Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has...

129
Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MD

Transcript of Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has...

Page 1: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

Harvey Aiges, MD

Joel Rosh, MD

Toba Weinstein, MD

Page 2: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

Compared to human milk, cow milk formula is more likely to contain which one of the following?

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1. More essential fatty acids

2. Higher protein concentration

3. Increased lactose content

4. Lower Calcium-phosphate ratio

5. Lower iron concentration

Page 3: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

Compared to human milk, cow milk formula is more likely to contain which one of the following?

A) More essential fatty acids

B) Higher protein concentration

C) Increased lactose content

D) Lower Calcium-phosphate ratio

E) Lower iron concentration

Page 4: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

Human Milk has: Low protein (very bio-available)

High lactose Low iron (very bio-available if taken alone)

Low Calcium-Phosphate ratio

Inadequate Vitamin K

? Adequate Vitamin D

Immunoglobulins (including SIgA)

Page 5: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

A 4 mo old boy with “short gut” from extensive small bowel resection at 2 wks of life is receiving amino acids, hypertonic glucose and trace mineral by PN and is growing well. Last week drying and thickening of skin with desquamation began. The most likely cause of a deficiency is:

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1. Riboflavin

2. Protein

3. Essential fatty acids

4. Vitamin B12

5. Copper

Countdown

6

Page 6: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

A 4 mo old boy with “short gut” from extensive small bowel resection at 2 wks of life is receiving amino acids, hypertonic glucose and trace mineral by PN and is growing well. Last week drying and thickening of skin with desquamation began.

The most likely cause is a deficiency of:

A) Riboflavin

B) Protein

C) Essential fatty acids

D) Vitamin B12

E) Copper

Page 7: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to 200 ml q3h (8 feeds/24 hrs). Birth wt = 3.2Kg. PE = afebrile, wt 5.0Kg (90th %ile). Abdomen is slightly protuberant. No tenderness and bowel sounds are hyperactive. Which is most appropriate at this time?

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1. Change feeds to soy-based formula

2. Obtain stool cultures

3. Determine stool pH

4. Instruct parents to reduce volume of feeds

5. Schedule rectal manometry

Page 8: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to 200 ml q3h (8 feeds/24 hrs). Birth wt = 3.2Kg. PE = afebrile, wt 5.0Kg (90th %ile). Abdomen is slightly protuberant. No tenderness and bowel sounds are hyperactive.

Which is most appropriate at this time?

A) Change feeds to soy-based formula

B) Obtain stool cultures

C) Determine stool pH

D) Instruct parents to reduce volume of feeds

E) Schedule rectal manometry

Page 9: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

A 7 yr old boy who has had school problems for the past 2 months received a megavitamin that supplies 50,000 u of Vitamin A, 100 mgs of thiamine, 100 mg of niacin, 1 g of ascorbic acid, 2000 u of Vit D, and 500 mg of Vit E . The most likely effect of this regimen will be:

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1. Improved school performance

2. Flushing and sweating

3. Increased thiamine level in CSF

4. Increased intracranial pressure

5. Less URIs than in his peers

Countdown

6

Page 10: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

A 7 yr old boy who has had school problems for the past 2 months received a megavitamin that supplies 50,000 u of Vitamin A, 100 mgs of thiamine, 100 mg of niacin, 1 g of ascorbic acid, 2000 u of Vit D, and 500 mg of Vit E

The most likely effect of this regimen will be:

A) Improved school performance

B) Flushing and sweating

C) Increased thiamine level in CSF

D) Increased intracranial pressure

E) Less URIs than in his peers

Page 11: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

Hypervitaminosis Vit A (>20,000 IU/d) – Inc ICP (pseudotumor),

irritability, headaches, dry skin, Hepatosplenomegaly, cortical thickening of bones of hands and feet

Vit D (>40,000IU/d)-Hypercalcemia, constipation, vomiting, nephrocalcinosis

Vit E (100mg/kg/d) – NEC/hepatotoxicity - ?due to polysorbate 80 (solubilizer)

Page 12: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

An adolescent girl on a strict vegan diet is most likely to develop deficiency of which of the following water-soluble vitamins?

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1. Folic acid

2. Niacin

3. Riboflavin

4. Cobalamin

5. Thiamine

Page 13: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

An adolescent girl on a strict vegan diet is most likely to develop deficiency of which of the following water-soluble vitamins?

A) Folic acid

B) Niacin

C) Riboflavin

D) Cobalamin

E) Thiamine

Page 14: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

Vitamin Sources Thiamine – grains, cereals, legumes Riboflavin – dairy, meat, poultry, leafy vegetables Pyridoxine – all foods Niacin – meats, poultry, fish, wheat Biotin – yeast, liver, kidneys, legumes, nuts Folic acid – leafy vegetables,fruits, grains B12 (Cobalamin) – eggs, dairy, meats (not in

plants) Vit C – fresh fruits and vegetables

Page 15: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

Vitamin Deficiencies (fat soluble) A – night blindness, xerophthalmia, Bitot spots,

keratomalacia

D – rickets/osteomalacia, low Ca/Phosp

E – neurologic deficit (ataxia, ocular palsy, decreased DTRs)

