseudomembranous colitis. What drug is the most likely cause?
* A. Amoxicillin
B. Azithromycin
C. Clindamycin
D. TMP-SMZ

Answer 5

A. Amoxicillin

Question 6

A 6-week old girl has had three, blood-streaked stools over the past 2 days.
She has not been vomiting and has been appeared otherwise well. She is formula- fed, has been gaining weight appropriately, and has no recent changes in her oral intake. She is afebrile with normal vital signs, and her physical examination is unremarkable.
All of these steps are appropriate in the INITIAL management of this child
EXCEPT:
A. Complete blood count with differential
B. Stool white blood cell count and culture
C. Change in formula
D. Barium or air-contrast enema

Answer 6

D. Barium or air-contrast enema

Question 7

An 8-year-old boy presents to the ED, and began complaining of diffuse, crampy abdominal pain that began last night. He denies fever, nausea or vomiting, but he has not wanted to eat since the onset of pain. His last bowel movement was two days ago. The child is afebrile, looks relatively well, and his abdominal examination is benign.
The NEXT appropriate step in this child’s workup should be which of the following:
A. Oral challenge, discharge if tolerated
B. Stool Cultures
C. Abdominal CT scan with oral and IV contrast
D. CBC, lipase, and liver function tests

Answer 7

A. Oral challenge, discharge if tolerated

Question 8

A 7-week-old, full-term girl has worsening jaundice that the parents first noticed 10 days ago. On her examination, she is well appearing and is noted to have a liver edge 4cm below her costal margin. Her direct bilirubin is 9.
The most likely cause of her direct hyperbilirubinemia is which of the following:
A. Biliary atresia
B. Cholecystitis
C. Sepsis
D. Acetaminophen toxicity

Answer 8

A. Biliary atresia

Question 9

Potentially life-threatening complications of inflammatory bowel disease include:
A. Toxic megacolon
B. Gastrointestinal bleeding
C. Intestinal obstruction
D. All of the above

Answer 9

D. All of the above

Question 10

A 5-year old girl presents with a purpuric rash on her abdomen and buttocks.
She has also had diffuse abdominal and bilateral ankle pain. All of the following are TRUE statements about this disease EXCEPT:
A. Children may develop occult or frank gastrointestinal bleeding
B: Patients commonly progress to end-stage renal disease
C. Abdominal pain may be caused by intussusception
D. Steroids frequently improve the rash, joint pain, and abdominal symptoms

Answer 10

D. Steroids frequently improve the rash, joint pain, and abdominal symptoms

Question 11

All of the following are common causes of pancréatitis in children EXCEPT:
A. Trauma
B. Idiopathic
C. Hypotrigyceridemia or Hypocalcemia
D. Biliary Disease

Answer 11

C. Hypotrigyceridemia or Hypocalcemia

Question 12

A 13 year old boy underwent an ERCP and spincterotomy for a common bile duct stone and now has pancreatitis. This can be explained by:
A. Nature of disease
B. Known complication of ERCP
C. Obstruction during the procedure
D. Stone still blocking the common bile ducti

Answer 12

B. Known complication of ERCP

Question 13

Hirschsprung Disease S/S & evaluaation

Answer 13

Male predominance
* Delayed passage of meconium;
Abdominal distention; Constipation is a
late presentation; can lead to
enterocolitis.
palpable fecal mass in LLQ, no stool in rectal vault
*Gold standard study: rectal biopsy;
Barium contrast enema can be used

Question 14

Hirschsprung Management

Answer 14

Decompress abdomen
with NG
* Rectal irrigations
* Surgical procedure:
bowel resection
* prevent colostomy in
infancy

Question 15

Intussusception

Answer 15

Most frequent cause of
intestinal obstruction in
the first 2 years of life.
Telescoping of the colon
usually starting proximal
to the ileocecal valve.
Swelling, hemorrhage,
incarceration and eventual
perforation and peritonitis
can occur.

