Carbohydrate malabsorption is indicated by all the following except:
A. stool reducing substance
B. stool acid pH
C. resolution of diarrhea with elimination of carbohydrates from diet
D. breath hydrogen less than 20 parts per million
E. positive clinitest
(D) Carbohydrate malabsorption results in a positive clinitest due to excess reducing substances in the stool, and breath hydrogen is elevated.
The minimal fluid intake recommended for a 6-month-old infant with mild diarrhea is:
A. 300 mL/kg/24 hr
B. 75 mL/kg/24 hr
C. 150 mL/kg/24 hr
D. 50 mL/kg/24 hr
E. 500 mL/kg/24 hr
(C) The minimum amount is 150 mL/kg/24 hr, and 300 mL/kg/24 hr would be unusual.
Hypernatremic dehydration associated with oral fluid therapy for treatment of acute diarrhea is usually the result of:
A. intake of insufficient volume of fluid
B. use of oral fluids with sodium concentrations of 80 to 90 mEq/L
for initial rehydration
C. oliguria secondary to hypovolemia
D. salt-retaining bacterial toxin
E. use of oral fluids with sodium concentrations of 40 to 60 mEq/L
for maintenance and for replacement of ongoing losses
(A) Infants have a limited renal ability to conserve water. Fever, high environmental temperatures, and hyperventilation all add to the amount of fluid loss that needs to be replaced. The amount of salt in choices B and E is not excessive and would not result in hypernatremic dehydration.
Signs of severe dehydration include each of the following except:
A. rapid feeble pulse
B. very sunken fontanelle
C. absent tears
D. skin pinch retracts very slowly
E. 5% body weight loss
(E) Severe dehydration involves a 10% or greater loss in body weight.
Which of the following statements regarding the stools of a child with “toddler’s diarrhea” is false?
A. They number four to six per day
B. They are often explosive
C. They are usually watery
D. They frequently are bloody
E. They may contain particles of undigested food, such as corn
kernels
(D) This syndrome usually begins at about 6 months and ceases between 3 or 4 years of age. Bloody stool is against the diagnosis.
Toddler’s diarrhea in children is associated with:
A. steatorrhea
B. protein malabsorption
C. growth failure
D. pathogenic bacteria in the stools
E. spontaneous remission
(E) These children grow normally despite recurrent bouts of loose stools. Spontaneous remissions at age 3 to 4 years are the rule.
The treatment for toddler’s diarrhea in a 2-year old is:
A. low-fat diet
B. milk-free diet
C. low-residue diet
D. low-carbohydrate diet
E. normal diet for age with relatively high fat content
(E) Dietary modifications are unnecessary, are potentially harmful, and lead to nutritionally unbalanced diets and unnecessary parental concern.
Features of functional abdominal pain include all the following except:
A. periumbilical and poorly localized
B. intermittently crampy
C. absence of associated diarrhea
D. never associated with nighttime awakening
E. occurs with and shortly after meals
(D) Although patients awakened by pain at night often have organic pathology, children with functional abdominal pain often seek attention in the middle of the night.
The major organic cause for recurrent abdominal pain in children is:
A. peptic ulcer
B. regional enteritis
C. Meckel’s diverticulum
D. urinary tract disease
E. Hirschsprung’s disease
(D) Every patient with the complaint of recurrent abdominal pain deserves urinalysis.
The most common type of congenital esophageal malformation (Fig. 1) is:
A. esophageal atresia with distal tracheoesophageal fistula
B. esophageal without fistula
C. tracheoesophageal fistula without atresia
D. esophageal atresia with proximal tracheoesophageal fistula
E. esophageal atresia and both proximal and distal tracheo-esophageal fistula
Fig. 1: Anatomy of major types of tracheoesophageal malformation in newborns.
(A) This variety accounts for about 86% of all cases.
An infant with the most common type of congenital esophageal malformation will present with all the following symptoms except
A. coughing
B. choking with feedings
C. excessive oral secretions
D. gasless abdomen
E. cyanosis associated with feeding
(D) The distal tracheoesophageal fistula allows large quantities of air into the gastrointestinal tract.
