GI BOARD REVIEW
December 16, 2010
INFANT NUTRITION

Breast milk ideal

Supplements:
Vitamin D
400IU/day
 Fluoride
 (exclusive breast feeding may require Fe supplements after
several months of age)


VLBW infants

Higher Ca, Phos, vitamin requirements
QUESTION 1
You are seeing a healthy 6 month old infant for a
well visit. The mother is concerned that the baby
is not taking in enough calories. What is the
required cal/kg/day for this child?
A. 70
B. 100
C. 50
D. 125
E. 80
MALNUTRITION

Explore diet and eating habits

Formula


Type, quantity, how it is mixed
Older Children
Food intake, preferences, avoidances
 Plot BMI

EXTREME MALNUTRITION

Marasmus
Caloric deficiency
 Emaciation
 Hypothermia and bradycardia late


Kwashiorkor
Protein deficiency
 Edema
 Hepatomegaly, AMS


Marasmic-kwashiorkor
QUESTION 2
Which of the following electrolyte abnormalities
may be seen in refeeding syndrome?
A.
B.
C.
D.
E.
Hyperkalemia
Hypercalcemia
Hypophosphatemia
Hypoglycemia
Hypermagnesemia
NUTRITION

Low weight for height


Diminished height (and wt) for age


Acute Failure to Thrive
Chronic undernutrition
Refeeding syndrome





Hypophosphatemia
Hypokalemia
Hypomagnesemia
Hypocalcemia
Glucose intolerance
VITAMIN DEFICIENCIES
B1 (THIAMINE)

Beri Beri





Mental confusion
Peripheral paralysis
Muscle weakness
Tachycardia
Cardiomegaly
B2 (RIBOFLAVIN)
Stomatitis (angular)
 Anemia
 Dermatitis (seborrheic)
 Infants on prolonged
phototherapy at risk

B3 (NIACIN)

3D’s of B3
Dermatitis
 Diarrhea
 Dementia
 Glossitis


Toxicity results in
vasodilation
B9 (FOLATE)

Large tongue and macrocytic anemia

Neural tube defects

When folate given for macrocytic anemia, may
mask B12 deficiency
B12 (CYANOCOBALAMIN)

Macrocytic anemia

Pernicious anemia

Poor absorption (decreased intrinsic factor)
VIT C (ASCORBIC ACID)

Scurvy
Bleeding gums
 Leg tenderness
 Poor wound healing


Toxicity
Nephrocalcinosis
 Hemolysis in G6PD

FAT SOLUBLE VITAMINS
ADEK
VIT A (RETINOL)
Most common cause of
childhood blindness worldwide
 Eye Findings

Dry eyes (xerophthalmia)
 Night blindness
 Bitot spots (shiny gray
triangular conjunctival lesions)


Follicular hyperkeratosis

Intoxication

Pseudotumor cerebri
VIT E (TOCOPHEROL)

Hemolytic anemia in preemies

Neuro changes
Neuropathies
 Absent DTRs
 Ataxia
 Weakness

VIT K (PHYLLOQUINONE)

Hemorrhagic disease of the newborn

Breast fed babies

Factors 2,7,9,10

Prolonged PT
GASTROENTEROLOGY
HELICOBACTER PYLORI

Endoscopic findings
Antral gastritis
 Nodularity of antrum
 Duodenal ulcers


Treatment: “Triple Therapy”

Antibiotics X2wks, PPI X4wks
Amoxicillin, clarithromycin, PPI
 Amoxicillin, metronidazole, PPI
 Clarithromycin, metronidazole, PPI

PANCREATITIS

Causes:
Gallstones in adults
 Trauma and systemic diseases (HUS) in children

Biliary tract disease
 Congenital anomalies
 Drugs
 Organ transplantation
 Idiopathic
 Infectious
 Metabolic
 Post-op
 Malignancy

INTUSSUSCEPTION

Age 3mos – 5yrs

Older children usually have lead point
Meckel’s
 HSP (ileo-ileal)