K - coagulapathy

Page 16: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

Vitamin Deficiencies(water-soluble) Thiamine (B1) –beriberi, cardiac failure

Riboflavin (B2) – seborrheic dermatitis, cheilosis, glossitis

Pyridoxine (B6) – dermatitis, cheilosis, glossitis, peripheral neuritis, irritability

Vit B12 – megaloblastic anemia, post spinal column changes

Page 17: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

Vitamin Deficiencies(water-soluble) Vit C – scurvy, poor wound healing, bleeds

Folic acid – megaloblastic anemia, FTT

Niacin – pellagra (diarrhea, dermatitis, dementia), glossitis, stomatitis

Biotin – organic acidemia, alopecia, seizures

Page 18: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

A previously healthy 15 mo appears pale. He has been fed goat milk exclusively since birth. Labs reveal: HgB=6.1, WBC=4800, plts=144K, MCV=109. Diff is 29%polys, 68%lymphs, 3%monos. Polys are hypersegmented. What is the most likely cause of these lab findings?

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1. ALL

2. Fanconi anemia

3. Folate deficiency

4. Iron deficiency

5. Vitamin B12 deficiency

Countdown

6

Page 19: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

A previously healthy 15 mo appears pale. He has been fed goat milk exclusively since birth. Labs reveal: HgB=6.1, WBC=4800, plts=144K, MCV=109. Diff is 29%polys, 68%lymphs, 3%monos. Polys are hypersegmented.

What is the most likely cause of lab findings?

A) ALL

B) Fanconi anemia

C) Folate deficiency

D) Iron deficiency

E) Vitamin B12 deficiency

Page 20: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

An 8 mo old white infant is noted to have yellow skin. The sclerae are normal in color. Of the following, which is the most useful diagnostic test?

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1. Measure serum bilirubin level

2. Measure urine urobilinogen conc

3. Measure serum Vitamin A level

4. Evaluate dietary history

5. Measure serum T4 level

Page 21: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

An 8 mo old white infant is noted to have yellow skin. The sclerae are normal in color

Of the following, which is the most useful diagnostic test:

A) Measure serum bilirubin level

B) Measure urine urobilinogen conc

C) Measure serum Vitamin A level

D) Evaluate dietary history

E) Measure serum T4 level

Page 22: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

A previously well 10 yr old has fever and persistent vomiting. Initially the emesis was clear, then bile-stained and now it contains bright red blood. Brother has AGE 1 wk ago. PE and CBC/SMA-7 are normal. The most likely cause of hematemesis is:

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1. Esophageal varices

2. Esophagitis

3. Gastric duplication

4. Mallory-Weiss tear

5. Peptic ulcer disease

Countdown

6

Page 23: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

A previously well 10 yr old has fever and persistent vomiting. Initially the emesis was clear, then bile-stained and now it contains bright red blood. Brother has AGE 1 wk ago. PE and CBC/SMA-7 are normal.

The most likely cause of the hematemesis is:

A) Esophageal varices

B) Esophagitis

C) Gastric duplication

D) Mallory-Weiss tear

E) Peptic ulcer disease

Page 24: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

Upper Presentation

Hematemesis Rapid bleeding lesion

Coffee ground emesis Slower bleed

Hematochezia

Melena

Page 25: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

Upper GI Bleeding Esophagitis

Gastritis

Ulcer disease H. pylori

Mallory-Weiss Tear

Caustic Ingestion/Foreign Body

Esophageal varices

Esophageal and gastric tumors

Vascular anomalies

Coagulapathy

Epistaxis

Tonsillitis/ENT

Varices

Duplication of gut

IBD

HSP

Munchausen’s syndrome by proxy

Page 26: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

Upper GI Bleeding (Infants) Swallowed maternal blood

Hemorrhagic disease of the newborn

Coagulopathy

Stress ulceration/gastritis

Mallory-Weiss tear

Allergy

Esophagitis (GERD)

Vascular anomaly

Epistaxis

Varices

Duplication of gut

Munchausen’s syndrome by proxy

Page 27: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

Evaluation PE and VS

Labs

Stool guaiac

Upper endoscopy with biopsy*

AXRay

Tagged rbc study

Page 28: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

A 5 yr old girl was tx with amoxicillin for OM. One week later, she developed abd pain, and has been passing 6 stools daily that contain blood and mucus. PE has T of 101, abdominal distention and diffuse abd tenderness. Among the following, the most appropriate initial diagnostic study to perform is:

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1. Barium enema

2. Colonoscopy

3. Clostridium difficile toxin evaluation

4. Stool for O & P

5. Stool for rotavirus

Countdown

6

Page 29: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

A 5 yr old girl was tx with amoxicillin for OM. One week later, she developed abd pain, and has been passing 6 stools daily that contain blood and mucus. PE has T of 101, abdominal distention and diffuse abd tenderness.