Features common in patients with Crohn’s disease include all the following except
A. delayed growth.
B. abdominal pain and diarrhea
C. normal sexual maturation
D. involvement of the terminal ileum in over 60% of cases
E. arthralgias
(C) Growth failure is common in children with inflammatory bowel disease and is usually accompanied by delayed skeletal and sexual maturation. Arthralgia occurs in 35% of children with inflammatory bowel disease.
Therapy directed at patients with Crohn disease should include:
A. early surgical intervention via resection of the gut with disease
B. megavitamin therapy
C. corticosteroid therapy
D. routine high-dose potassium supplementation
E. high-fiber diet
(C) Corticosteroid therapy is eventually required for most patients and is useful in control of the disease. Megavitamin therapy is of no proven benefit. Surgical intervention is restricted to specific complications.
All of the following are features of the clinical course of ulcerative colitis except:
A. diarrhea and abdominal pain are the most common presenting features
B. barium enema is always diagnostic at the onset of symptoms.
C. anemia is common
D. sulfasalazine is 80% effective in controlling symptoms in mild
ulcerative colitis
E. colectomy
(B) Barium enema may appear entirely normal for periods of up to 2 to 3 years after onset of disease.
All the following are true concerning intussusception except
A. it usually affects infants in the first 2 years of life
B. a local lesion is usually found as a cause
C. most cases begin at or near the ilecocecal valve
D. males are more frequently affected than females
E. a stool mixed with blood and mucus is often passed
(B) A cause is rarely clear. An identifiable cause is more likely (2 to 8%) in older children.
The signs and symptoms of intussusception may include all the following except
A. the infant is well nourished and hydrated
B. attacks of colicky pain recurring regularly with intervals in which
the infant is in no distress
C. the presence of blood and mucus in the stools
D. vomiting rarely occurs as an initial symptom
E. abdominal pain is a frequent presenting complaint
(D) Vomiting is often a prominent symptom, often starting shortly after the first episodes of abdominal pain. Initially, emesis may be nonbilious, but it often becomes bilious as the obstruction progresses. the infant is well nourished and hydrated at the beginning of illness though may be dehydrated if not diagnosed early.
Which of the following statements is true regarding the treatment of intussusception?
A. Treatment should be delayed for 4 to 6 hours owing to the high
incidence of spontaneous reduction
B. Recurrence is not more common after hydrostatic pressure
reduction than operative reduction
C. Hydrostatic pressure reduction is the method of choice
D. Distention is an absolute contraindication for hydrostatic pressure
reduction
E. Rupture of bowel is frequently a complication of hydrostatic
pressure reduction
(C) Hydrostatic pressure reduction is the method of choice because discomfort is less than with surgery. The complications in the absence of anesthesia are fewer, and the period of hospitalization is much shorter. Intussusception recurs in 10 to 20 percent of children after successful nonoperative reduction while only 1% after surgical management. perforation of the bowel, which occurs in 1 percent or fewer patients, Risk factors for perforation include age younger than six months, long duration of symptoms (eg, three days or longer), and evidence of small bowel obstruction; use of higher pressures during the reduction is a contributing factor in some patients
Concerning benign polyps of the gastrointestinal tract (GI) tract, which of the following is false?
A. Most common intestinal tumor
B. Usually occurs in the colon
C. Most frequent symptom is bleeding
D. Bleeding is usually profuse
E. Blood is generally bright red
(D) Rarely is bleeding from benign polyps profuse. The blood may be mixed with the stool or be present on the surface of the stool.
All of the following metabolic alterations can occur in pyloric stenosis except:
A. hypokalemia
B. hypochloremia
C. decreased serum pH
D. dehydration
E. alkalosis
(C) Pyloric stenosis usually results in hypochloremic alkalosis. This can be corrected by the administration of fluids containing sodium and potassium.
All the following may be features of pyloric stenosis except:
A. it is more common in males
B. it usually becomes symptomatic in the first month of life
C. initially there is nonprojectile vomiting
D. vomitus is bile stained
E. failure to thrive
(D) The vomitus is not bile stained in pyloric stenosis.
Which of the following statements concerning congenital high intestinal obstructions is false?