Classic Triad: colicky abd pain, vomiting, current
jelly stools: 30%
 May present with lethargy or seizure
 Air contrast or barium enema
 Recurrence in 10%

CONSTIPATION
Delay or difficulty passing stool for >2wks
resulting in discomfort to patient
 Usually functional
 Overflow incontenence or encopresis

Chronic distal fecal impaction
 Stretching of rectal wall
 Relaxation of internal anal sphincter


Bladder dysfunction with UTI
QUESTION 3
You are seeing a 2 year old child that has had
chronic constipation since infancy. You suspect
Hirschprung disease. Which of the following
tests is necessary for the confirmation of
diagnosis?
A.
B.
C.
D.
E.
Rectal suction biopsy
Unprepped barium enema
Prepped barium enema
Endoscopy
Upper GI with small bowel follow through
HIRSCHSPRUNG DISEASE

Constipation from early infancy

Unprepped barium enema


Transition zone
Rectal bx for ganglion cells
VOMITING
PYLORIC STENOSIS

Narrowing of pyloric channel


Unknown etiology


Secondary to hypertrophy of
musculature
Erythromycin
Presentation






3-5 weeks
Forceful, projectile, nonbilious
vomiting
Persistent hunger
Constipation
Dehydration
Unconjugated hyperbili
PYLORIC STENOSIS

Physical Exam
Peristaltic wave
 Olive


Lab finding


Hypokalemic,
hypochloremic metabolic
alkalosis
Diagnosis

US

Near 100% sensitivity and
specificity
PYLORIC STENOSIS

Diagnosis

US


UGI


Near 100% sensitivity
and specificity
“string sign”
Treatment

Pyloromyotomy
QUESTION 4
The diagnostic approach to a child with symptoms
typical of uncomplicated GER is:
A.
B.
C.
D.
E.
Barium swallow and pH probe
Barium swallow
No investigation
pH probe
Subspecialty consultation
REFLUX

GER


GERD


Passage of contents into the esophagus
Symptoms and complications
Symptoms







Vomiting
Poor weight gain
Substernal chest pain
Abdominal pain
Dysphagia
Esophagitis
Respiratory disorders
REFLUX

GER
Common
 Usually self-limited
 Disappears by 1 to 2 years of age


GERD







Growth failure
Aspiration
Esophagitis
Hemorrhage
Apnea
Sandifer syndrome
RARE
REFLUX

Diagnosis
Based clinically
 UGI

Does not diagnose reflux!
 Anatomic abnormalities


pH probe


Correlates symptoms with
episodes
Esophagoscopy

Assess esophageal injury
REFLUX

Therapy
Frequent small feedings
 Upright position?
 Prone??
 Thickened feeds


1 tablespoon/ounce
H2 blockers
 PPIs
 Prokinetics



Controversial
Nissen
INTESTINAL MALROTATION AND VOLVULUS


Incomplete rotation of
the intestine during
embryonic life
Presentation

Sudden onset
Bilious emesis
 Abdominal pain


Bilious emesis is a
surgical emergency until
proven otherwise
INTESTINAL MALROTATION AND VOLVULUS

Studies

Plain film


Paucity of air in lower
abdomen
UGI
Gold standard
 “corkscrew”
 Small intestine on right
 C-loop does not cross
midline


Treatment

Surgical Emergency
DIARRHEA
QUESTION 5
The mother of a 2-year-old complains that her son has
frequent, watery, foul-smelling stools with visible food
particles that has been occurring for >2 weeks. The
child appears well on physical exam and his weight is
at the 50%ile. Stool analysis reveals a pH of 5 and no
evidence of fat malabsorption. Of the following the
MOST appropriate management plan for this infant
is to:
A. Avoid all fresh fruits and vegetables
B. Avoid all lactose-containing dairy products
C. Begin a high-fat, low-carbohydrate diet
D. Keep a food diary
E. Increase the total daily fluid intake
DIARRHEA