Among the following, the most appropriate initial diagnostic study to perform is:

A) Barium enema

B) Colonoscopy

C) Clostridium difficile toxin evaluation

D) Stool for O & P

E) Stool for rotavirus

Page 30: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

For the past 6 wks, a 4 yr old has had painless, bright red rectal bleeding assoc with bowel movements. PE of abdomen and anus are normal. The rectal vault is empty and no blood is noted on gross inspection. The most likely cause of hematochezia is:

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1. Hemolytic-Uremic syndrome

2. Henoch-Schonlein purpura

3. Intussusception

4. Juvenile Polyps

5. Meckel’s diverticulum

Page 31: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

For the past 6 wks, a 4 yr old has had painless, bright red rectal bleeding assoc with bowel movements. PE of abdomen and anus are normal. The rectal vault is empty and no blood is noted on gross inspection.

The most likely cause of the hematochezia is:

A) Hemolytic-Uremic syndrome

B) Henoch-Schonlein purpura

C) Intussusception

D) Juvenile Polyps

E) Meckel’s diverticulum

Page 32: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

Lower GI Bleed – 0 to 30 days Anorectal lesions

Swallowed maternal blood (APT test)

Milk allergy

NEC

Midgut volvulus

Hirschsprung’s disease

Page 33: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

A 4 week old is brought to you for streaks of bright red blood in the stool. Child is breast fed, thriving and content. Exam shows seborrhea, benign abdomen and perianal exam. Your next intervention:

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33% 33%33%

1. Remove milk and soy from the maternal diet

2. GI referral for colonoscopy

3. Call child welfare for possible abuse

Page 34: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

A 4 week old is brought to you for streaks of bright red blood in the stool. Child is breast fed, thriving and content. Exam shows seborrhea, benign abdomen and perianal exam. Your next intervention:

a) Remove milk and soy from the maternal diet

b) GI referral for colonoscopy

c) Call child welfare for possible abuse

Page 35: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

Lower GI bleed – 30 days to 1 yr Anorectal lesions

Milk Allergy

Intussusception

Meckel’s diverticulum

Infectious diarrhea

Hirschsprung’s disease

Page 36: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

Allergic Colitis Well appearing

Irritable

Occurs with formula and breast milk

Remove milk and soy from diet

Protein hydrolysate

Flex sig

Reintroduce dairy at 1 year

Page 37: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

Lower GI Bleed – 1-12 years COMMON:

Anal fissure

Juvenile polyp

Meckel’s diverticulum

Infectious diarrhea

IBD

LESS COMMON:

Henoch-Scholein purpura

Hemolytic uremic syndrome

Intestinal duplication

Hemorrhoids

Page 38: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

Meckel Diverticulum Painless rectal bleeding

< 4 years of age

Failure of omphalomesenteric duct to obliterate

2% of population

Within 2 feet of ileocecal valve

Meckel scan technetium 99m pertechnetate scan

Page 39: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

amt Color Stool Pain Think

Small Red Hard Yes fissure

Sm-

mod

Red loose Varies

(abd)

IBD,H

US, inf

“ Red nl,

coated

No Polyp

Mod Red-T nl Yes-

abd

HSP

Mod “ nl “ Intuss

Mod “ loose “ HD??

???

Large “ nl No MD

Page 40: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

A 3,200 gm newborn is noted to be jaundiced on postnatal day #10. Total Bili is 9.0 with a direct Bili of 0.8 mg/dl. Hct is 48%. Baby and mom are blood type O, Rh+. Baby is breast fed exclusively. The most likely explanation of high Bili is:

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1. Biliary atresia

2. “breast milk” jaundice

3. Choledochal cyst

4. Hypothyroidism

5. Neonatal hepatitis

Page 41: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

A 3,200 gm newborn is noted to be jaundiced on postnatal day #10. Total Bili is 9.0 with a direct Bili of 0.8 mg/dl. Hct is 48%. Baby and mom are blood type O, Rh+. Baby is breast fed exclusively.

The most likely explanation for high Bili is:

A) Biliary atresia

B) “breast milk” jaundice

C) Choledochal cyst

D) Hypothyroidism

E) Neonatal hepatitis

Page 42: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

Unconjugated Hyperbilirubinemia Physiologic – exaggerated by hemolysis or hematoma

Breast feeding

Breast Milk (late onset)

Crigler-Najjar syndrome I & II

Hypothyroid

Intestinal obstruction

Page 43: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

A 3 wk old girl has fever and vomiting. PE include bulging fontanelle and hepatomegaly. The pt had jaundice and vomiting during the 1st wk after birth. She has been breast-fed. What is the most likely Dx?

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6

1. Fructose aldolase deficiency

2. Fructose 1,6 diphosphatase deficiency

3. Glycogen Storage Disease type 1

4. Neonatal adrenoleukodystrophy

5. Galactosemia

Page 44: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

A 3 wk old girl has fever and vomiting. PE include bulging fontanelle and hepatomegaly. The pt had jaundice and vomiting during the 1st wk after birth. She has been breast-fed.

What is the most likely Dx?

