NSG6435 Final Questions and Answers
Rated A
GER ✔✔uncomplicated recurrent spitting & vomiting in healthy infants that resolves
spontaneously
GERD ✔✔: is present when reflux causes secondary symptoms or complications
GERD Test ✔✔UGI when anatomic etiologies of recurrent vomiting are considered, but should
not be considered to be a test for
GER and GERD pharmacotherapy ✔✔•There is no sufficient evidence to support the use of
prokinetic agents for GERD Rx
•Medications are usually not recommended unless pathologic GER has been demonstrated
EOE ✔✔•Occurs in all ages, most frequently ♂
•Initial presentation feeding dysfunction & vague nonspecific S/S GERD -abd. pain, vomiting &
regurgitation
•History
-Personal & FMH atopy, asthma, dysphagia, heartburn, feeding dysfunction, or food impaction
-Young children- lengthy chewing, long mealtimes, washing food down w liquids & avoiding
highly textured foods
-Adolescents - solid food dysphagia, acute & recurrent food impactions
•Suspect EoE when S/S unresponsive to Rx
Most common complications: esophageal food impaction and stricture
EOE treatment ✔✔-Fluticasone BID puffed in the mouth and swallow, do not rinse mouth for 30
minutes
,H. Pylori treatment ✔✔-: 7-10 days Amoxil + clarithromycin + PPI. Be aware of abx. resistance
to biaxin, if so consider metronidazole, imidazole levofloxacin
•Sequential Rx for Biaxin resistance: Amoxil + PPI x5 days, then Biaxin+Flagyl+PPI x 5 days
Intussusception treatment ✔✔•Reduction should not be attempted if signs of strangulated bowel,
perforation or toxicity present -surgery is required.
Acute appendicitis ✔✔•Incidence of perforation high (40%) esp. younger kids (<2 y/o) -pain is
poorly localized & S/S are nonspecific-high fever perforation very high
Acute appendicitis PE ✔✔-Peri-umbilical pain at palpation, initially
-+ McBurney's point tenderness
-+ Rovsing's sign: palpation LLQ ↑ pain in RLQ
-+ Psoas sign: passively extending thigh of pt. lying on side w knees extended (or flexing thigh at
the hip) ↑ pain
-+ Obturator sign: while child lies on back with hip & knee flexed at 90 degrees , examiner rotates
the hip by moving the patient's ankle away from the patient's body while allowing the knee to
move only inward. This is flexion and internal rotation of the hip.
-+ Reboundness: not always reliable & very painful for child
Celiac Disease, who to test? ✔✔•Screening is recommended for patients with suggestive
symptoms, and also for children in groups at ↑risk for having the disease, regardless of symptoms.
•***Screening of asymptomatic patients who do not have risk factors is not generally
recommended. ***
•North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition
(NASPGHAN) recommend serologic screening to be performed in children with the classic
clinical features and high-risk groups, provided they are on a gluten-containing diet
CD clinical presentation ✔✔•Classic clinical features of patients with celiac disease include
symptoms of malabsorption such as diarrhea, steatorrhea, and weight loss.
,•Other GI symptoms may include abdominal pain, flatulence, abdominal distension, and
paradoxical constipation
•Many patients with celiac disease have non-gastrointestinal manifestations, in addition to or
instead of GI symptoms.
•The most specific non-gastrointestinal manifestation is dermatitis herpetiformis
CD Diagnostics ✔✔Most valuable test is for immunoglobulin A (IgA) antibodies against tissue
transglutaminase (tTG-IgA),
-Testing should be performed while on a gluten-containing diet.
-Individuals previously started on a gluten-free diet without prior testing should resume a diet
containing ideally at least 3 g gluten/day (equivalent to about one slice of bread daily) for at least
6- weeks before undergoing antibody testing, although the duration and amount of gluten required
for diagnostic accuracy has not been fully clarified
•Antiendomysial antibodies (EMA) is as accurate as tTG-IgA, yet is more expensive and
somewhat dependent on operator interpretation.
-EMA is typically used as a second-line test, to clarify the diagnosis in patients with equivocal
results of tTG-IgA, including asymptomatic members of a high-risk group
-EMA is an immunofluorescence test for IgA antibodies to endomysium, a structure of the smooth
muscle connective tissue
•Deamidated gliadin peptide (DGP) also has good diagnostic accuracy and may be particularly
useful for young children; this is a second-generation antigliadin antibody test.