Usually acute and infectious

Chronic
>2 weeks
 Most commonly postinfectious or dietary


History

Small bowel


Watery and free of mucus
Infectious or inflammatory

Blood and/or mucus
DIARRHEA

Stool Examination

Reducing substances


Stool pH


Infection or inflammation
Ova and parasites


Malabsorption
Fecal leukocytes


Low (<5) in carbohydrate
maldigestion and malabsorption
Fat


Unabsorbed sugar
Parasitic pathogens
Stool culture

Bacterial pathogens
E.COLI DIARRHEA

Enterotoxigenic E.coli








Traveler’s diarrhea
Thrives in environment (food and water)
Incubation 1-3 days
Large outbreaks in US
Watery diarrhea, voluminous, may resemble cholera
Self limited
Fluid therapy
Prophylaxis not necessary in healthy children

If asked to choose: Bactrim
E.COLI DIARRHEA

Enteroinvasive E.coli
Closely related to Shigella
 Clinical course nearly identical to Shigella

E.COLI DIARRHEA

Enterohemorrhagic E.coli (O157:H7)

Undercooked ground beef
Reported in apple cider/ raw vegetables
 Summer months

Shiga toxin-positive
 Bloody diarrhea
 Hemolytic uremic syndrome

PATHOGENESIS
Shigella
Person-to-person
transmission
 Incubation up to 7
days
 Carrier state up to
4wks

salmonella
Killed rapidly by
acidity
 Animal transmission

Common source
outbreaks
 Eggs/poultry

Incubation 24hrs
 Longer carrier state

CLINICAL MANIFESTATIONS
Shigella
salmonella
Leukemoid reaction
 Neuro symptoms
 HUS


Mild leukocytosis
 Focal infections


Reactive arthritis


Osteo in Sickle Cell Dz
HLA-B27
Typhoid fever
Salmonella typhi
 Fever, H/A, abd pain,
muscle aches, rose
spots

TREATMENT
Shigella

Treat with antibiotics
salmonella

Ceftriaxone
 Cipro
Infants <3mos
 Immune compromised
 Bacteremia


Decreased carrier
state
Treat ONLY high risk


Ceftriaxone or
ampicillin


Beware resistance!!
Increased carrier state
ROSE SPOTS OF TYPHOID FEVER
CAMPYLOBACTER
Undercooked poultry, unpasteurized milk
 Second most common documented foodborne illnesss
in US
 Watery or hemorrhagic
 Sequelae

Reactive arthritis
 Guillian-barre

YERSINIA ENTEROCOLITICA
Mimics appendicitis
 Peak in winter
 Contaminated food and water


Undercooked pork (chitterlings)
May have insidious onset
 May last up to 3 wks


Prolonged shedding 2-3 mos
Low mortality
 Sequelae

Reactive arthritis
 Erythema nodosum

VIBRO CHOLERAE
Most common Asia, Africa,
S.America
 Endemic along gulf coast

Contaminated seafood
 Reports following Katrina and Rita






Incubation 1-3 days
Sudden and severe dehydration
Rice water stools
If untreated, 50-70%mortality
within 1-2 days
Treatment
Aggressive rehydration
 Abx as adjunct

DIARRHEA

Acute infectious

Bacterial


C. Diff
 Bloody diarrhea
 Abdominal pain
 Vomiting
 Test for toxin
 Recent antibiotics
 Treat with flagyl unless <6 months
Viral
Rotavirus is leading cause worldwide
 Low grade fever, vomiting, large loose watery stools
 Adeno is second

DIARRHEA AND FEEDING
AAP Recs…
 Continue age appropriate diet


Pedialyte if dehydrated


2% glucose and 90mEq NaCl
Avoid ONLY foods high in fat and simple sugars
NO BRAT: “unnecessary starvation”
 Do not use antidiarrheal medications