A) Fructose aldolase deficiency

B) Fructose 1,6 diphosphatase deficiency

C) Glycogen Storage Disease type 1

D) Neonatal adrenoleukodystrophy

E) Galactosemia

Page 45: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

Direct Hyperbilirubinemia Extrahepatic

1.*** Extrahepatic Biliary Atresia

2. ***Choledochal Cyst

3. Choledocholithiasis

4. Extrinsic bile duct compression

Page 46: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

Direct Hyperbilirubinemia Intrahepatic

1. Metabolic

2. Familial intrahepatic cholestasis

3. Infectious

4. Anatomic – Paucity of intrahepatic bile ducts

5. Misc – TPN, Neonatal Lupus

Page 47: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

EHBA Direct Hyperbili

Acholic stool

Elevated transaminases and GGT

DISIDA scan (99mTc-disofenin)

Liver biopsy

Kasai portoenterostomy <8 weeks

Page 48: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

Alagille syndrome Hereditary condition

Mutations JAGGED-1 gene

Bile duct paucity

Peripheral pulmonary artery stenosis

Vertebral anomalies

Posterior embroyotoxin

Characteristic facies

Page 49: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

A 12 yr old girl has recurrent bouts of scleral icterus, often after viral illnesses. She is otherwise well and is taking no meds. Labs reveal: Total Bili of 3.4 mg/dl with direct Bili of 0.3 mg/dl. ALT/PT/APPT are all normal. The most likely cause of hyperbilirubinemia is:

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6

1. Chronic active hepatitis

2. Dubin-Johnson syndrome

3. Gilbert syndrome

4. Hepatitis A

5. Infectious Mononucleosis

Page 50: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

A 12 yr old girl has recurrent bouts of scleral icterus, often after viral illnesses. She is otherwise well and is taking no meds. Labs reveal: Total Bili of 3.4 mg/dl with direct Bili of 0.3 mg/dl. ALT/PT/APPT are all normal

The most like cause of the hyperbilirubinemia

A) Chronic active hepatitis

B) Dubin-Johnson syndrome

C) Gilbert syndrome

D) Hepatitis A

E) Infectious Mononucleosis

Page 51: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

Hepatitis Most common infectious cause viral

Mild-Asymptomatic transaminase elevation

Hep A, EBV, CMV

Clinical Hepatitis

Fulminant Hepatic Failure

Rare in HepA, Hep B

Page 52: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

Hepatitis A Transmission oral/fecal

RNA virus

Incubation 2-6 weeks

Milder in young children

Does not cause chronic infection

Some patients may experience a relapsing course

Hepatitis A vaccine to all children at 1 year

Page 53: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

Severe RUQ pain, intense jaundice and dark urine in a 9 yr old girl w chronic mild jaundice from spherocytosis. Which diagnostic test is most likely to give correct diagnosis of her current state:

1 2 3 4 5

20% 20% 20%20%20%

1. Determine AST/ALT levels

2. Determine presence of Hepatitis B surface Ag

3. Radionuclide scan of liver

4. Ultrasound of abdomen

5. PAPIDA scan

Countdown

6

Page 54: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

Severe RUQ pain, intense jaundice and dark urine in a 9 yr old girl w chronic mild jaundice from spherocytosis.

Which diagnostic test is most likely to give correct diagnosis of her current state:

A) Determine AST/ALT levels

B) Determine presence of Hepatitis B surface Ag

C) Radionuclide scan of liver

D) Ultrasound of abdomen

E) PAPIDA scan

Page 55: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

A 6 year old boy is brought to your office with a history of 36 hours of increasing anorexia and periumbilical pain. Last night he had his first episode of nocturnal enuresis in 3 years. He is afebrile and has a benign abdominal exam. Your diagnosis:

1 2 3 4

25% 25%25%25%

Countdown

6

1. Acute appendicitis

2. Strep Pharyngitis

3. School (first grade) avoidance

4. Constipation

Page 56: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

A 6 year old boy is brought to your office with a history of 36 hours of increasing anorexia and periumbilical pain. Last night he had his first episode of nocturnal enuresis in 3 years. He is afebrile and has a benign abdominal exam. Your diagnosis:

a) Acute appendicitis

b) Strep Pharyngitis

c) School (first grade) avoidance

d) Constipation

Page 57: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

Evaluation of Acute Abdominal Pain History-

Other sxs (Vomit, BM changes, Systemic)

Physical Exam Skin, Lungs, Abdomen, Rectal exam (guaiac)

Imaging Plain Films, Sonogram

Lab CBC, lytes, Liver/albumin, Pancreas, Urine

Page 58: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

A 12 year girl comes to the office with 36 hours of abdominal pain, fever and anorexia. Pain is periumbilical and worse in the car than now. You think of appendicitis. Helpful lab tests could include all except

1 2 3 4

25% 25%25%25%1. Stool for guaiac

2. CBC

3. Urinalysis

4. Abdominal sonogram

Countdown

6

Page 59: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

A 12 year girl comes to the office with 36 hours of abdominal pain, fever and anorexia. Pain is periumbilical and worse in the car than now. You think of appendicitis. Helpful lab tests could include all except

a) Stool for guaiac

b) CBC

c) Urinalysis

d) Abdominal sonogram

Page 60: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

A 17 year old member of the track team comes in with epigastric discomfort and nausea. The big meet is tomorrow and he has been training hard for his last chance to win the medal in his event. He has no significant past medical history other than mild exercise induced asthma and uses an inhaler as he needs. He also uses ibuprofen for muscle pain when training. Your diagnosis:

