27 - Abdominal Pain, 28 - Jaundice, 29 - Nausea and Vomiting, 30 - Gastrointestinal Bleeding, 89 - Esophagus, Stomach, Duodenum, 91 - Disorders of the Pancreas, 92 - Disorders of the Small Intestine, 93 - Acute Appendicitis, 94 - Gastroenteritis, 95...

List indications for endoscopic management in intestinal FB (1)

CONSIDER if remain in same location > 1 week

What are the indications for referral to a pediatrician in an infant with GERD?

Failure to thrive

What is Henoch Scholein Purpura?

Hypersensitivity vasculitis with immune complex deposition with immunoglobulin A

Classic metabolic distubance with vomiting

Hypokalemic, hypochloremic metabolic alkalosis

What is the most common position for intussusception?

Ileocolic

Why are high bilirubin levels a concern?

Kernicterus (yellow staining of the brain)

Describe the components of the alvarado score for What is the alvarado score.

MANTRELS M igration to RLQ A norexia N /v T ENDER RLQ (2) R ebound pain E levated temp > 37.5

Name 4 reasons why kids with appendicitis are more likely to be diagnosed after perforation

Non-specific symptoms Difficulty communicating Thinner appendiceal wall Less developed omentum

What is the classic physical exam finding in pyloric stenosis?

Palpation of olive-like structure in RUQ

What is Dance's sign?

Sausage-like mass in RUQ with empty space in RLQ suggestive of intussusception

List extra-intestinal manifestations of IBD (8)

• Fever • Anemia • Oral ulcerations (aphthous) • Erythma nodosum • Pyoderma gangrenosum • Uveitis • Liver dysfunction • Failure to thrive

What is the treatment for intussusception?

• Fluid bolus • Consider NG tube if significant evidence of obstruction • Pain medication • Triple-coverage antibiotics: ampicillin + gentamycin + clindamycin/metronidazole • Surgical consultation • Contrast enema (may also be diagnostic) • Air-contrast enema

What is the management of malrotation with midgut volvulus?

• Fluid bolus • NG tube • Triple antibiotic coverage: ampicillin + gentamycin + clindamycin/flagyl • Surgical consultation

What is the management of Hirschsprung's disease?

• Fluids • Electrolyte repletion • Consider decompression with rectal tube • Triple-antibiotic coverage if enterocolitis with ampicillin + gentamycin + clindamycin/metronidazole • Surgical consult for toxic megacolon or enterocolitis

What is the management of pancreatitis in children?

• Fluids • Electrolyte repletion • Pain medication • NPO • Consult pediatrics for admission

What is the management of an IBD flare?

• Fluids • Steroids 1 mg/kg/day • Sulfasalazine • Azathioprine • Consult GI • Triple-antibiotic therapy if toxic megacolon: ampicillin + gentamycin + metronidazole • Consult surgery if toxic megacolon

List 4 ways of removing an esophageal foreign body

• Foley catheter removal • Bougie advancement • Endoscopic removal • Rigid bronchoscopy

What are the findings of intussusception on US? (2)

• Transverse view: multilayered or wrapped complex mass • Longitudinal view: tube within a tube as the ileum projects up into the cecum

What are "currant jelly" stools associated with?

• Intussusception • = mucous + blood

List complications of Meckel's diverticulum (4)

• Intussusception • Obstruction • Performation • Peritonitis

What are the TORCHS infections?

• Toxoplasmosis • Other • Rubella • CMV • HSV • Syphilis

List common locations of anal fissures. Diseases that have other locations?

6 or 12 o'clock Leukemia Crohn's Syphilis TB HIV

What is the classic finding on upper GI series for pyloric stenosis?

"String" sign: thin passage of contrast through narrowed pylorus

What percentage of patients with NEC have pneumatosis intestinalis?

75%

When do infants with pyloric stenosis present?

2 - 6 weeks old

Jaundice is usually not evident until total serum bilirubin rises above

2.5mg/dl (Page 232 of Rosen)

What kind of bilirubin is always pathologic?

Conjugated

How can you tell the difference between a button battery and coin on XR?

Double density of button battery

Describe all terms that describe the "bad" E. coli

EHEC = Shiga toxin producing E. coli = E. coli 0157:H7

List options for reducing rectal prolapse

Manual pressure/reduction Sugar Salt Prone positioning Surgery

What is the classic US finding in pyloric stenosis?

Thickened pylorus

At what bilirubin level will all infants < 28 days old be treated with phototherapy?

Total bilirubin > 340 mmol/L

At what bilirubin level will all infants < 28 days be treated with exchange transfusion?

Total bilirubin > 445 mmol/L

List an abdominal complication of IBD

Toxic megacolon

What is the imaging modality of choice in suspected pyloric stenosis?

Ultrasound

BOX 91-3: Describe Ranson's criteria for pancreatitis, non gallstone (11). Mortality?

WALLS OF CHUB At Admission WBC > 16 Age> 55 Liver enzyme AST > 250 LDH > 350 Sugar Gluc > 11 mmol/L At 48 hours pO2 < 60 mmHg Fluid Sequestration > 6L Ca <2 mmol/L Hematocrit drop > 10% Urea incr. by > 1.8 mmol/L Base deficit > 4 mEq/L **Score 0-3: 1% mortality

When should jaundice resolve?

Within 2 weeks

Discuss the use of WBC/CRP in appendicitis

• -LR 0.09 if WBC < 10 and CRP < 12 • +LR 23 if WBC > 10 and CRP > 8 • In adults (less reliable in peds) • May be a use for repeat CRP (6 hour rise ~5)

What the Meckel's diverticulum rule of 2's?