A. Vomiting may be persistent if there is no feeding of the infant
B. Polyhydramnios is a frequent accompaniment
C. Meconium stools may be passed initially
D. Vomitus is usually bile stained
E. Gross abdominal distention is usually present
(E) High intestinal obstruction (usually below the ampulla of Vater) presents with persistent vomiting, usually bile stained, and absence of gross distention.
All the following statements are true of intestinal occlusions present at birth except:
A. stenosis is more common than atresia
B. the ileum is the site of 50% of the lesions
C. infants with Down syndrome have an increased incidence of
duodenal atresia
D. in about 15% of infants, multiple intestinal occlusions occur
E. symptoms may or may not be present at birth
(A) Atresia is the more common lesion. Symptoms may be delayed to an indeterminate length of time if the obstruction is incomplete.
All the following are true concerning Meckel’s diverticulum except:
A. it occurs in 2 to 3% of all persons
B. mucosal lining may be gastric, and this is the type most likely to
produce symptoms
C. symptoms most commonly occur in the first 2 years of life
D. mucosal lining may be gastric, ileal, or pancreatic
E. acute painful hemorrhage is the most common symptom
(E) Bleeding is the most common symptom, but it is not accompanied by pain. Bleeding is usually acute but may be intermittent and recurrent.
The absence of ganglion cells of the intramural and submucous plexuses of the colon may be manifest by all the following except:
A. severe enterocolitis in the neonate
B. 80% of patients have the lesion confined to the rectosigmoid area
C. a patient who fails to thrive
D. history of constipation and abdominal distention from early
infancy
E. large stools and fecal soling are common symptoms in children
more than 5 years of age
(E) The stools of the older infant or child may have a consistency of small pellets, be ribbon-like, or have a fluid consistency. Large stools and fecal soiling are typical of the patient with functional constipation.
Papular acrodematitis is associated with:
A. hepatitis A
B. hepatitis B
C. hepatitis of any viral etiology
D. alcoholic hepatitis
E. 1-antitrypsin deficiency
(B) Gianotti-Crosti syndrome is associated with hepatitis B.
All of the following are symptoms characteristic of the early phase of hepatitis A except:
A. fever
B. malaise
C. anorexia
D. jaundice
E. nausea and vomiting
(D) All the other symptoms usually occur 4 to 5 days before the onset of jaundice.
Which of the major nutrients is less likely to have decreased absorption during diarrhea?
A. Fat
B. Monosaccharides
C. Protein
D. Starch
E. Disaccharides
(C) There is minimal or no protein malabsorption in acute infectious diarrhea.
DIRECTIONS: This section consists of five lettered headings followed by a list of numbered words, phrases, or statements. For each numbered word, phrase, or statement, select the one lettered heading that is most closely associated with it. Each lettered heading may be selected once, more than once, or not at all.
Questions 28-33:
A. Esophageal atresia
B. Pyloric stenosis
C. Achalasia
D. Duodenal atresia
E. Intussusception
High incidence in Down syndrome
A. Esophageal atresia
B. Pyloric stenosis
C. Achalasia
D. Duodenal atresia
E. Intussusception
(D) there is a high incidence of duodenal atresia in Down syndrome
Bloody stool may be seen
A. Esophageal atresia
B. Pyloric stenosis
C. Achalasia
D. Duodenal atresia
E. Intussusception
(E) Bloody stool is common.
Surgery is usually not indicated
A. Esophageal atresia
B. Pyloric stenosis
C. Achalasia
D. Duodenal atresia
E. Intussusception
(C) Achalasia is not considered a surgical problem.
Passage of radiopaque catheter is usually diagnostic
A. Esophageal atresia
B. Pyloric stenosis
C. Achalasia
D. Duodenal atresia
E. Intussusception
(A) Esophageal atresia can be diagnosed by the passage of a radiopaque catheter.
More frequent in male infants
A. Esophageal atresia
B. Pyloric stenosis
C. Achalasia
D. Duodenal atresia
E. Intussusception
(B) Pyloric stenosis is seen more commonly in males.