Page 61: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

Diagnosis

1 2 3 4

25% 25%25%25%

Countdown

6

1. Atypical asthma

2. Performance anxiety

3. Intestinal parasite

4. NSAID complication

Page 62: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

Diagnosis a) Atypical asthma

b) Performance anxiety

c) Intestinal parasite

d) NSAID complication

Page 63: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

An 18 year old who saw you to start birth control pills prior to going to college now comes in with recurrent, crampy post-prandial epigastric pain that sometimes travels below her right ribs. On exam you find that she has slight scleral icterus, vague epigastric tenderness and a belly button ring. Her urine pregnancy test is negative. Your next step:

1 2 3 4

25% 25%25%25%

Countdown

6

1. GI referral for upper endoscopy

2. Counseling for drug and alcohol abuse

3. Switch the form of birth control

4. Order an abdominal sonogram

Page 64: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

An 18 year old who saw you to start birth control pills prior to going to college now comes in with recurrent, crampy post-prandial epigastric pain that sometimes travels below her right ribs. On exam you find that she has slight scleral icterus, vague epigastric tenderness and a belly button ring. Her urine pregnancy test is negative. Your next step:

a) GI referral for upper endoscopy

b) Counseling for drug and alcohol abuse

c) Switch the form of birth control

d) Order an abdominal sonogram

Page 65: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

A seven year old is seen for a bicycle accident. He is fine other than a few abrasions and an ecchymotic area on his abdomen where he hit the handlebars. 24 hours later, he has significant abdominal and back pain and recurrent non-bilious vomiting. You make the diagnosis with:

1 2 3 4

25% 25%25%25%

Countdown

6

1. Further family and social history

2. Liver chemistries, amylase and lipase

3. An upper GI series

4. Stool for guaiac

Page 66: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

A seven year old is seen for a bicycle accident. He is fine other than a few abrasions and an ecchymotic area on his abdomen where he hit the handlebars. 24 hours later, he has significant abdominal and back pain and recurrent non-bilious vomiting. You make the diagnosis with:

a) Further family and social history

b) Liver chemistries, amylase and lipase

c) An upper GI series

d) Stool for guaiac

Page 67: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

Trauma Duodenal Hematoma

Handlebar, seatbelts, abuse

NGT relieves distention

Pancreatic pseudocyst

Pancreatitis

Page 68: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

A 2 year old is brought to you for trouble stooling. Over the last 18 hours he has become “tired and miserable”. He now seems to vomit when straining to pass stool. On exam you notice that he appears lethargic and has a palpable mass in the mid-abdomen. Your next intervention is:

1 2 3 4

25% 25%25%25%

Countdown

6

1. disimpaction dose of PEG (polyethelene glycol)

2. counseling on toilet training

3. stat abdominal CT scan for appendicitis

4. barium enema

Page 69: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

A 2 year old is brought to you for trouble stooling. Over the last 18 hours he has become “tired and miserable”. He now seems to vomit when straining to pass stool. On exam you notice that he appears lethargic and has a palpable mass in the mid-abdomen. Your next intervention is:

a) disimpaction dose of PEG (polyethelene glycol)

b) counseling on toilet training

c) stat abdominal CT scan for appendicitis

d) barium enema

Page 70: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

Intussusception Most common cause of intestinal obstruction between

3 months – 6 years

Sudden acute onset of severe, paroxysmal colicky pain that recurs at frequent intervals

Well in between, can become weak and lethargic

Current jelly stools

70-90% reduction

Page 71: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

A 11 year girl comes to see you for recurrent periumbilical pain for the last 9 months. It is worse in the morning, especially on school days. There is no vomiting or weight loss but she does frequently have non-bloody diarrhea with resolution of the pain. Her exam is benign and stool is guaiac negative.

Page 72: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

Your preferred working diagnosis:

1 2 3 4

25% 25%25%25%

Countdown

6

1. school avoidance

2. Crohn Disease

3. irritable bowel syndrome

4. ulcerative colitis

Page 73: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

Your preferred working diagnosis:

a) school avoidance

b) Crohn Disease

c) irritable bowel syndrome

d) ulcerative colitis

Page 74: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

Her symptoms persist so you plan an evaluation that should include all of the following EXCEPT:

1 2 3 4

25% 25%25%25%

Countdown

6

1. celiac serology

2. lactose breath test

3. abdominal CT scan

4. stool for ova and parasites

Page 75: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

Her symptoms persist so you plan an evaluation that should include all of the following EXCEPT:

a) celiac serology

b) lactose breath test

c) abdominal CT scan

d) stool for ova and parasites

Page 76: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

Reasonable interventions for this patient would not include:

1 2 3 4 5

20% 20% 20%20%20%

Countdown

6

1. Cognitive behavioral therapy

2. Dietary manipulation

3. Trial of low dose Tri-cyclic antidepressants

4. Empiric therapy for Helicobacter pylori

5. Symptom-based therapy

Page 77: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

Reasonable interventions for this patient would not include:

a) Cognitive behavioral therapy

b) Dietary manipulation

c) Trial of low dose Tri-cyclic antidepressants

d) Empiric therapy for Helicobacter pylori

e) Symptom-based therapy

Page 78: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

RAP—Red Flag Symptoms

Nocturnal awakening

Persistent Vomiting

Dysphagia

Bleeding

Systemic Signs (Fever, Rash, Arthritis)