• 2% population • 2 cm wide x 2 cm long • Within 2 feet of iliocecal valve • 2% of patients become symptomatic • Half of patients symptomatic by age 2 and most by age 20

When do infants of different gestational ages at birth present with necrotizing enterocolitis?

• 24 - 28 weeks: 2 - 3 weeks of life • 29 - 32 weeks: 1 - 3 weeks of life • Full term: 1st week of life (10%)

BOX 95-6: List medications used in the treatment of IBD (6)

• 5-Aminosalicylic acid agents (5-ASA): sulfasalazine • Antibiotics: Cipro, flagyl • Corticosteroids: Prednisone • Antimetabolites: azathioprine, MTX • Immunosuppressants: cyclosporine • Anti-tumor necrosis factor antibody: infliximab

BOX 94-1: List notifiable food-borne diseases and related conditions (++)

• Botulism • Cholera • Shiga toxin producing E. coli (STEC) • HUS • Salmonellosis • Shigellosis • Thypoid fever • Vibriosis • Hepatitis A • Cryptosporidosis • Trichinosis

List causes of conjugated hyperbilirubinemia + significantly elevated transaminases (7) "1000s club"

• = Hepatocelluar or cholestatic process • Viral hepatitis (Hep A/B, HSV, VZV, EBV, CMV) • Fulminant hepatic failure • Alcoholic hepatitis • Ischemia (sepsis, hypoperfusion, arterial occlusion) • Toxins (acetaminophen, mushrooms) • Autoimmune hepatitis • HELLP syndrome

List factors increasing neurotoxicity/BBB transmission in hyperbilirubinemia (4)

• = Unconjugated hyperbilirubinemia • Hemolysis • Hypoalbuminemia • Acidemia • Drugs that bind competitively to albumin

List the diagnostic feature of spontaneous bacterial peritonitis. Treatment?

• > 250 PMNs/mm3 in ascitic fluid • Third generation cephalosporin • (leukocyte esterase positive on dip of fluid is also sensitive)

List indications for removal of GI foreign bodies once past the stomach

• ?Two magnets • Same location > 1 week

List the top 3 causes of SBO

• ABC • Adhesions • Bulge = hernia • Cancer

List risk factors for development of thrombi that may cause embolic acute mesenteric ischemia (5)

• ACS/MI • Cardiomyopathies • Ventricular aneurysms • Endocarditis • Atrial dysrhythmias (esp atrial fibrillation)

List three reasons why prophylaxis for traveller's diarrhea is not recommended (3)

• ASA related complications (pepto bismol) • Ramifications of widespread antibiotic use with resistant organisms • Highly successful treatment strategies

What is the classic triad of intussusception?

• Abdominal pain • Vomiting • Bloody stools

List features of malrotation with midgut volvulus on US (2)

• Abnormal position of the duodenal C loop and superior mesenteric artery • "Whirlpool" sign: spiraled mesentery causing echogenic twisting pattern • Not a test of choice

List the four conditions that make diverticulitis "complicated"

• Abscess • Peritonitis/perforation • Obstruction • Fistula

What is the evidence for PPI infusion in UGIB? (2)

• Accelerated resolution of signs of bleeding in ulcers • Reduces need for endoscopic therapy

List esophageal motility disorders (4)

• Achalasia • Diffuse esophageal spasm • Nutcracker esophagus • Hypertensive LES

Define acute, chronic, invasive, and noninvasive gastroenteritis

• Acute: duration < 2 weeks • Chronic: duration > 2 weeks • Invasive: mucosal invasion evidenced by fever, blood, tenesmus, significant AP • Noninvasive: no mucosal invasion (viral or toxin producing bacteria)

What is the management of cholecystitis in children?

• Admit to CTU if pain, fever, dehydration, or need for surgery • Fluids • Pain management • Triple-antibiotic therapy with ampicillin + gentamycin + clindamycin/metronidazole • Consider ursodeoxycholic acid to dissolve stone • Consult general surgery

What is the management of pyloric stenosis?

• Admit to hospital • Fluid and electrolyte replacements • Surgical consultation for pyloromyotomy

List risk factors for acute mesenteric ischemia secondary to arterial thrombosis (4)

• Advanced age • HTN • DM • Tobacco use • ?chronic mesenteric ischemia

BOX 91-4: APACHE II scoring for pancreatitis (14)

• Age • Chronic health problems • Temperature • MAP • HR • RR • PaO2 or A-a gradient • pH or serum HCO3 • Sodium • Potassium • Creatinine • Hematocrit • WBCs • GCS

What is the most common cause of intussusception in children < 5 years old versus > 5 years old?

• Age < 5 years: Peyer's patches secondary to recent URTI • Age > 5 years: Underlying lesion (HSP, Meckel's, lymphoma, polyps, celiac disease, cystic fibrosis, postsurgical scars)

List criteria for discharge home in UGIB (5)

• Age < 60 • No comorbidities • Reliable patient with access to prompt f/u • HD stable/vitals normal/no orthostasis • Normal labs: hgb, BUN, coags

List patients at higher risk for NSAID induced PUD who require consideration of co-treatment with PPI (5)

• Age > 60 • PMHx ulcer or GI bleed • High dose NSAIDs • Glucocorticoid use • Anticoagulant use

List "high risk" clinical predictors in a patient currently having a GI bleed (10)

• Age > 65 • Shock • Poor overall health • Comorbid illness • Low initial hgb level • Melena • Transfusion requirement • Fresh blood on rectal examination, in emesis, or in NG aspirate • Sepsis • Elevated urea, creatinine, or ALT

List features of malrotation with midgut volvulus on AXR (4)

• Air-fluid levels • Dilated loops overlying the liver • Paucity of small bowel gas distally • Double bubble sign (dilated stomach and obstructed proximal duodenum seen in malrotation with midgut volvulus and duodenal atresia) • NOT pneumatosis intestinalis (suggests NEC)

List risk factors for acquired megacolon (6)

• Anal fissures • Fecal impaction • Toilet training issues • Neuromuscular dysfunction (neurologic disease) • Drugs • Metabolic

List diagnostic criteria for appendicitis on US (2)

• Appendix noncompressive • Diameter > 6 - 7 mm Complete signs: Pain while scanning over appendix Enlarged, non compressible appendix (diameter > 6 - 7 mm) Target sign (fecalith in appendix) Pericecal inflammation/abscess Free fluid (ruptured appendix)

How can you distinguish maternal hgb from fetal hgb in potential GI bleed?