Barium enema is indicated if there is no intestinal perforation
A. Esophageal atresia
B. Pyloric stenosis
C. Achalasia
D. Duodenal atresia
E. Intussusception
(E) This procedure can be curative and is indicated if perforation has not occurred
A 2-year-old boy without significant medical history developed emesis and intermittent abdominal pain yesterday, with several small partially formed stools. His parents were not overly con-cerned, as the child seemed fine between the episodes of pain. Today, however, the child has developed persistent bilious eme¬sis and has had several bloody stools. The examination reveals a lethargic child in mild distress that is tachycardic and febrile. The abdominal examination reveals a diffusely tender abdomen with a vague tubular mass in the right upper quadrant. The next step in managing this condition should be:
A. IV antibiotics for Shigella
B. Computerized tomography of the abdomen
C. Parental reassurance
D. Contrast enema
E. Stool cultures
D. This child has an intussusception. Although the child has bloody stools, the child also has bilious emesis, colicky abdom¬inal pain, and a tubular or “sausage-shaped” mass in the right upper quadrant. A contrast enema may be diagnostic as well as therapeutic when performed by an experienced radiologist A surgeon and a prepared operating room must be available if the attempt of reduction via contrast enema fail or result into intestinal perforation
A 14-year-old girl with a 3-day history of abdominal pain, anorexia, and vomiting, and a I-day history of fever, underwent laparoscopic surgery for suspected appendicitis. The appendix was found to be perforated at the time of surgery. Intravenous ampicillin, gentamicin, and clindamycin were initiated prior to surgery and continued postoperatively. On the third postoperative day, she continues to spike fever to 102°F (38.9°C). The next most appropriate step in her management is to:
A. Add metronidazole to the antibiotic regimen.
B. Change the antibiotic coverage to amikacin and a cephalosporin.
C. Order a STAT computerized tomography scan.
D. Send a urinalysis and urine culture.
E. Perform a pelvic examination.
C. This girl is at risk for an intra-abdominal abscess despite her recent appendectomy and intravenous antibiotics. Furthermore, it would be unusual for a urinary tract infection or pelvic in¬flammatory disease to cause persistent fever in the face of broad-spectrum intravenous antibiotics.
A previously healthy 8-year-old boy presents to his primary care provider with a complaint of abdominal pain, anorexia, and vomiting that have progressively worsened over the past 24 hours. He localizes the pain to the umbilical region with mild right side abdominal tenderness. Despite the emesis, he appears well-hydrated. A complete blood count ob¬tained in the office shows a white blood count of 17,000 cells/mm3 with 50% polymorphonuclear cells. A urine dipstick on a clean-catch specimen shows 2 + leukocytes and 1 + pro¬tein, but no nitrites. Appropriate management at this point is to:
A. Obtain a complete chemistry panel and continue to observe the patient in the office.
B. Send the patient immediately to the hospital for an abdominal ultrasonogram.
C. Give the patient a prescription for trimethoprim-sulfa-methoxazole and schedule a follow-up visit in 2 days to reevaluate the urine.
D. Admit the patient to the hospital for intravenous antibiotics to treat presumed pyelonephritis.
E. Schedule a computerized tomography scan of the abdomen for the next morning.
B. This boy’s symptoms and signs are most consistent with a di¬agnosis of acute appendicitis. A urinary tract infection in an oth¬erwise healthy boy would be unusual. His pyuria is most likely the result of irritation of the bladder wall or· ureter caused by an inflamed appendix.
An infant with a history of recurrent pneumonia is diagnosed with tracheoesophageal fistula at the age of 8 months. Which of the following statements is correct?
A. The infant most likely has a “H-type'” tracheoesophageal fistula.
B. The infant most likely has proximal esophageal atresia with distal fistula.
C. The infant is likely to have a previously undetected, associ¬ated finding of imperforate anus.
D. The infant is unlikely to have gastroesophageal reflux.
E. The infant is likely to have cystic fibrosis.
A. This infant is most likely to the H-type fistula that often presents later in infancy with recurrent pneumonias and/or feeding difficulty. Patients with esophageal atresia and distal fistula present within the first hours of life secondary to their inability to swallow oropharyngeal secretions. Infants with imperforate anus will also present early in the neonatal period. All patients with tracheoesophageal fistula are at high risk for gastro esophageal reflux.