Question 16

Intussuception S/S

Answer 16

Intermittent colicky
abdominal pain,
vomiting, currant
jelly stools, sausage-
shaped mass in RUQ
Diagnosis: US,
Barium or air
contrast enema

Question 17

Intussuception Management

Answer 17

Barium or air
Definition
Presentation
Treatment
enema with
surgical back
up.

Question 18

Pyloric Stenosis

Answer 18

narrowing of the
pylorus
* enlarged/hypertrophic
pyloric sphincter
* typically occurs in first 8
weeks of life

Question 19

Pyloric Stenosis S/S

Answer 19

nonbilious projectile vomiting
* weight loss
* dehydration
* hungry post-emesis & eager to feed
* 2 cm olive-shaped mass in mid-
epigastric area beneath liver edge
* + gastric peristaltic waves
* *Metabolic alkalosis
* hypochloremia, hypokalemia, hypo or
hypernatremia

Question 20

Pyloric Stenosis Evaluation & Management

Answer 20

Diagnosis: Ultrasound
Stabilize
electrolytes, rehydration Surgery -open or
laparoscopic

Question 21

Appendicitis

Answer 21

Inflammatory
process involving
lumen of the
appendix with
occlusion.
*Most common
age is adolescent.

Question 22

Appendicitis S/S

Answer 22

Focal right lower quadrant pain, or
periumbilical pain, fever (not always),
testicular pain, flank and back pain,
nausea, vomiting, and anorexia.
Mcburney point tenderness,
rebound tenderness, + psoas sign,obturator sign

Question 23

Appendicitis Evaluation

Answer 23

CT has been choice imaging, but MRI
and US often effective.

Question 24

Appendicitis Management

Answer 24

Urgent
surgery or
observation;
Antibiotics if
ruptured and post op

Question 25

Malrotation/Acute Volvulus description and S/S

Answer 25

can be congenital * disruption of embryological bowel development * volvulus - bowel twisting, occurs 50% of malrotation * midgut occurs in 1st year of life * bilious emesis, abdominal pain

Question 26

Malrotation/Acute Volvulus Evaluation & Management

Answer 26

Diagnosis: * CBC and electrolytes * acidosis * radiograph, upper GI, CT Management: * Surgery: Ladd procedure

Question 27

Toxic Megacolon

Answer 27

marked dilation of the colon * inflammatory bowel disease * infection * antidiarrheal agents * electrolyte disturbances

Question 28

Toxic Megacolon S/S

Answer 28

fever * abdominal distention * tenderness * shock * leukocytosis * hypokalemia * hypoalbuminemia

Question 29

Toxic Megacolon Evaluation & Management

Answer 29

Diagnostics- abdominal image, CBC, electrolytes Management: antibiotics * fluid and electrolyte management * Surgery: Colectomy

Question 30

Bowel Perforation

Answer 30

Rupture of wall of the stomach, small intestine, large bowel, or gallbladder * Medical emergency

Question 31

Bowel Perforation S/S & Evaluation

Answer 31

Acute abdominal pain * hemodynamic instability **Acidosis * Radiograph * air in the abdominal cavity (not in the stomach or intestines) * Diagnostics - CT scan increased WB

Question 32

Bowel Perforation Management

Answer 32

Surgical exploration broad-spectrum antibiotics fluid/metabolic stabilization Complications - Bleeding, infection, intra-abdominal abscess

Question 33

Meckel’s Diverticulum

Answer 33

Congenital malformation of the small bowel, present at birth. Usually asymptomatic. The omphalomesenteric/vitelline duct does not obliterate in utero * Symptoms: Painless rectal bleeding. Most common in ages 2 – 4 (may vary) Complications: bowel obstruction, infection, diverticulitis, umbilical fistula. Diagnosis: Meckel’s nuclear medicine scan

Question 34

Inflammatory Bowel Disease Ulcerative Colitis

Answer 34

Diagnosis: Endoscopy *gold standard * Acute, severe colitis = GI emergency Management Acute phase: Corticosteroids, Aminosalicylates, Immunosuppressants, Biologic agents, JAK inhibitors (most recent addition) * Hospitalization * IV fluids, nutrition * Surgery * Colectomy (may be curative)