• Apt test • 1% sodium hydroxide to bloody stool • Fetal = pinkish red (resists oxidation) • Maternal = brown

How is the BUN useful in GI bleed? Describe.

• BUN elevated from absorption of digested blood into circulatory system during intestinal transit or from prerenal azotemia • BUN:Cr > 36 with no renal failure suggests GI bleed

BOX 89-2: List substances and conditions that damage the gastric mucosal barrier, therefore predisposing to PUD (9)

• Bile • Cigarette smoking • ETOH • Glucocorticoids • H. pylori • NSAIDs • Pancreatic secretions • Shock conditions • Stress

BOX 89-4: List causes of dysphagia (++)

• CVA • MS • Myasthenia gravis • Botulism • Tetanus • Rabies • Lead poisoning • ALS • Brain tumor • Diabetes • Parkinson's • Esophageal motility disorders (achalasia, spasm) • Esophageal rings • Esophageal strictures • Esophagitis • FB • Neoplasm • Zenker's diverticulum • EOTH • GERD

List systemic diseases associated with anorectal disease (4)

• Cancer • DM • IBD • Immunodeficiency (HIV)

Describe the major arterial blood supply to the bowel and areas they supply (3)

• Celiac trunk: distal esophagus to duodenum • SMA: distal half of duodenum to the proximal 2/3 of transverse colon • IMA: distal 1/3 transverse colon to the rectum

List indications for stool for O&P in patients with diarrhea (4)

• Chronic diarrhea > 2 weeks • Travel to developing countries • Exposure to infants in daycare • HIV+

List patient populations increasingly at risk for vibrio (5)

• Chronic liver disease • Alcoholism • AIDS • Immunideficiency states in general • Chronic disease in general

TABLE 94-3: List causes of post-colonization toxin-Induced bacterial enteritis and treatment if not supportive

• Clostridium perfringes • Vibrio (septra, azithro, cipro, doxy) • E. coli • C. diff • Aeromonas

List the most common causes of LBO (3)

• Colorectal cancer (53%) • Volvulus (17%) • Diverticuclitis (12%)

BOX 96-6: List causes of anorectal lesions in HIV+ patients (++)

• Common conditions: anal fissue, abscess, fistula, hemorrhoids, pilonidal • STDs: gonorrhea, chlamydia, herpes, chancroid, syphilis, condyloma acuminata • Infectious: TB, CMV, cryptococcosis • Neoplastic: lymphoma, Kaposi's sarcoma, SCC

What is Hirschsprung's disease?

• Congenital aganglionosis of the colon (absence of ganglion cells in the myenteric plexus of the distal colon) • Creates a functional obstruction (anus and distal colon cannot relax) • Stool accumulates proximally and produces megacolon

List the three subtypes of IBS

• Constipation-predominant • Diarrhea-predominant • Mixed pattern

List the four anatomical areas of esophageal FB entrapment and the radiologic finding

• Cricopharyngeus muscle/UES: thoracic inlet • Aortic arch: carina • Left mainstem bronchus: left mainstem bronchus • Lower esophageal spincter/GE junction: 2-4 vertebral bodies above gastric bubble

List AXR findings of NEC

• Dilated loops of bowel • Asymmetrical pattern of bowel gas with a variable degree of dilation • Pneumatosis intestinalis (intramural air) • Portal venous gas • Pneumatosis gastralis

List AXR signs of toxic megacolon (2)

• Dilation transverse colon > 6 - 7 cm • Free air (associated perforation)

List AXR findings of small bowel obstruction (5)

• Distended loops of bowel > 3 cm centrally in radiograph • Paucity of gass in large bowel • Air fluid levels on upright AXR • Free air under diaphragm on upright CXR • "String of pearls/beads": Row of air bubbles on upright AXR/decubitus

TABLE 30-1: List common causes of LGIB in adults (6)

• Diverticular disease • Angiodysplasia • Colitis (inflammatory, infectious, ischemic) • Anorectal sources • Neoplasm • Rapid UGIB

Why is antibiotic treatment contraindicated in STEC?

• Does not shorten course/eradicate organism • May increase risk of HUS (relationship unclear)

List side effects of metoclopramide (3)

• Dystonic reactions • Tardive dyskinesia • NMS

BOX 92-1: List causes of SBO (12)

• EXTERNAL, INTRINSIC, and INTRALUMINAL • Adhesions • Hernias • Masses (tumor, abscess, hematoma) • Volvulus • Neoplasms • Inflammatory (Crohn's, radiation) • Infectious (TB) • Intussusception • Traumatic (hematoma) • Bezoars • FB • Gallstones

List CT findings in appendicitis (4)

• Enlarged appendix (diameter > 6 mm) • Pericecal inflammation • Appendicolith • Periappendiceal phlegmon or abscess

List US findings of appendicitis (5)

• Enlarged, non-compressible appendix • Painful during scanning • Target sign (fecalith inside appendix) • Assocaited abscess/fluid collection • Free fluid (perforation)

What is Courvoisier's sign?