A 2 year old boy presents to your office with his foster parents. The child has been living with his foster parents for 3 weeks and during that time has become progressively short of breath. When he first arrived at their home, the child was active and playful. Now he appears too tired to play. They are aware that he had surgery as an infant, for a problem with “esophagus being connected to his lungs” and that he is not on any medication currently: however, they are unable to provide any specific de¬tails. Upon examination the child is afebrile, diaphoretic, tachy¬cardic, and tachypneic. His symptoms can most likely be attrib¬uted to:
A. Adjustment disorder
B. Reactive airway disease
C. Rheumatic heart disease
D. Kawasaki disease
E. Heart failure secondary to ventricular septal defect
E. This child most likely has a history of repaired tracheo¬esophageal fistula with associated congenital heart disease with symptoms of heart failure.
A 12-month-old boy presents to the emergency department with a 6-hour history of vomiting colicky abdominal pain, and fever. Upon physical examination a sausage-like mass is palpable in the right upper quadrant of the abdomen. The most appropriate next step in the child’s management is to:
A. Order an abdominal ultrasonograph.
B. Order a computerired tomography scan of the abdomen.
C. Order a barium swallow with small bowel follow-through.
D. Obtain a surgical consultation.
E. Order a chest radiograph.
D. A surgical consultation should be obtained.
An 18-month-old male undergoes successful reduction of his intussusception by hydrostatic enema. Eighteen hours following the procedure the child has severe paroxysms of abdominal pain. The next best step in management is to:
A. Administer morphine for pain ·control.
B. Order a computerized tomography of the abdomen.
C. Order a radiograph of the abdomen.
D. Administer an intravenous fluid bolus.
E. Obtain an emergent surgical consultation.
E. Recurrence of intussusception following successful reduc¬tion occurs in 5% of cases. A surgical consultation should be obtained.
A 6-week-old male infant presents with projectile emesis after feeding. Upon physical examination he is found to have an olive-shaped abdominal mass. Which of the following state¬ments is true?
A. He is likely to have a hypochloremic metabolic alkalosis.
B. He is likely to have metabolic acidosis.
C. This condition is more common in female infants.
D. The infant should be restarted on feeds when the vomiting resolves.
E. It is likely that the infant will develop diarrhea.
A. This infant has the features of pyloric stenosis, a condition that is four times more common in males, and more common in children who are first in birth order. Affected infants most com¬monly present between the third week and second month of life with increasing projectile emesis. Abdominal examination may reveal an olive-shaped mass and visible peristaltic waves. Mea¬surement of serum electrolytes is indicated, as infants are prone to develop hypochloremic metabolic alkalosis. Ultrasonography is useful in confirming the diagnosis
A 3-month-old male infant presents with intermittent torticollis .He was a term baby with a normal prenatal course and uneventful delivery. He frequently spits up after feeding and has had one episode of pneumonia. The next step in management is to:
A. Begin gentle stretching of the sternocleidomastoid muscle.
B. Evaluate the infant for gastroesophageal reflux.
C. Refer the infant for orthopedic evaluation.
D. Obtain radiographs of the cervical spine.
E. Observe and, if the condition persists, refer the infant for orthopedic evaluation.
B. This infant most likely has gastroesophageal reflux with in¬termittent torticollis or Sandifer syndrome. The infant has a his¬tory of frequently spitting up and has had pneumonia (possibly aspiration), which indicates that the child has gastroesophageal reflux. Infants with Sandifer syndrome have abnormal head posturing associated with reflux. The head movements are thought to occur either in response to pain or in order to protect the airway.
A family reunion picnic went away when the majority of attendees developed emesis and watery diarrhea with streaks blood Those who were unaffected did not eat the potato salad. A few of the ill family members are mildly febrile. They come as a group to your office, seeking medications. After you exam¬ine them all and wash your hands thoroughly, the most appro¬priate step in managing their condition is:
A. Oral amoxicillin
B. Oral metronidazole
C. Antimotility medication
D. Intramuscular ceftriaxone
E. Hydration and careful follow-up
E. This family probably has Salmonella food poisoning. Antibiotics are not indicated for this healthy family and antimotility agents may prolong the illness. Frequent hand washing should be emphasized.