Question 35

Inflammatory Bowel Disease Crohn's Disease

Answer 35

Crohn disease * inflammation of any segment of GI tract, mouth to anus (may extend through entire thickness of bowel wall) malabsorption of Fe, Zn, Folate, and Vit B12 possible genetic or environmental factors most patients will experience relapse * Symptoms: abdominal pain, diarrhea, rectal bleeding, fissures/tags*, fistulas, anorexia, weight loss * Diagnosis: CRP, CBC, electrolytes, Gold standard endoscopy

Question 36

Inflammatory Bowel Disease Crohn's Disease Management

Answer 36

Management: Prevent exacerbation and progression of disease: * Acute phase: corticosteroids, Immunosuppressants: Thiopurines, Methotrexate, Biologics (anti-TNF [infliximab, adalimumab, and certolizumab pegol], and anti-adhesion molecules (vedolizumab) Antibiotics, restricted to disease complicated by fistulas, abscesses, or both Avoid NSAIDs, Hospital admission, severe exacerbation, fluids, bowel rest, procedures

Question 37

Bowel Disease – Key Points

Answer 37

Acute abdominal pain: Intestinal obstruction, pancreatitis, cholelithiasis, genitourinary disorders * GI obstruction: esophageal (excessive secretions, vomiting),stomach (nonbilious vomiting), duodenum/jejunum (bilious emesis), ileum/colon (bilious emesis), * Abdominal compartment syndrome (consider if pain severe): fixed compartment, increased pressure, leading to ischemia and organ dysfunction

Question 38

Pancreatitis Description, S/S

Answer 38

Description: inflammatory process,triggered by intra and extracellular processes. Cytokines and chemokines lead to a systemic inflammatory response which determines the severity Presentation: epigastric pain, radiating to left and back, nausea and vomiting, diarrhea

Question 39

Pancreatitis Evaluation & Management

Answer 39

Diagnostics: amylase level rises early and lasts 3-5 days, (3 x greater than upper limit). lipase more specific & elevated longer CRP, highest at 48 hours, Abdominal radiograph, Chest radiograph to exclude pleural effusion, Endoscopic US, magnetic resonance cholangiopancreatography (MRCP), or transabdominal US * Management: NPO (not always) – depends on the severity of pain and frequency of vomiting, nasogastric decompression, IVF and intravenous nutrition,pain control, low-fat diet until complete recovery from emesis (low-fat foods empty the stomach faster)

Question 40

Cholelithiasis/Cholecystitis Description & S/S

Answer 40

Cholecystitis: inflammation of gallbladder. acute or chronic Cholelithiasis (gallstones): most common reason for cholecystitis. may cause obstruction of the common bile duct. acute or chronic cholecystitis. cholangitis, gallbladder perforation. pancreatitis - most common complication in children S/S: abdominal pain radiating to back, nausea, vomiting, especially after eating. Murphy sign-pain on inspiration over gallbladder

Question 41

Cholelithiasis/Cholecystitis

Answer 41

Abdominal ultrasound * ERCP – gold standard**

Question 42

Cholelithiasis/Cholecystitis Evaluation & Management

Answer 42

Labs: WBC, GGT, transaminases, alkaline phosphatase, direct and indirect bilirubin,amylase (mild if biliary duct obstructed). Imaging: Abdominal radiograph, Ultrasound, GI referral, Biliary scintigraphy (HIDA) – hepatobiliary iminodiacetic acid scan) MRCP (magnetic resonance cholangiopancreatography) ERCP (endoscopic retrograde cholangiopancreatography) Management: surgery to removal GB or stones.

Question 43

GERD-Gastroesophageal Reflux Disease: description & evaluation.