• Enlarged, palpable but painless gallbladder in the presence of jaundice • Most commonly associated with pancreatic cancer

List two indications for removal of button batteries

• Esophageal • Failure to pass gastric pylorus within 24 - 48 hours

List indications for urgent intervention in esophageal foreign body (4)

• Esophageal button battery • Sharp objects • Coins in proximal esophagus • Impactions impairing ability to handle secretions • FB or food bolus > 24 hours impaction

List indications for removal of GI foreign bodies (4)

• Esophageal foreign body (removal within 24 hours) • Gastric FB > 2 cm width • Gastric FB > 5 cm length • Sharp gastric FB (pins, razor blades) • Intestinal FB same location > 1 week • ?Two magnets • ?Button battery not passing pylorus > 24 - 48 hours • ?Symptomatic • ?Gastric > 1 month

List delayed complications of esophageal button battery impaction (4)

• Esophageal perforation • TE fistula • Exsanguination secondary to fistula development with vessel • Esophageal strictures

List findings of Hirschsprung's disease on AXR (3)

• Fecal impaction with proximal obstruction • Air-fluid levels • Dilated colon

BOX 96-5: List causes of pruritus ani (++)

• Fecal irritation dermatitis: poor hygiene, fissures, hemorrhoids, fistulas, caffeine, tea, spicy foods, citrus fruits • Contact dermatitis: anesthetic agents, topical corticosteroids, perfumed soap • Dermatologic: psoriasis, lichen sclerosus • Systemic disease: CRF, DM, thyrotoxicosis, lymphoma • Infections: syphilis, HSV, HPV, scabies, pinworm, fungal

TABLE 28-2: List critical causes of jaundice (++)

• Fulminant hepatic failure • Toxins (acetaminophen) • Viral hepatitis • Alcoholic hepatitis • Choangitis • Sepsis • Heatstroke • Obstructing AAA • Transfusion reaction • Pre-eclampsia or HELLP • Acute fatty liver of pregnancy

List the rick factors that lower the threshold of treatment for phototherapy/exchange transfusion in hyperbilirubinemia (8)

• GA < 38 weeks at birth • Isoimmune hemolytic disease • G6PD deficiency • Asphyxia • Significant lethargy • Temperature instability • Sepsis • Acidosis • Albumin < 3g/dL

List types of esophagitis (7)

• GERD • Infectious (candida, CMV, HSV, HPV) • Pill (NSAIDs, antibiotics, antivirals, KCl, ASA) • Caustic ingestion • Radiation • Sclerotherapy • Eosinophilic

What is Sandifer's syndrome?

• GERD associated extension and stiffening of the arms and legs with extension of the neck and a shrill or guttural cry +/- brief apnea and pallor as formula is refluxed into the esophagus • Occurs shortly after feeding • Usually no cyanosis

List types of heterotopic tissue in Meckel's diverticulum (4)

• Gastric* • Pancreatic • Duodenal • Endometrial

List investigation modalities in ?esophageal perforation (5). What is the test of choice?

• Gastrografin (water soluble contrast) test of choice* • CXR • Barium swallow • CT • Endoscopy

List the two most common causes of PUD. Rare but classic cause?

• H. pylori • NSAIDs • Zollinger-Ellison syndrome (gastrin-secreting tumor)

List intestinal disasters in infants

• HIDE IV • Hirschsprung's toxic megacolon • Intussusception • Duodenal atresia • Enterocolitis (necrotizing) • Incarcerated hernia • Volvulus

What are the two main complications of STEC (shiga toxin producing E. coli)?

• HUS • TTP

List three physiologic mecahnisms/categories of increased bilirubin

• Hemolysis (indirect/unconjugated) • Hepatocellular dysfunction/choletasis (direct/conjugated) • Biliary obstruction (direct/conjugated)

List risk factors for gallstones in children (5)

• Hemolytic disease (sickle cell) • CF • TPN • Sepsis • Dehydration • Ceftriaxone (sluding)

List complications of pancreatitis (5)

• Hemorrhagic pancreatitis • Necrotizing pancreatitis • Abscess formation • Pseudocysts • Fistulas

TABLE 30-3: Blatchford Score main categories (8). Interpretation?

• Hgb ≥ 130 in men, ≥ 120 in women • BUN ≤ 6.5 • sBP ≥ 110 • HR < 100 • No melena • No syncope • No hepatic disease • No heart failure • Score = 0 = low risk (d/c home) • Score > 0 = high risk (consult) • Score > 6 = 50% chance of needing intervention

BOX 95-4 + 95-5: List management options in diverticulitis (8)

• High fiber diet • Analgesia • Consider bowel rest (fluids only) • Uncomplicated, oral: Cipro 750 mg PO BID + Metronidazole 500mg PO QID OR TMP-SMX DS 1 tab BID + Metronidazole OR Amox-clav ER 1000/62.5 mg 2 tabs BID ALL FOR 7 - 10 days • Complicated, mild to moderate: Cipro 400 mg IV BID + Metronidazole 1000mg IV BID • Complicated, severe: Imipenem 500 mg IV QID • Drainage (large abscesses > 5cm) • Surgery (peritonitis/perforation, fistula)

Discuss the relationship between ALT, AST, ALP, and bili in pancreatitis

• Higher (especially ALT) = more likely gallstone etiology • ALT > 150 mmol/L = 96% specific for gallstone pancreatitis

How does the guaiac bedside test for FOB work?