Affected Growth/Development

Page 79: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

Organic Causes of RAP

Crohn’s Disease

Celiac Disease

Acid-Peptic/GERD

Carbohydrate malabsorption

Infection (eg Giardia)

Page 80: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

Symptom Based Diagnoses Irritable Bowel Syndrome:

Diarrhea Predominant

Constipation Predominant

Alternating Stool Pattern

Nonulcer Dyspepsia

Functional Abdominal Pain

Abdominal Migraine

Aerophagia

Page 81: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

IBS Functional disorder

Rome criteria

Abdominal discomfort or pain relieved with defecation an is associated with a change in frequency or consistency of stool

No rectal bleeding

Exclude other etiologies

Infection, inflammatory, celiac

Page 82: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

IBS--Treatment Education and reassurance Proper nutrition/food avoidance

Some studies up to 50% improve with fiber

Counseling/Cognitive-Behavior Medications:

Antispasmodic Anti-diarrheal Probiotics Tricyclic antidepressants Serotonin receptor agents

Page 83: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

A concerned 22 year old first time mom brings in her 6 week old “vomiter”. After every feed her son “vomits the whole thing”. You note the child is slightly above birth weight and the mother states he seems to be urinating less. You make the diagnosis with:

1 2 3 4

25% 25%25%25%

Countdown

6

1. A metabolic evaluation

2. Stat head CT scan

3. Upper endoscopy by your local Pediatric GI

4. Abdominal sonography

Page 84: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

A concerned 22 year old first time mom brings in her 6 week old “vomiter”. After every feed her son “vomits the whole thing”. You note the child is slightly above birth weight and the mother states he seems to be urinating less. You make the diagnosis with:

a) A metabolic evaluation

b) Stat head CT scan

c) Upper endoscopy by your local Pediatric GI

d) Abdominal sonography

Page 85: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

Pyloric Stenosis Projectile, non-bilious emesis

Most common cause of gastric outlet obstruction in neonates, M>F

“olive”

pyloric sonogram

Hypochloremic metabolic alkalosis

Surgery

Page 86: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

Your previous patient is now 2 and accompanies his mother with his 6 week old brother who has “vomiting”. This has increased over the last 24 hours. The mother is tired, overwhelmed and complains of her increased dry cleaning expenses as she shows you her vomit stained white blouse that now has green and yellow stains. As your nurse provides her a sympathetic ear, you

1 2 3 4

25% 25%25%25%

Countdown

6

1. Get samples of a low allergy formula

2. Order a pyloric sonogram

3. Call the ED to alert them of a neonatal bowel obstruction patient

4. Send in your junior partner “to deal with it”

Page 87: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

Your previous patient is now 2 and accompanies his mother with his 6 week old brother who has “vomiting”. This has increased over the last 24 hours. The mother is tired, overwhelmed and complains of her increased dry cleaning expenses as she shows you her vomit stained white blouse that now has green and yellow stains. As your nurse provides her a sympathetic ear, you

a) Get samples of a low allergy formula

b) Order a pyloric sonogram

c) Call the ED to alert them of a neonatal bowel obstruction patient

d) Send in your junior partner “to deal with it”

Page 88: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

Once in the emergency room, proper management of this infant would include:

1 2 3 4 5

20% 20% 20%20%20%

Countdown

6

1. Intravenous fluid resuscitation

2. Stat pediatric surgical consultation

3. Contrast imaging of the bowel

4. Nasogastric decompression

5. All of the above

Page 89: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

Once in the emergency room, proper management of this infant would include:

a) Intravenous fluid resuscitation

b) Stat pediatric surgical consultation

c) Contrast imaging of the bowel

d) Nasogastric decompression

e) All of the above

Page 90: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

Volvulus Abnormal fixation of bowel mesentery during fetal

development

Most occur in utero or early infancy

Sudden onset of abdominal pain and bilious emesis

Ischemia and necrosis

UGI series

Page 91: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

The previous mother is grateful and sends her own 45 year old post-partum mother to see you with her Trisomy 21 infant who was just sent home from the hospital “vomiting”. The child is just at birth weight. You send her to the ED and a series of radiographs do not show an obstructive pattern. Rather, there are only two pockets of air in the epigastric region. You are again the star as you diagnose:

1 2 3 4

25% 25%25%25%

Countdown

6

1. Vulnerable child syndrome

2. Celiac disease

3. Milk protein allergy

4. Duodenal atresia

Page 92: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

The previous mother is grateful and sends her own 45 year old post-partum mother to see you with her Trisomy 21 infant who was just sent home from the hospital “vomiting”. The child is just at birth weight. You send her to the ED and a series of radiographs do not show an obstructive pattern. Rather, there are only two pockets of air in the epigastric region. You are again the star as you diagnose:

a) Vulnerable child syndrome

b) Celiac disease

c) Milk protein allergy

d) Duodenal atresia

Page 93: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

Duodenal Atresia Double-bubble sign

1:4,500 newborns

2-5% Trisomy 21

Assoc with obstructive processes i.e. annular pancreas

Also found in fetal alcohol syndrome

Page 94: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

Differentiating GER and GERD

GER Gastroesophageal Reflux. Passage of gastric contents into the esophagus

Regurgitation Passage of refluxed gastric contents into oral pharynx

Vomiting Expulsion of refluxed gastric contents from mouth

GERD

Gastroesophageal Reflux Disease. Symptoms or complications that occur when gastric contents reflux into esophagus or oropharynx