Answer 43

The most common pediatric esophageal disorder Passage of gastric contents and acids into the esophagus * Neurological impairment, obesity, CF, family history, BRUE * Irritation can lead to histological changes, esophagitis, or erosion * Symptoms: Infants: coughing, vomiting, food refusal, aversions, unexplained crying, sleep disturbances, choking, gagging * Older kids: heartburn, sore throat, epigastric pain

Question 44

GERD-Gastroesophageal Reflux Disease Evaluation & Management

Answer 44

Diagnosis (no standard): history most important consider – 24-hour pH probe, barium contrast * Treatment prefer non-pharmacologic – Diet, positioning; PPI’s or H2-blocker therapy many potential side effects,Nissen fundoplication in severe cases

Question 45

Acute Liver Failure Evaluation & S/S

Answer 45

Causes: metabolic, autoimmune,infectious, drug toxicity (acetaminophen most common), infiltrative/ischemic injury. * Infancy – Biliary atresia-(acute or chronic) * Adolescence – acetaminophen ingestion Diagnostics: Elevated AST/ALT, hypoglycemia, INR >1.5 Symptoms: tachycardia, tachypnea, GI bleeding, low urine output/anuria, altered mental status, +/- fever, jaundice

Question 46

Acute Liver Failure Treatment & Monitoring

Answer 46

Treatment: supportive care, identify cause, fluid and glucose management, vitamin K, H2 blockers/PPI, avoid hepatotoxic medications, serial neuro exams, antibiotics, apheresis, CKRT, liver transplant. Monitoring: high-risk for infection/sepsis, coagulopathy, fluid overload, consider the need for transplant versus recovery.

Question 47

Unconjugated (Indirect) Hyperbilirubinemia: Lack of enzyme systems to eliminate bilirubin/impede clearance

Answer 47

Diagnosis: jaundice skin and sclera, poor feeding, vomiting, lethargy. Labs: LFT’s, GGT, markers of synthetic function (albumin, ammonia, glucose, coags), fractionated bilirubin levels, direct Coombs test, retic count, sepsis evaluation,NBS. Treatment: AAP guidelines for phototherapy and exchange transfusion (less common), Treat dehydration, IVIG or phenobarbital. Monitoring: follow labs and etiology will guide.

Question 48

Conjugated (Direct) Hyperbilirubinemia: found with intrinsic liver functional disorders. Can be intrinsic or hepatocellular, TPN related in ICU setting, infection, bowel disorders, hematologic, metabolic.

Answer 48

Diagnosis: jaundice, acholic stools,hepatomegaly,neonatal sepsis. * Evaluation: LFT’s, GGT, Imaging studies (hepatic US, MRCP/ERCP, hepatobiliary disease - HIDA scan or DISIDA scans). Liver biopsy is diagnostic. For biliary atresia (BA) - intraoperative cholangiogram and biopsy. Treatment: BA-Kasai procedure, correct metabolic or sepsis causes. Monitoring: follow labs (use etiology as guide), Nutrition: malnutrition, need fat-soluble vitamin supplements and special low-fat formulas

Question 49

Complications of Hyperbilirubinemia: Kernicterus and Bilirubin induced neurologic disorders (BIND).

Answer 49

Kernicterus: free bilirubin deposits in brain,affects the basal ganglia, results in movement disorders. Can see Choreoathetoid cerebral palsy, sensorineural hearing loss,impairment of upward gaze and dental dysplasia. Bilirubin-induced neurologic disorders (BIND): Neonatal encephalopathy. Can be mild to severe.

Question 50

Hepatitis: presentation, S/S

Answer 50

Comprehensive history. Identify Causes: Autoimmune, infectious, toxin-mediated, storage diseases, hemodynamic instability. Presentation varies with types: A, B, C, etc. Is determined by acquired infection. Symptoms: elevated transaminases (maybe only sign), jaundice, fever, joint pains, RUQ pain, AMS, malaise, N/V.

Question 51

Hepatitis: Evaluation/Management

Answer 51

Diagnosis: abdominal US with Doppler, assess vessel patency, may require biopsy for etiology. Labs: AST, ALT, conjugated bilirubin, alkaline phosphate. Synthesized in the liver: glucose, coagulation factors, albumin, ammonia. Treatment: supportive treatment, depends on etiology, avoid toxins. Monitoring: liver function studies, acute illness.