• Hydrogen peroxide dripped onto guaiac paper with stool sample • Pseudoperoxidase found in hgb results in oxidative reaction that turns the paper blue

BOX 92-3: List factors associated with mesenteric venous thrombosis (causing mesenteric ischemic) (++)

• Hypercoagulable states: sickle cell, antithrombin III, Protein C/S deficiency, OCP • Inflammatory conditions: pancretitis, cholangitis, diverticulitis, appendicitis • Trauma: postsplenectomy, blunt/abdominal trauma, CHF, renal failure, portal HTN

List complications of vomiting (6)

• Hypovolemia • Metabolic alkalosis • Hypokalemia • Mallory-Weiss tear • Boerhaave's syndrome • Aspiration

BOX 91-1: List causes of pancreatitis (++)

• I GET SMASHED • Idiopathic • Gallstones* • ETOH* • Trauma* • Steroids • Mumps(infection, coxsackie)/malignancy • Autoimmune • Scorpion stings/spider bites • Hyperlipidemia/hypercalcemia • ERCP • Drugs • *Most common adults: gallstones then ETOH • *Most common peds: trauma

List uses of US in bedside evaluation of abdominal pain (7)

• Identification of IUP • Determining presence of AAA • Detection of free fluid • Identification of gallstones or dilated CBD of choledocholithiasis • Identification of ascites • Hydronephrosis indicating renal stone • IVC collapsability indicating volume status

Ddx GI bleeding in an infant

• Idiopathic • Anal fissure • Perirectal excoriation • Meckel's diverticulum • Milk protein allergy • NEC • Intussusception • Swallowed maternal blood • Gastroenteritis

List causes of pancreatitis in children (6)

• Idiopathic* • Trauma: especially handlebar • Infection: Mumps*, Influenza A, EBV, CMV, Hepatitis A and B, Rubella, Rubeola, Salmonellosis, Leptospirosis • Structural disease: Choledochal cyst, duplication cyst, anomalous bile dut, duodenal stenosis, pancreas divisum, tumor, cholelithiasis • Systemic disease: CF, glycogen storage disease, familial hyperlipidemia, alph-1-antitrypsin deficiency, sickle cell disease, SLE, Kawasaki, HUS, HSP, Crohn's disease, Reye syndrome, DM • Drugs: steroids, OCP, valproic acid, sulfasalazine, azathioprine, rifampin, metronidazole, tetracycline, thiazides, furosemide • Toxins: alcohol

List contraindications to foley balloon catheter method of removal of esophageal FB (4)

• Impaction > 1 week • Object not smooth • Evidence of perforation • Underlying structural abnormalities

List complications of appendectomy (6)

• Infection • Ileus • SBO • Pneumonia • UTI • Premature labour + fetal death in pregnancy

BOX 172-1: Indications for Workup in Jaundiced Infants (6)

• Jaundice within 24 hours of birth • Elevated conjugated/direct bilirubin • Rapidly rising serum bilirubin unexplained by history or physical exam • Total serum bilirubin level approaching exchange level or not responding to phototherapy • Jaundice persisting beyond 3 weeks of age • Sick-appearing infant

List risk factors/causes of large bowel/colon ischemia (++)

• LOW FLOW STATES • CHF • Vasoactive drugs • Atherosclerosis • Renal failure • Recent cardiac/vascular surgery • E. coli 0157:H7 • Thrombophilia • Cocaine • Collagen vascular disease • Hematologic disorders

List management options in GI bleed

• Labs: crossmatch, coags, hgb, urea • IV access and fluids • Consider blood • Correct coagulopathy with FFP • Consider plt if < 50,000 • UGIB pantoloc 80 mg IV bolus then infusion at 8 mg/hr • Varices/liver disease/ETOH: octreotide 50 mcg bolus then infusion 50 mcg/hr • Consider vasopressin • Blakemore tube • Endoscopy +/- endoscopic procedures • Angiography

How is large and small bowel differentiated on AXR?

• Large bowel: Haustra, do not cross full diameter • Small bowel: plicae circularis/valvulae conniventes cross the entire lumen

List four mechanisms by which esophageal button batteries cause damage

• Leakage of alkaline electrolyte • Pressure necrosis • Generation of external current → electrolysis of tissue fluids • Heavy metal toxicity

Ddx vomiting in the neonate (7)

• Malrotation with midgut volvulous • GERD • NEC • Pyloric stenosis • Sepsis • Meningitis • UTI

What is bilious vomiting concerning for in the neonate?

• Malrotation with midgut volvulus • (NEC also possible)

How is Meckel's diverticulum diagnosed?

• Meckel's scan (technetium scan) • CT abdomen • Laparoscopy/laparotomy

TABLE 30-2: List characteristics of patients with high risk GI bleeds (8)

• Medication use: ASA, NSAIDs, steroids, anticoagulants, chemotherapeutics • Hx PUD • Liver disease or cirrhosis • Age > 60 • Alcoholism • Current smoking • Chronic medical co-morbidities: CHF, DM, CRF, malignancy, CAD • Hx AAA graft

What is the gold standard test for mesenteric ischemia? Reality?

• Mesenteric angiography • Reality: CT angiography (NO telebrex)

List the four main categories of acute mesenteric ischemia

• Mesenteric arterial embolus (most common → SMA) • Mesenteric arterial thrombosis (prox SMA) • Nonocclusive mesenteric ischemia (vasospasm from hypoperfusion) • Mesenteric venous thrombosis (SMV; factor V leiden, etc.) • Others: SMA dissection, vasculitis

BOX 92-2: List causes of adynamic ileus/functions obstruction (5)

• Metabolic disease (hypokalemia) • Medications (narcotics) • Infection (retroperitoneal) • Abdominal trauma • Laparotomy

List physical exam/historical features with a high positive liklihood ratio for appendicitis (3)

• Migration of pain periumbilical to RLQ • RLQ tenderness • Abdominal wall rigidity

BOX 95-7: Define criteria for mild to moderate, moderate to severe, and severe Crohn's disease

• Mild to moderate: pt ambulatory/eating, no dehydration, no significant AP/mass, no toxicity, weight loss 10% • Moderate to severe (any 1 of): mild disease that fails to respond to treatment, systemic toxicity/weight loss/anemia, fever/AP/N/V • Severe: persistence of symptoms with corticosteroid or biologic therapy, high fever/persistent vomiting, obstruction, rebound tenderness, cachexia, abscess

BOX 95-7: Define criteria for mild, moderate, and severe ulcerative colitis

• Mild: < 4 BM/day, may contain blood, no systemic toxicity • Moderate: > 4 BM/day, minimal signs of toxicity • Severe: > 6 bloody BM/day, signs of systemic toxicity • Systemic toxicity: fever, tachycardia, anemia, elevated ESR

What is the treatment of appendicitis?