Page 95: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

Prevalence of Regurgitation in Healthy Infants

Nelson et al. Arch Pediatr Adolesc Med. 1997;151:569

Infa

nts

(%

)

100

0

50

0-3 4-6 7-9 10-12

Age (months)

≥ 1 time a day

≥ 4 times a day

n = 948

Page 96: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

Delayed gastric emptying time

Transient lower esophageal sphincter relaxation; decreased LES pressure

Impaired esophageal clearance

Pathophysiology of GERD

Orlando et al, eds. Textbook of Gastroenterology: JB Lippincott Co;1995:1214. Fennerty et al. Arch Intern Med. 1996;156:477.

Kawahara et al. Gastroenterology 1997;113:399.

Page 97: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

Presenting Symptoms and Signs of GERD Infants Feeding refusal

Recurrent vomiting

Poor weight gain

Irritability

Sleep disturbance

Apnea or Apparent Life-Threatening Event (ALTE)

Rudolph et al. J Pediatr Gastroenterol Nutr. 2001;32:S1.

Older child/adolescent

Recurrent vomiting

Heartburn

Dysphagia

Asthma

Recurrent pneumonia

Upper airway symptoms

(chronic cough, hoarse

voice)

Page 98: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

Diagnosis of GERD Barium swallow/Upper gastrointestinal series

(anatomy)

Ambulatory single or dual-channel pH monitoring

Impedance

Endoscopy and biopsy

Radionuclide scanning

Page 99: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

Complications of GERD Erosive esophagitis

Peptic stricture

Barrett’s esophagus

Adenocarcinoma

Rudolph et al. J Pediatr Gastroenterol Nutr. 2001;32:S1.

Page 100: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

Step-Up Therapy for GERD FOR INFANTS Normalize feeding volume

and frequency

Consider thickened formula

Positioning

Consider trial of hypoallergenic formula

FOR OLDER CHILDREN Avoid large meals

Do not lie down immediately after eating

Lose weight, if obese

Avoid caffeine, chocolate, and spicy foods that provoke symptoms

Eliminate exposure to cigarette smoke

Shalaby et al. J. Ped. 2003;142:57.

Page 101: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

Rudolph et al. J Pediatr Gastroenterol Nutr. 2001;32:S1. Gold. Paediatric Drugs 2002;4:673.

Gibbons et al. Paediatric Drugs 2003;5:25.

Pharmacologic Management of Moderate-to-Severe GERD

Prokinetics Metoclopramide

Many possible side effects which may include tardive dyskinesis (may be irreversible)

Other agents include domperidone, bethanechol* and erythromycin

H2RAs Available in tablet, elixir, or rapid dissolve form (must be

dissolved in water, not on tongue)

Pediatric safety, dosing data for ranitidine and famotidine

PPIs Available in capsule, liquid suspension, or rapid dissolve form

Pediatric safety, dosing data for lansoprazole and omeprazole

*Bethanechol not approved for pediatric GERD.

Page 102: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

Ingestions Foreign bodies present with dysphagia and possibly

poor handling of secretions

Not all foreign bodies are seen on plain film—may need barium

Endoscopic removal by 24 hours

Alkali ingestions may burn esophagus and not the mouth

Page 103: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

Diarrhea--Infectious

Viral—less than one week Rotavirus: most common cause of viral diarrheal disease

in infants and toddlers

Bacterial—sick, blood Salmonella, Shigella, Yersinia, Campylobacter, E Coli

Parasitic—persistent

**C. Difficile: After antibiotics/hospitalization

Check for toxin A and B

Colonization not pathogen in neonates

Page 104: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

Diarrhea Leading cause of morbidity and mortality in

developing countries

Daycare centers important reservior

In US

35-40 million episodes annually in kids <5 yrs

170,00 hospitalizations

300 deaths

Page 105: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

Food Borne Fecal-oral

Salmonella and Campylobacter Poultry, unpasteurized milk

Yersinia enterocolitica Pork

Norwalk virus Raw seafood

Water Giardia lamblia, Campylobacter, Cryptosporidium,

Norwalk virus

Page 106: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

E. Coli 0157:H7: associated Hemolytic Uremic Syndrome Often presents with colitis (bloody diarrhea)

Hemolysis, uremia develop

Poly-- then oligouric renal failure

Thrombocytopenia

Severity varies

Risk factors Uncooked meat, unpasteurized milk

**associated with anti-diarrheal and antibiotic use***

Page 107: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

Malabsorption Defect in intraluminal digestion

Cholestasis

Pancreatic insufficiency

Damage to intestine

Infection Viral, giardia

Allergic enteropathy

Celiac disease

Short Bowel

Page 108: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

Malabsorption Evaluation Carbohydrate

Check stool pH

Check stool reducing substances

Fat

Qualitative vs. Quantitative (72 hour) measures

Think CF—treated with enzyme replacement

Protein

Page 109: Harvey Aiges, MD Joel Rosh, MD Toba Weinstein, MDnysaap.org/blog/GI.pdf · A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to

Dietary Diarrhea Clinically:

Well

No blood, fever, etc.