•Standard (first-generation) IgA or immunoglobulin G (IgG) antigliadin antibodies are
considerably less reliable and are not recommended.
•Tests of antireticulin antibodies have reasonably high specificity, but lower sensitivity, and are
no longer commonly used.
Congenital Aganglionic Megacolon:Hirschsprung Disease ✔✔•Failure to pass meconium stool
within 24-48hours after birth
•Ominous signs: fever, lethargy, bloody diarrhea
Ecopresis ✔✔•Consistency of stools will vary from normal to pellet like stools to liquid
, Mild Constipation ✔✔•DO NOT GIVE MINERAL OIL TO NONAMBULATORY PEDS OR
BED-BOUND OR GER Hx
Acute watery diarrhea ✔✔•the main danger is dehydration
Dehydration management ✔✔•Supportive treatment
•Replacement of fluid & electrolytes deficits
-ORT with Pedialyte is best; can continue breastfeeding
-CLD or hypocaloric (diluted formula) diet for more than 48hrs IS NOT ADVISABLE
•Early initiation of refeeding is recommended
•BRAT diet initially- controversial
•Lactose-free diet associated with shorter period of diarrhea but is not critical to successful
recovery in healthy infants
•Reduced-fat during recovery may ↓ N/V
•Antibiotics only for culture proven bacterial/parasitic infection.
•Antidiarrheal medications (kaolin-pectin combo) are ineffective & in some circumstance can be
dangerous (particularly loperamide, tincture of opium, diphenoxylate with atropine)
•Bismuth subsalicylate preparations may reduce stool volume but are not critical to recovery and
are NOT RECOMMENDED due to salicylate component & risk of Reye syndrome
•Close surveillance/observation: refer to be admitted if mod. or severe rehydration not responding
to ORT
•Parental reassurance
Chronic Diarrhea ✔✔diarrhea >14 days
Abdominal pain treatment ✔✔-REASSURANCE, REASSURANCE, REASSURANCE...
REASSURANCE...
Acute Abdomen ✔✔•Timely & accurate Dx critical
Rated A
GER ✔✔uncomplicated recurrent spitting & vomiting in healthy infants that resolves
spontaneously
GERD ✔✔: is present when reflux causes secondary symptoms or complications
GERD Test ✔✔UGI when anatomic etiologies of recurrent vomiting are considered, but should
not be considered to be a test for
GER and GERD pharmacotherapy ✔✔•There is no sufficient evidence to support the use of
prokinetic agents for GERD Rx
•Medications are usually not recommended unless pathologic GER has been demonstrated
EOE ✔✔•Occurs in all ages, most frequently ♂
•Initial presentation feeding dysfunction & vague nonspecific S/S GERD -abd. pain, vomiting &
regurgitation
•History
-Personal & FMH atopy, asthma, dysphagia, heartburn, feeding dysfunction, or food impaction
-Young children- lengthy chewing, long mealtimes, washing food down w liquids & avoiding
highly textured foods
-Adolescents - solid food dysphagia, acute & recurrent food impactions
•Suspect EoE when S/S unresponsive to Rx
Most common complications: esophageal food impaction and stricture
EOE treatment ✔✔-Fluticasone BID puffed in the mouth and swallow, do not rinse mouth for 30
minutes
,H. Pylori treatment ✔✔-: 7-10 days Amoxil + clarithromycin + PPI. Be aware of abx. resistance
to biaxin, if so consider metronidazole, imidazole levofloxacin
•Sequential Rx for Biaxin resistance: Amoxil + PPI x5 days, then Biaxin+Flagyl+PPI x 5 days
Intussusception treatment ✔✔•Reduction should not be attempted if signs of strangulated bowel,
perforation or toxicity present -surgery is required.
Acute appendicitis ✔✔•Incidence of perforation high (40%) esp. younger kids (<2 y/o) -pain is
poorly localized & S/S are nonspecific-high fever perforation very high
Acute appendicitis PE ✔✔-Peri-umbilical pain at palpation, initially
-+ McBurney's point tenderness
-+ Rovsing's sign: palpation LLQ ↑ pain in RLQ
-+ Psoas sign: passively extending thigh of pt. lying on side w knees extended (or flexing thigh at
the hip) ↑ pain
-+ Obturator sign: while child lies on back with hip & knee flexed at 90 degrees , examiner rotates
the hip by moving the patient's ankle away from the patient's body while allowing the knee to
move only inward. This is flexion and internal rotation of the hip.