• NPO • IV fluids • Pain management • Triple-antibiotic therapy with ampicillin + gentamycin + clindamycin/metronidazole for high fever, suspected perforation, or delay to surgery • General surgery consult for appendectomy

List management options in appendicitis (5)

• NPO • IV hydration if needed • Analgesia • Antibiotics (ceftriazone + metronidazole) • Surgical consult for appendectomy

What is the management of NEC?

• NPO • NG • Consider intubating for anticipated clinical course • IV access • Fluids • Electrolyte repletion • Pressors (epinephrine, dopamine) • Triple-coverage antibiotics: ampicillin + gentamycin + clindamycin/metronidazole • Surgical consult • Admit to ICU

TABLE 93-2: List a differential diagnosis for appendicitis (++)

• Nonspecific AP • Gastroenteritis • Ascending diverticulitis • GB disease • IBD • Renal colic • Ovarian pathology: cyst, torsion, PID, ectopic • Childhood pathology: HSP, testicular torsion, mesenteric adenitis, Meckel's

List limitations to the use of amylase in pacreatitis (4)

• Normalizes within 3 - 7 days of onset • Uncertain source of elevation (not specific) • No fomalized "normal" level • Poor sensitivity in chronic pancreatitis, alcoholics, or hypertriglyceridemia

List limitations of use of lipase in diagnosis of pancreatitis (3)

• Not sensitive in delayed presentation: falls 8 - 14 days (but better than amylase) • Not specific for pancreatitis (present in other tissures and elevated in other conditions) • No formalized "normal" level • BL: As sensitive and more specific than amylase

List indications for endoscopic management in gastric FB (4)

• Object > 5 cm length • Object > 2.5 cm wide • Sharp/pointed FB • Consider if remain in stomach > 3 - 4 weeks

What is pseudo obstruction of large bowel called? Causes?

• Ogilvie's syndrome • Spine/retroperitoneal trauma, electrolyte disturbances, narcotics

List and describe the two types of dysphagia

• Oropharyngeal: difficulty transferring food bolus from oropharynx to proximal esophagus • Esophageal: difficulty transporting material down esophagus

List methods of removing an esophageal foreign body (6)

• Oropharynx: Direct visualization + Magill forceps • Upper esophageal, smooth FB: Foley catheter (pt prone, inflate balloon) • Lower esophagus: glucagon 1mg (relaxation of muscle)*, carbonated beverage (probably not) • Bougienage (esophageal dilator) • Flexible endoscopy • Rigid endoscopy • *may cause vomiting and too many complications

BOX 95-3: List medications used in IBS treatment (6)

• Osmotic laxatives • Antidiarrheals • Antispasmotics (anticholinergics and CCBs) • TCAs • SSRIs • Prokinetics

TABLE 30-1: List common causes of UGIB in adults (6)

• PUD (gastric > duodenal) • Gastric erosion • Esophagogastric varicies • Mallory-Weiss tears • Esophagitis • Gastric cancer

What is the classic triad of Henoch Scholein Purpura?

• Palpable purpura • Abdominal pain • Hematuria (arthritis in another chapter)

List conditions that cause elevated lipase (4)

• Pancreatitis • Bowel obstruction • Duodenal ulcers • Idiopathic

List risk factors ("main categories") for esophageal foreign body (4)

• Pediatric population • Psychiatric patients and prisoners • Underlying esophageal disease • Edentulous adults

List criteria for surgical intervention in NEC (3)

• Perforation • Peritonitis • Gangrenous bowel

TABLE 96-4: List types of anorectal abscesses (5)

• Perianal • Ischiorectal • Intersphincteric • Supralevator • Postanal

Ddx causes of intussusception

• Peyer's patches (URTI) • HSP • Meckel's • Lymphome • Polyps • Celiac disease • Cystic fibrosis • Post-surgical scars

List the two most common causes of jaundice in the newborn

• Physiologic jaundice of the newborn (60% of newborns) • Breast milk jaundice

List the two types of gallstones in childhood versus adulthood

• Pigment stones: childhood stones resulting from excess breakdown of RBCs • Cholesterol: adolescent and adult stones resulting from obeisity, OCPs, etc.

List CXR finding in esophageal perforation (5)

• Pneumomediastinum • Pleural effusion • Subcutaneous emphysema • Mediastinal widening • Pulmonary infiltrates • *within first few hours normal CXR

Treatment options in mesenteric ischemia

• Preferential fluid resuscitation • Pressors: Consider dobutamine or dopamine (less mesenteric vasocontriction) • Broad spectrum antibiotics • General surgery/vascular consult • Laparotomy for infarction/perforation/peritonitis • Consider IR for embolectomy/stent/angioplasty or thrombolytics • Non-occlusive + venous thrombosis: heparin

List risk factors for NEC (4)

• Prematurity • Aggressive enteral feedings • Birth-related hypoxic-ischemic insults • Infectious

List CT findings of diverticulitis (5)

• Presence of diverticula • Inflammation of pericolonic fat • Thickening of bowel wall ≥ 4 mm • Free abdominal air • Abscess