Contributors:

Sorbitol, fruit juice, excessive fluids

Lactose intolerance

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Toddler’s Diarrhea Clinically well

Good wt gain and growth

Stool

Frequent, undigested food

Low fat - most commonly due to milk restriction

High osmolarity fluids

- juice, gatorade, powerade, ice tea, etc.

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Lactose Intolerance Primary vs Secondary

Primary rare < 5 years

Management Restriction v. supplement If restriction supplement calcium

Diagnosis: Clinical Breath test Disaccharidase levels in tissue ??genetics

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Celiac Disease Autoimmune

Triggered by gluten

Associated with hi risk populations Type 1 DM

Down syndrome

Chronic lymphocytic thyroiditis (Hashimoto)

IgA deficiency

Family history

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Gastrointestinal Manifestations (“Classic”)

Most common age of presentation: 6-24 months

Chronic or recurrent diarrhea

Abdominal distension

Anorexia

Failure to thrive or weight loss

Rarely: Celiac crisis

• Abdominal pain

• Vomiting

• Constipation

• Irritability

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Non-Gastrointestinal Manifestations

Dermatitis Herpetiformis

Dental enamel hypoplasia

of permanent teeth

Osteopenia/Osteoporosis

Short Stature

Delayed Puberty

• Iron-deficient anemia

resistant to oral Fe

• Hepatitis

• Arthritis

• Epilepsy with occipital

calcifications

Most common age of presentation: older child to adult

Listed in descending order of strength of evidence

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Serological Tests Antigliadin antibodies (AGA)

Antiendomysial antibodies (EMA)

Anti tissue transglutaminase antibodies (TTG)

– first generation (guinea pig protein)

– second generation (human recombinant)

HLA typing

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Histological Features

Normal 0 Infiltrative 1 Hyperplastic 2

Partial atrophy 3a Subtotal atrophy 3b Total atrophy 3c

Horvath K. Recent Advances in Pediatrics, 2002.

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Treatment

Only treatment for celiac disease is a gluten-free diet (GFD)

Strict, lifelong diet

Avoid:

Wheat

Rye

Barley

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Hirschsprung’s Disease History of delayed passage of meconium

Failure to thrive

Abdominal distension

Vomiting/obstructive picture

Potential complications: Perforation esp. cecal

Enterocolitis/sepsis

death

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Hirschsprung’s Disease: Diagnosis CLINICAL SUSPICION

Obstructive series radiographs

Barium enema (older child)

Suction rectal biopsy—gold standard

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A six year old is brought to you for diarrhea. Child stools multiple times during the day—seems to be all day. Often there is stool in the underwear. Your exam is notable for a tympanitic abdomen and LLQ mass. Your diagnosis:

a) Neuroblastoma

b) Giardiasis

c) Lactose intolerance

d) Fecal overflow incontinence

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A six year old is brought to you for diarrhea. Child stools multiple times during the day—seems to be all day. Often there is stool in the underwear. Your exam is notable for a tympanitic abdomen and LLQ mass. Your diagnosis:

a) Neuroblastoma

b) Giardiasis

c) Lactose intolerance

d) Fecal overflow incontinence

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Treatment of Constipation Stimulant laxatives—

Senna, bisacodyl

Stool softeners/osmotics PEG

Lactulose

ducosate

Lubricants Mineral oil

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Rectal Prolapse CF till proven otherwise

Constipation more common cause

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IBD

INFECTION?

SMOKING

GENETIC

PSYCHOGENIC

ENVIRONMENTAL DIETARY

DRUGS?

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Crohn Disease Autoimmune

Inflammatory process Mouth to the anus; TI

Presentation Abdominal pain, diarrhea, rectal bleeding, growth

failure

Associated symptom—GI/systemic

Extra-intestinal manifestations Peri-anal changes, Fever, Apthous stomatitis,

Uveitis/iritis, Skin Manifestations, Joint, Ankylosing spondylitis, Clubbing

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IBD Interaction between genetic predisposition and

environment

Increased in Northern European and Jewish population

Family History increased risk

Typically presents in adolescence and young adulthood

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Crohn’s and Growth Failure Can be presenting symptom

Multi-factorial

Nutritional ie. Poor intake

Malabsorption

Direct cytokine/inflammatory effect on bone

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Ulcerative Colitis

Inflammatory

“the bloody diarrhea”

Limited to colon

Continuous disease

Extra-intestinal manifestations

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Refeeding Syndrome Malnourished patients

Electrolyte abnormalities

Hypophosphatemia

Fluid retention

Careful monitoring and slow refeeding

Edema, muscle weakness, arrhythmias