A 5-year-old child is noted to be iron deficient. Upon questioning, his family reports several episodes of grossly bloody (maroon) stools. Which of the following is the most likely explanation for his anemia?
a. Increased demands for iron due to accelerated growth
b. Meckel diverticulum
c. Infestation by hookworm
d. Peptic ulcer
e. Recurrent epistaxis
b. The Meckel diverticulum results from an embryologic remnant of the vitelline duct. Gastric tissue in the area ulcer¬ates, causing intermittent bleeding. Blood can be microscopic or massive and grossly positive. The bleeding is often painless and is intermittent. The diverticulum can serve as a lead point for intussusception with resultant symptoms of obstruction. The diagnosis is with a Meckel scan (Tc99m pertechnetate nuclear scan), which demonstrates a lesion in the right lower quadrant.
Iron deficiency is most common between 6 months and 3 years of age. During this period, the need for iron is increased because of accelerated growth, and this need is often not met when the diet consists predomi¬nantly of cow’s milk, a uniquely iron-poor food. Growth plateaus during the preschool and preadolescent years and the mixed diets of children in this period are more likely to provide them with adequate iron. Chronic loss of blood from the intestinal tract or from nosebleeds can quickly deplete the iron stores of children.
In adolescence, increased requirements for iron are found because of rapid growth. The adolescent female has the additional risk of becoming iron deficient from the loss of menstrual blood. Grossly positive blood in the stool of this patient requires further evaluation.
Hookworms are caused by two species of roundworm. Necator americanus and Ancylostoma duodenale. Symptoms include abdominal pain, weakness, dizziness, eosinophilia, pica, guaiac-positive stools, and anemia. Gross bleeding and melena are rare.
Peptic ulcer disease often presents with epigastric pain, discomfort, anorexia, early satiety, and weight loss. Bleeding is usually noted as hematemesis or melena. Bright red blood from the rectum is unusual without severe disease.
Epistaxis causes anemia of chronic blood loss, but the blood in the stool usually is only guaiac-positive or is melanotic. Bright red blood from the rectum caused by nosebleeds is distinctly abnormal.
A 6-month-old infant has large, foul-smelling stools and is not gaining weight. Sweat chloride level was 68 mmol/L. Appropriate nutritional recommendations include which one of the following?
a. Change to elemental formula
b. Pancreatic enzyme replacement
c. High-fat diet
d. Low-protein diet
e. Low-carbohydrate diet
b. The goal in treatment of patients with cystic fibrosis is to supply enough calories to maintain normal growth. Extra calories are needed to replace those lost as a result of gastrointestinal losses, to off¬set the catabolic and anorectic effects of respiratory infection, and for catch-up growth. Almost 90% of patients have poor digestion of fat and protein as a result of the deficiency of pancreatic function, which may be, partially corrected by oral pancreatic enzyme replacement; protein and fat losses are reduced, and patients are usually able to tolerate a reasonably normal diet. The high caloric density of fat is useful in meeting the patient’s caloric needs. Supplementation with fat-soluble vitamins (A. D. E. and K) is necessary. With severe disease, feedings by nasogastric tube, percuta¬neous enterostomy, or intravenous nutrition may be necessary.
A 7-month-old infant receives chronic total parenteral nutrition for short gut syndrome. In preparing the parents for discharge from the neona¬tal unit, you discuss potential complications of this mode of nutrition. Which of the following is a typical complication of total parenteral nutri¬tion?
a. Sepsis
b. Renal failure
c. Chronic diarrhea
d. Vitamin A deficiency
e. Irreversible atrophy of the mucosa of the small intestine
a. Parenteral ‘nutrition, particularly when a central line is used, has a relatively high risk of complications, so it should not be used without good indication. The most common complication, and one of the most serious, is sepsis (1 to 5% of patients). Cholestasis and subsequent liver dysfunction are also commonly seen in patients receiving TPN. In addition to the complications mentioned, thrombosis of central veins, perforations of veins with infusion and bleeding into the pleural space and other sites, pneumothorax, brachial plexus injury, and skin sloughing can also occur. Small intestinal mucosal atrophy is reversed with oral feedings. The other options are not typically noted to be compli¬cations of parenteral nutrition; although children with short gut do fre¬quently have chronic diarrhea, parenteral nutrition is not the direct cause. Awareness of these complications and the practice of careful techniques may minimize the risks of this sometimes lifesaving nutritional procedure.