TABLE 89-1 and 89-2: List and example of histamine blockers and PPIs used for GERD/PUD

• Ranitidine: 150 mg PO BID • Pantoprazole: 40 mg PO qdaily (or BID)

BOX 91-5: Atlanta Criteria for predicting SEVERE pancreatitis (5)

• Ranson score ≥ 3 on admission • APACHE II score ≥ 8 at any time • Presence of organ failure (shock, renal failure) • Systemic complications (DIC, metabolic) • Presence ≥ 1 local complication (necrosis, pseudocyst, abscess) • *These are criteria for ICU admission

List risk factors for C. diff (6)

• Recent antimicrobial use • Age > 65 • Severe underlying illness • Nasogastric intubation • Use of antiulcer medications • Prolonged hospital stay

BOX 95-1: Rome III Criteria for IBS (4)

• Recurrent abdominal pain or discomfort for ≥ 3 days/month x 3 months with ≥ 2 of the following: • Improvement with defecation • Onset associated with change in stool frequency • Onset associated with change in form of stool

List false positive causes of guaiac bedside tests +FOB (6)

• Red meat • Turnips • Horseradish • Vit C • Methylene blue • Bromide preparations • (Iron and bismuth medications cause dark stools but are guaniac negative)

What is the evidence for octreotide infusion in variceal bleeds? (4)

• Reduce portal HTN • Reduce risk of persistent bleeding • Reduce risk of rebleeding • Reduce transfusion requirements

What is the evidence of high dose PPI, shown in Asian populations, in GI bleed (3)

• Reduce risk of rebleeding • Reduce need for surgery • Reduce risk of death

Describe a major difference in the management of intussusception in adults vs. kids. Why?

• Reduction with air/barium enema not desirable before surgery • Concern of spreading malignant cells

List methods of removing rectal foreign bodies

• Remove digitally with fingers • Grasp FB with forceps • Apply suprapubic pressure to assist • Patient can assist with Valsalva • Foley catheter removal • Procedural sedation • Laparotomy

List risk factors for acalculous cholesytitis in children

• Rocky Mountain Spotted Fever • Bacterial infections (esp Salmonella, Shigella)

List the two most common causes of viral gastroenteritis

• Rotavirus (children) • Norovirus (adults)

BOX 91-2: List drugs that cause pancreatitis (9)

• SAND + MR VET • Sulphasalazine • Azathioprine • NSAIDs • Diuretics • Metronidazole • Ranitidine • Valproate • Erythromycin • Tetracyclines

Describe the difference between HUS and TTP

• Same 5 features: • Micoangiopathic hemolytic anemia • Thrombocytopenia • Fever • Neurologic deficits • Renal dysfunction • TTP: neurologic symptoms predominate, usually in adults • HUS: renal dysfunction predominates, usually in kids age < 4

BOX 94-3: List current recommendations for the prevention and treatment of traveler's diarrhea

• Sensible dietary practices and drinking water management • Prophylaxis only for severe concurrent illness, immunosupression • If insist on prophylaxis, take bismuth subsalicylate (pepto bismol) • Quinolones recommended if meet criteria for prophylaxis (cipro) • If on prophylaxis and develop diarrhea, treat with cipro 750 mg

List indications for treatment of Salmonella diarrhea (7)

• Severe colitis • Age < 3 months • Age > 50 years • Immunocompromised • Sickle cell • Prothetic grafts • Public health risk

List indications for surgery in IBD (5)

• Severe disease refractory to medical management • Obstruction • Significant bleeding • Abscess • Fistula • ?Toxic megacolon

List indications for immediate exchange transfusion in hyperbilirubinemia (7)

• Signs of acute bilirubin encephalopathy o Hypertonia o Arching o Retrocolis o Opisthotonos o Fever o High-pitched cry • Total serum bilirubin > 85 mmol/L above standard treatment guideline levels

Define simple versus closed loop obstruction

• Simple: occurs at a single point • Closed loop: obstruction at two locations, creating a segment of bowel with both proximal and distal blood flow compromised

What is the management of GERD?

• Smaller, frequent feedings • Frequent burping • Thickening formula with cereal • Semi-upright position for 45 minutes after feeding • Ranitidine • Metoclopramide • Nissen fundoplication

List risk factors for pancreatic cancer (6)

• Smoking • Advanced age • High fat diet • FMHx pancreatic cancer • Chronic pancreatitis • DM

List AXR findings of intussusception (6)

• Soft tissue mass or mass effect RUQ • Obstruction (dilated bowel loops) • Target sign • Meniscus sign • Free air • Obscuration of the liver edge

List the US findings of cholecystitis (6)

• Sonographic Murphy's sign • Presence of gallstones • Distended gall bladder • Duct dilation • Thick gallbladder wall • Pericholecystic fluid

What are Bell's three stages of NEC?

• Stage I: early or suspected NEC with feeding intolerance, vomiting, or ileus • Stage II: definite NEC with AXR showing intestinal dilation and penumatosis intestinalis • Stage III: Advanced NEC with perforation

TABLE 94-3: List preformed toxin-Induced bacterial enteritis causes and treatment if not supportive

• Staphylococcus • Bacillus ceres • Emetic toxin • Diarrheal toxin • Scromboid fish poisoning • Ciguatera fish poisoning

BOX 94-2: List investigations in paients with diarrhea and AIDS (4)

• Stool culture for Salmonella, Shigella, Campylobacter, Yersinia, and STEC • Stool examination for giardia, cryptosporidium, amebas, C. diff toxin assay • Blood cultures • Proctosigmoidoscopy if severe colitis • Further: repeat cultures, scope +/ biopsies

List management options in C. diff colitis (4)

• Stop offending antibiotic (resolves in ~20%) • Mild: Metronidazole 250 mg PO QID x 10 - 14 days • Moderate/severe/failed: Vancomycin 500 mg PO QID • Avoid antimotility agents

List long term complications of NEC (3)

• Strictures (10-20%) • Fistulas • Short gut syndrome

List Meckler's triad of esophageal perforation

• Subcutaneous emphysema • Chest pain • Vomiting

What is the management of Henoch Scholein Purpura?