Question 52

Acute GI Bleeding Neonate Causes

Answer 52

Rectal fissures, Milk protein allergy, Gastritis, esophagitis from medication or stress. Mechanical ventilation and other NICU therapies. Congenital vascular lesions

Question 53

Acute GI Bleeding Infants to age 1 and ages 1-2 yrs old

Answer 53

Infants to age 1: GERD, Gastritis, IBD, Stress from acute or critical illness. Age 1 – 2 yrs old: Esophageal varices, biliary atresia, portal vein thrombosis, Vascular lesions, Infectious diarrhea.

Question 54

Acute GI Bleeding over age 2

Answer 54

Portal hypertension: esophageal varices, Infectious diarrhea, and IBD.

Question 55

Acute GI Bleeding Evaluation & Management

Answer 55

Diagnosis: history and probable cause. Treatment: stabilization, fluid, and PRBC resuscitation. Octreotide, vasopressin, beta-blocker, H2 blockers, PPI**, Surgical and Endoscopic procedures. Monitoring: signs of continued bleeding, hemoccult, CBC, and coagulation studies.

Question 56

Gastroenteritis

Answer 56

Acquired by fecal-oral route, depends on pathogen (Viral, bacterial, or parasitic). Symptoms: fever, vomiting and/or diarrhea. Many differentials: Food allergies, ileus, colitis, medications, malabsorption Follow CDC/AAP treatment guidelines. Oral rehydration for mild to moderate dehydration, Feed in small volumes, then increase. Prevention: rotavirus vaccine. Monitoring/ repeat assessment. Hospitalization: severe dehydration, fluid replacement. Anti-diarrheal medications are not recommended!! May give ondansetron-found to be safe and effective.

Question 57

A school-age child presents to their PCP with acute periumbilical pain with mild diarrhea, rebound tenderness, and pain at Mcburney’s point. He cannot stand up straight, nor jump. What is the most likely diagnosis and referral? 1.Appendicitis; ED for further testing 2.Urinary tract infection; treat in office 3.Appendicitis; monitor and refer if fever 4.Bowel obstruction; ED for further evaluation

Answer 57

1.Appendicitis; ED for further testing. Classic presentation for appendicitis : McBurney's point is in lower quadrant (1/2 distance between the umbilicus and anterior superior iliac spine). Children do not always have an associated fever.

Question 58

An unconscious adolescent has acute liver failure from an unknown ingestion. What medication can be administered? 1.N-acetyl-p-benzoquinoneimine 2.Romazicon 3.N-acetylcysteine 4.Flumazenil

Answer 58

3.N-acetylcysteine N-acetylcysteine produces antioxidants. It is an essential component in the body's ability to make and replenish glutathione. It is also used in liver detoxification and decreases damage to the kidney and liver after toxin exposure. Treats acetaminophen overdose. Naloxone is another option for treating an unconscious patient from unknown ingestion. However, it was not a choice. Romazicon is the trade name for flumazenil which is used to reverse the effects of benzos. N-acetyl-p-benzoquinoneimine is a reactive metabolite of acetaminophen.

Question 59

An infant with suspected pyloric stenosis would typically present with which of the following lab values? 1.Sodium 135, Potassium 3.5, Cl 115, HCO 20 2.Sodium 132, Potassium 3.0, Cl 95, HCO 32 3.Sodium 128, Potassium 5.6, Cl 112, HCO 26 4.Sodium 146, Potassium 2.8, Cl 98, HCO 15

Answer 59

2.Sodium 132, Potassium 3.0, Cl 95, HCO 32. Pyloric stenosis causes vomiting which leads to metabolic alkalosis with hypokalemia & hypochloremia.

Question 60

An infant presents with bilious emesis, gastric distention and has been very irritable over the past 24 hours. Which of the following studies should be obtained FIRST to assist in diagnosing this potential emergency? 1.Abdominal radiograph 2.CT 3.Upper GI series 4.MRI

Answer 60

1.Abdominal radiograph We are concerned about bowel obstruction. A plain abdominal radiograph is fast & diagnostic for an obstruction.