A 3-year-old child presents to your office for an evaluation of consti-pation. The mother notes that since birth, and despite frequent use of stool softeners, the child has only about one stool per week. He does not have fecal soiling or diarrhea. He was born at term and without pregnancy com¬plications. The child stayed an extra day in the hospital at birth because he did not stool for 48 hours, but has not been in the hospital since. Initial evaluation of this child should include which of the following?
a. A child psychiatry evaluation for stool retention and parenting assistance
b. A barium enema and rectal manometry
c. Plain films of the abdomen
d. Dietary log and observation
e. Beginning oral antispasmodic medication
b. The diagnosis of Hirschsprung disease should be suspected in a child with intractable chronic constipation without fecal soiling (approximately 3% have fecal soiling). In contrast, overflow diar¬rhea caused by leakage of the unformed fecal stream around a rectal impaction is common in functional constipation. A neonatal history of delayed passage of meconium is often obtained, and the infant can continue to be constipated and to have bouts of abdominal distention and vomiting. The infant is also at risk of developing enterocolitis, a life-threatening consequence of the partial obstruction. Radiologic study by barium enema and rectal manometry are accurate diagnostic tools. Identi¬fication of an aganglionic segment of bowel by punch or suction biopsy can establish the diagnosis. Histochemical tissue examination showing in¬creased amounts of acetylcholinesterase and an absence of ganglia cells is confirmatory. Rectal manometric studies have shown that in aganglionic megacolon, the usual relaxation of the internal rectal sphincter in response to balloon inflation does not occur. Surgery is indicated as soon as the diagnosis is made. Antispasmodic agents and dietary’ changes are not helpful, and a plain film of the abdomen would not confirm the diagnosis.
An 8-year-old is accidentally hit in the abdomen by a baseball bat. After several minutes of discomfort, he seems to be fine. Over the ensuing 24 h, however, he develops a fever, abdominal pain radiating to the back, and persistent vomiting. On examination, the child appears quite uncom¬fortable. The abdomen is tender, with decreased bowel sounds throughout, but especially painful, with guarding in the midepigastric region. Which of the following tests is most likely to confirm the diagnosis?
a. Serum amylase
b. Complete blood count with differential and platelets
c. Serum total and direct bilirubin levels
d. Abdominal radiograph
e. Electrolyte panel
a. The causes of pancreatitis in children are varied, with about one-fourth of cases without predisposing etiology and abo one-third of cases as a feature of another systemic disease. Traumatic cases are usually due to blunt trauma to the abdomen. Acute pancreatitis is diffi-cult to diagnose; a high index of suspicion is necessary. Common clinical features include severe pain with nausea and vomiting. Tenderness, guard¬ing or rebound pain, abdominal distention. and a paralytic ileus are signs and symptoms often seen. No diagnostic test is completely accurate. An elevated total serum amylase with the correct clinical history and signs and symptoms is the best diagnostic tool. Plain films of the abdomen may-exclude other diagnoses; ultrasonography of the pancreas can reveal enlargement of the pancreas, gallstones, cysts, and pseudocysts. Supportive care is indicated until the condition resolves.
A 10-month-old boy, recently arrived from Guyana, has a 5-h history of crying, with intermittent drawing up of his knees to his chest. On the way to the emergency room he passes a loose, bloody stool. He has had no vomiting and has refused his bottle since the crying began. Physical exam¬ination is noteworthy for an irritable infant whose abdomen is very diffi¬cult to examine because of constant crying. His temperature is 38.8°C (101.8°F). The rectal ampulla is empty, but there is some gross blood on the examining finger. Which of the following studies would be most help¬ful study in the immediate management of this patient?
a. Stool culture
b. Examination of the stool for ova and parasites
c. An air-contrast enema
d. Examination of the blood smear
e. Coagulation studies
c. The usual presentation of intussusception is that of an infant between 4 and 10 months of age who has a sudden onset of intermittent colicky abdominal pain. The child can appear normal when > the pain abates, but as it recurs with increasing frequency, the child can begin to vomit and become progressively more obtunded. The passage of stool containing blood and mucus, and resembling currant jelly, is often observed. Early examination of the abdomen can he unremarkable, but as the problem persists, a sausage-shaped mass in the right upper quadrant is frequently palpated. A contrast enema examination under fluoroscopic control can be therapeutic as well as diagnostic when the hydrostatic effects of the column of air serve to reduce the intussusception. Early diagnosis prevents bowel ischemia. The cause of most intussusceptions is unknown, but a Meckels diverticulum or polyp can serve as a lead point.