• Supportive care • Corticosteroids 1 mg/kg/day for severe illness • Rule out complications (intussusception) • Admit if severe abdominal pain or vomiting

List two indications for AXR in abdominal pain

• Suspected bowel obstruction • Suspected radiopaque foreign body • (Upright chest for suspected perforated viscus)

TABLE 172-1: List causes of conjugated hyperbilirubinemia

• THINK: Infectious, obstructive, metabolic/genetic • TORCHS infections • UTI • Sepsis • Listeriosis • TB • Hepatitis B • Varicella • Coxsackie infection • Echovirus infection • HIV infection • Biliary atresia • Choledochal cyst • Bile duct strictures • Inspissated bile syndrome • Neonatal hepatitis • Alagille syndrome • Byler's disease • Congenital hepatic fibrosis • Galactosemia • Tyrosinemia • Glycogen storage disease • Niemann-Pick disease • Wolman's disease • Gaucher's disease • Alpha-1-antitrypsin • Cystic fibrosis • Drugs and toxins • Parenteral nutrition

TABLE 172-1: List causes of unconjugated hyperbilirubinemia

• THINK: benign, hemolysis, infectious, obstructive, metabolic/genetic • HI MOM: hemolytic, infectious, metabolic, obstructive, miscellaneous • Physiologic jaundice of the newborn • Breast milk jaundice • Breast feeding jaundice • ABO incompatibility • Physiologic breakdown of cephalohermatoma • IVH or ICH • Spherocytosis • Sickle cell anemia • Thalassemia • Glucose-6-phosphate dehydrogenase deficiency • Pyruvate kinase deficiency • TORCHS infections • UTI • Sepsis • Meconium ileus • Hirschsprung's disease • Duodenal atresia • Pyloric stenosis • Galactosemia • Congenital hypothyroidism • Crigler-Najjar syndrome • Gilbert's syndrome

BOX 89-1: List agent/conditions related to GERD (++)

• THINK: decreased LES pressure, decreased esophageal motility, decreased gastric emptying • Drugs: anticholinergics, benzos, CCBs, nitrates • Diet: chocolate, fatty foods, peppermint • Drugs: ETOH, caffeine, smoking • Dames: progesterone, estrogen, pregnancy • Diabetes: DM, gastroparesis • Achalasia • Gastric outlet obstruction • Achalasia

List AXR findings of mesenteric ischemia (3)

• Thumbprinting • Pneumatosis intestinalis • Portal venous gas • ?Thickened bowel wall

What is the work up for newborn jaundice?

• Total, conjugated (direct), and unconjugated (indirect) bilirubin levels • CBC • Peripheral smear • Coombs test (DAT) • Glucose • Electrolytes • Ammonia

What are two complications of Hirschsprung's disease?

• Toxic megacolon • Enterocolitis

List complications of C. diff (5)

• Toxic megacolon • Shock • Relapse • Need for colectomy • Death

BOX 96-4: List causes of fecal incontinence (++)

• Traumatic: spinal cord injury, sphincter injury • Neurologic: spinal cord lesions, dementia, Hirschsprung's • Mass effect: anal carcinoma, FB, fecal impaction • Medical: diarrhea, laxative abuse • Pediatric: spina bifida, sexual abuse, encopresis

What is the imaging modality of choice in suspected malrotation with midgut volvulus and what does it show (2)?

• Upper GI series with small bowel follow through • Shows abnormal positioning of the duodenal C loop to the right of the spinal column • Shows corkscrew appearance of small bowel

List the four most common areas for esophageal foreign bodies

• Upper esophageal sphincter (cricopharyngeous muscle) • Thoracic inlet (C6 - T1) • Aortic arch/tracheal bifurcation (T4 - T6) • Lower esophageal sphincter/diaphragmatic hiatus (T10 - T11)

List the mechanisms for upper/mid versus distal esophageal perforation and their associated CXR findings

• Upper/mid: blunt trauma: pneumomediatinum and R plerual effusion • Distal: spontaneous: L pleural effusion

List investigation modalities for H. pylori (4)

• Urea breath test • Biopsy during endoscopy • Serum antibody testing • Stool antigen testing

Describe visceral, somatic, and referred pain

• Visceral pain: stimulation of autonomic nerves in peritoneum and surrounding organs; poorly localized • Somatic pain: irritation of parietal peritoneum; localized • Referred pain: peripheral afferent nerve fibers; pain distant from source

List risk factors for esophageal rupture (9)

• Vomiting (Boerhaave's) • Valsalva maneuver • NG tube placement • Endotracheal intubation • FB ingestion • Caustic substance ingestion • Severe esophagitis • Carcinoma • Trauma

BOX 96-3: List treatment options for anal fissures (6)

• WASH regimen (warm water, analgesia, stool softeners, high fiber diet) • Nitroglycerin ointment 0.4% TID • Nifedipine 0.2% gel BID with 1.5 % lidocaine • Botulinum toxin • Anal dilation • Surgical excision

Describe the four elements of the WASH regimen for management of hemorrhoids

• Warm water • Analgesic agents • Stool softeners • High fiber diet

List criteria for discharge home in LGIB (5)

• Young and reliable patient • HD stable/vitals normal • No coagulopathy • No significant risk factors/comorbities • Bleeding source clearly visualized • ?????????STUPID