Question 61

An 18-month-old has had intermittent irritability and then will go back to playing normally. He also had loose, maroon-colored stools the past two days. What is the MOST likely diagnosis? 1.Malrotation 2.Intussusception 3.Meckels diverticulum 4.Toxic megacolon

Answer 61

2.Intussusception Colicky or intermittent episodes of abdominal pain with passage of maroon or currant jelly stools is diagnostic for intussusception. Meckels diverticulum= painful rectal bleeding. Malrotation: asymptomatic unless volvulus which acts like an obstruction. Toxic megacolon: persistently toxic, ill appearing.

Question 62

A 48-hour-old infant is ready to be discharged, but he has not had a first meconium stool. The infant is breastfeeding well, is not vomiting, and has had wet diapers. Excluding which potential diagnosis should be the primary consideration? 1.Hirschsprung disease 2.Dehydration 3.Delayed stool passage related to breastmilk 4.Volvulus

Answer 62

1.Hirschsprung disease. Hirschsprung's is a congenital abnormality characterized by the absence of rectal ganglion cells. The involvement ranges from ultrashort segment to total aganglionosis.

Question 63

What should be at the TOP of the differential list for a 4-year-old who presents with painless rectal bleeding, occurring intermittently, but more frequently over the past week? 1.Hemorrhoids 2.Meckel’s diverticulum 3.Upper GI bleeding 4.Rectal fissure

Answer 63

2.Meckel’s diverticulum Meckel's diverticulum causes painless rectal bleeding. Hemorrhoids are less common in children then adults and are typically uncomfortable/painful. Upper GI bleeding would result in hematemesis or black tarry stools. Anal/rectal fissures usually cause streaking of blood on stool or toilet tissue.

Question 64

Failure to Thrive (inappropriate weight loss/gain)

Answer 64

Diagnosis * when <5% on a standard growth chart * when a child’s weight for age crosses more than two major centile lines * Caused by many medical, psychosocial, and environmental conditions * Organic * inadequate caloric intake, inadequate absorption, excess metabolic demand, or defective utilization * 90% inorganic * Genetic short stature, premature birth, constitutional * Referrals * genetics * GI * cardiology * endocrine * psychology/psychiatry * nutrition * social work

Question 65

Feeding Complications

Answer 65

Refeeding * hypophosphatemia is a hallmark * may have hypomagnesemia * hypokalemia * can have arrhythmias and CHF * Intolerance/Allergies * Ileus * Motility and emptying issues * Obstruction-volvulus * Constipation * GERD

Question 66

Nutrition Parameters

Answer 66

Pre-albumin * reflects last 24-48hrs * useful in acute nutritional changes * not useful in inflammatory states, steroids, or hemodialysis * Albumin * less reliable * longer half-life (14-20 days) * negative acute phase protein * affected by dehydration, sepsis, trauma, liver disease, and albumin infusions * Resting Energy Expenditure (REE) * based on age * equations to modify when sedated or paralyzed, burns, stress, or trauma states

Question 67

Nutrition Parameters

Answer 67

Growth chart/BMI/Diet History * Essential Fatty Acid Deficiency (EFAD) * increase demands and limited reserves * linoleic/alpha-linoleic are essential * in neonates can occur in days * Indirect calorimetry * used to ascertain substrate needs * prevents overfeeding and underfeeding * expensive

Question 68

Biliary Atresia

Answer 68

absence or obstruction of extra hepatic biliary tree causing intrahepatic bile duct obstruction. Prevents bile transport from liver to GI tract causing cirrhosis & liver failure

Question 69

Biliary Atresia S/S

Answer 69

jaundice, acholic stool, dark urine

Question 70

Biliary Atresia Evaluation

Answer 70

LFT's: Elevated conj bili, liver transaminases. Abd US & cholangiogram.

Question 71

Tracheal-Esophageal fistula

Answer 71

typically occurs with Esophageal atresia.Types designated on location. Associated with VACTERL & CHARGE syndrome.

Question 72

Tracheal-Esophageal fistula S/S

Answer 72

Coughing, choking, recurrent pneumonia. with EA have drooling, choking, inability to feed, resp distress.