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GI B OARD R EVIEW December 16, 2010. I NFANT N UTRITION Breast milk ideal Supplements: Vitamin D 400IU/day Fluoride (exclusive breast feeding may require.

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Presentation on theme: "GI B OARD R EVIEW December 16, 2010. I NFANT N UTRITION Breast milk ideal Supplements: Vitamin D 400IU/day Fluoride (exclusive breast feeding may require."— Presentation transcript:

1 GI B OARD R EVIEW December 16, 2010

2 I NFANT N UTRITION 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

3 Q UESTION 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

4 M ALNUTRITION Explore diet and eating habits Formula Type, quantity, how it is mixed Older Children Food intake, preferences, avoidances Plot BMI

5 E XTREME M ALNUTRITION Marasmus Caloric deficiency Emaciation Hypothermia and bradycardia late Kwashiorkor Protein deficiency Edema Hepatomegaly, AMS Marasmic-kwashiorkor

6 Q UESTION 2 Which of the following electrolyte abnormalities may be seen in refeeding syndrome? A. Hyperkalemia B. Hypercalcemia C. Hypophosphatemia D. Hypoglycemia E. Hypermagnesemia

7 N UTRITION Low weight for height Acute Failure to Thrive Diminished height (and wt) for age Chronic undernutrition Refeeding syndrome Hypophosphatemia Hypokalemia Hypomagnesemia Hypocalcemia Glucose intolerance


9 B1 (T HIAMINE ) Beri Mental confusion Peripheral paralysis Muscle weakness Tachycardia Cardiomegaly

10 B2 (R IBOFLAVIN ) Stomatitis (angular) Anemia Dermatitis (seborrheic) Infants on prolonged phototherapy at risk

11 B3 (N IACIN ) 3D’s of B3 Dermatitis Diarrhea Dementia Glossitis Toxicity results in vasodilation

12 B9 (F OLATE ) Large tongue and macrocytic anemia Neural tube defects When folate given for macrocytic anemia, may mask B12 deficiency

13 B12 (C YANOCOBALAMIN ) Macrocytic anemia Pernicious anemia Poor absorption (decreased intrinsic factor)

14 V IT C ( ASCORBIC ACID ) Scurvy Bleeding gums Leg tenderness Poor wound healing Toxicity Nephrocalcinosis Hemolysis in G6PD


16 V IT A (R ETINOL ) 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

17 V IT E ( TOCOPHEROL ) Hemolytic anemia in preemies Neuro changes Neuropathies Absent DTRs Ataxia Weakness

18 V IT K ( PHYLLOQUINONE ) Hemorrhagic disease of the newborn Breast fed babies Factors 2,7,9,10 Prolonged PT


20 H ELICOBACTER 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

21 P ANCREATITIS 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

22 I NTUSSUSCEPTION 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%

23 C ONSTIPATION 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

24 Q UESTION 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. Rectal suction biopsy B. Unprepped barium enema C. Prepped barium enema D. Endoscopy E. Upper GI with small bowel follow through

25 H IRSCHSPRUNG DISEASE Constipation from early infancy Unprepped barium enema Transition zone Rectal bx for ganglion cells


27 P YLORIC STENOSIS Narrowing of pyloric channel Secondary to hypertrophy of musculature Unknown etiology Erythromycin Presentation 3-5 weeks Forceful, projectile, nonbilious vomiting Persistent hunger Constipation Dehydration Unconjugated hyperbili

28 P YLORIC STENOSIS Physical Exam Peristaltic wave Olive Lab finding Hypokalemic, hypochloremic metabolic alkalosis Diagnosis US Near 100% sensitivity and specificity

29 P YLORIC STENOSIS Diagnosis US Near 100% sensitivity and specificity UGI “string sign” Treatment Pyloromyotomy

30 Q UESTION 4 The diagnostic approach to a child with symptoms typical of uncomplicated GER is: A. Barium swallow and pH probe B. Barium swallow C. No investigation D. pH probe E. Subspecialty consultation

31 R EFLUX GER Passage of contents into the esophagus GERD Symptoms and complications Symptoms Vomiting Poor weight gain Substernal chest pain Abdominal pain Dysphagia Esophagitis Respiratory disorders

32 REFLUX GER Common Usually self-limited Disappears by 1 to 2 years of age GERD Growth failure Aspiration Esophagitis Hemorrhage Apnea Sandifer syndrome RARE

33 REFLUX Diagnosis Based clinically UGI Does not diagnose reflux! Anatomic abnormalities pH probe Correlates symptoms with episodes Esophagoscopy Assess esophageal injury

34 REFLUX Therapy Frequent small feedings Upright position? Prone?? Thickened feeds 1 tablespoon/ounce H2 blockers PPIs Prokinetics Controversial Nissen

35 I NTESTINAL 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

36 I NTESTINAL 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


38 Q UESTION 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

39 D IARRHEA 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

40 DIARRHEA Stool Examination Reducing substances Unabsorbed sugar Stool pH Low (<5) in carbohydrate maldigestion and malabsorption Fat Malabsorption Fecal leukocytes Infection or inflammation Ova and parasites Parasitic pathogens Stool culture Bacterial pathogens

41 E.C OLI D IARRHEA 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

42 E.C OLI D IARRHEA Enteroinvasive E.coli Closely related to Shigella Clinical course nearly identical to Shigella

43 E.C OLI D IARRHEA Enterohemorrhagic E.coli (O157:H7) Undercooked ground beef Reported in apple cider/ raw vegetables Summer months Shiga toxin-positive Bloody diarrhea Hemolytic uremic syndrome

44 P ATHOGENESIS 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

45 C LINICAL M ANIFESTATIONS Shigella Leukemoid reaction Neuro symptoms HUS salmonella Mild leukocytosis Focal infections Osteo in Sickle Cell Dz Reactive arthritis HLA-B27 Typhoid fever Salmonella typhi Fever, H/A, abd pain, muscle aches, rose spots

46 T REATMENT Shigella Treat with antibiotics Ceftriaxone Cipro Decreased carrier state salmonella Treat ONLY high risk Infants <3mos Immune compromised Bacteremia Ceftriaxone or ampicillin Beware resistance!! Increased carrier state


48 C AMPYLOBACTER Undercooked poultry, unpasteurized milk Second most common documented foodborne illnesss in US Watery or hemorrhagic Sequelae Reactive arthritis Guillian-barre

49 Y ERSINIA 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

50 V IBRO 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

51 D IARRHEA 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

52 D IARRHEA 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

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