-+ Reboundness: not always reliable & very painful for child
Celiac Disease, who to test? ✔✔•Screening is recommended for patients with suggestive
symptoms, and also for children in groups at ↑risk for having the disease, regardless of symptoms.
•***Screening of asymptomatic patients who do not have risk factors is not generally
recommended. ***
•North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition
(NASPGHAN) recommend serologic screening to be performed in children with the classic
clinical features and high-risk groups, provided they are on a gluten-containing diet
CD clinical presentation ✔✔•Classic clinical features of patients with celiac disease include
symptoms of malabsorption such as diarrhea, steatorrhea, and weight loss.
,•Other GI symptoms may include abdominal pain, flatulence, abdominal distension, and
paradoxical constipation
•Many patients with celiac disease have non-gastrointestinal manifestations, in addition to or
instead of GI symptoms.
•The most specific non-gastrointestinal manifestation is dermatitis herpetiformis
CD Diagnostics ✔✔Most valuable test is for immunoglobulin A (IgA) antibodies against tissue
transglutaminase (tTG-IgA),
-Testing should be performed while on a gluten-containing diet.
-Individuals previously started on a gluten-free diet without prior testing should resume a diet
containing ideally at least 3 g gluten/day (equivalent to about one slice of bread daily) for at least
6- weeks before undergoing antibody testing, although the duration and amount of gluten required
for diagnostic accuracy has not been fully clarified
•Antiendomysial antibodies (EMA) is as accurate as tTG-IgA, yet is more expensive and
somewhat dependent on operator interpretation.
-EMA is typically used as a second-line test, to clarify the diagnosis in patients with equivocal
results of tTG-IgA, including asymptomatic members of a high-risk group
-EMA is an immunofluorescence test for IgA antibodies to endomysium, a structure of the smooth
muscle connective tissue
•Deamidated gliadin peptide (DGP) also has good diagnostic accuracy and may be particularly
useful for young children; this is a second-generation antigliadin antibody test.
•Standard (first-generation) IgA or immunoglobulin G (IgG) antigliadin antibodies are
considerably less reliable and are not recommended.
•Tests of antireticulin antibodies have reasonably high specificity, but lower sensitivity, and are
no longer commonly used.
Congenital Aganglionic Megacolon:Hirschsprung Disease ✔✔•Failure to pass meconium stool
within 24-48hours after birth
•Ominous signs: fever, lethargy, bloody diarrhea
Ecopresis ✔✔•Consistency of stools will vary from normal to pellet like stools to liquid
, Mild Constipation ✔✔•DO NOT GIVE MINERAL OIL TO NONAMBULATORY PEDS OR
BED-BOUND OR GER Hx
Acute watery diarrhea ✔✔•the main danger is dehydration
Dehydration management ✔✔•Supportive treatment
•Replacement of fluid & electrolytes deficits
-ORT with Pedialyte is best; can continue breastfeeding
-CLD or hypocaloric (diluted formula) diet for more than 48hrs IS NOT ADVISABLE
•Early initiation of refeeding is recommended
•BRAT diet initially- controversial
•Lactose-free diet associated with shorter period of diarrhea but is not critical to successful
recovery in healthy infants
•Reduced-fat during recovery may ↓ N/V
•Antibiotics only for culture proven bacterial/parasitic infection.
•Antidiarrheal medications (kaolin-pectin combo) are ineffective & in some circumstance can be
dangerous (particularly loperamide, tincture of opium, diphenoxylate with atropine)
•Bismuth subsalicylate preparations may reduce stool volume but are not critical to recovery and
are NOT RECOMMENDED due to salicylate component & risk of Reye syndrome
•Close surveillance/observation: refer to be admitted if mod. or severe rehydration not responding
to ORT
•Parental reassurance
Chronic Diarrhea ✔✔diarrhea >14 days
Abdominal pain treatment ✔✔-REASSURANCE, REASSURANCE, REASSURANCE...
REASSURANCE...
Acute Abdomen ✔✔•Timely & accurate Dx critical