A 12-month-old girl has been spitting up her meals since 1 month of age. Her growth is at the ninety-fifth percentile, and she is otherwise asymptomatic and without findings on physical examination. Which of the following is the most likely diagnosis?
a. Pyloric stenosis
b. Partial duodenal atresia
c. Hypothyroidism
d. Gastroesophageal reflux disease
e. Tracheoesophageal fistula
d. Gastroesophageal reflux is a common pediatric complaint, often seen in the first 1 to 2 months of life and resolving by 1 to 2 years of age. About 7% of children have reflux severe enough to come to medical attention, and only 2% of that group requires investigation. For children who are growing well and do not have respiratory symptoms attributed to reflux, conservative treatment (small feeds, thickened for¬mula, avoiding high-fat meals, etc.) suffices. A small number need pharmacologic therapy and an even smaller number require surgery.
A 14-year-old girl has a 9-month history of diarrhea, abdominal pain (usually periumbilical and postprandial), fever, and weight loss. She has had several episodes of blood in her stools. Which of the following is the most likely diagnosis?
a. Chronic appendicitis
b. Chronic pancreatitis
c. Crohn disease
d. Bulimia
e. Gallstones
c. The presentation of Crohn depends on the loca¬tion and extent of lesions. Onset of the gastrointestinal or extraintestinal symptoms is insidious. The common presentation is as described. Crohn disease (granulomatous colitis) characteristically is associated with trans-mural, granulomatous intestinal lesions that are discontinuous and can appear in both the small and large intestines. Although Crohn disease can first appear as a rectal fissure or fistula, the rectum is often spared. Arthritis/ arthralgia occurs in a minority (11%) of affected children. Other extraintestinal symptoms include erythema nodosum or pyoderma gangrenosum, liver disease, renal calculi, uveitis, anemia, specific nutrient deficiency, and growth failure. In relation to the general population, the risk of colonic car¬cinoma in affected persons is increased, but not nearly to the degree asso¬ciated with ulcerative colitis.
A 6-momh-old infant has eaten a diet with the following content and intake for the past 5 months: protein 4% of calories, fat 50% of calories, carbohydrates 46% of calories, 105 calories per kilogram of body weight per day. This patient will display symptoms consistent with which of the following?
a. Rickets
b. Marasmus
c. Obesity
d. Tetany
e. Kwashiorkor
e. The syndrome of kwashiorkor is caused by a diet that is deficient in protein/leading to low serum albumin, which causes decreased plasma volume and increased interstitial fluid, or edema. The term maras¬mus refers to a combined inadequacy of protein and energy in which the deficiency is dominated by the of food in general. The minimum requirement. for protein is 8% calories when the protein provided is from high-quality anima1 sources. These’ patients have a high death rate from intercurrent infection.
A 2-year-old presents to the emergency center with several days of rectal bleeding. The mother first noticed reddish-colored stools 2 days prior to arrival and has since changed several diapers with just blood. The child is afebrile, alert, and playful, and is eating well without emesis. He is slightly tachycardic, and his abdominal examination is normal. Which of the following is the best diagnostic study to order at this time?
a. Exploratory laparotomy
b. Barium enema
c. Ultrasound of the abdomen
d. Radionucleotide scan
e. Stool culture
d. The child described has a typical presentation for Meckel diverticulum. Children with this condition usually present with painless rectal bleeding in the first 2 years of life, but they can have symp¬toms throughout the first decade. The embryonic duct connecting the yolk sac to the intestine can fail to regress completely and persist as a diverticu¬lum attached to the ileum. The lining of this Meckel diverticulum usually contains acid-secreting gastric mucosa that can produce ulcerations of the diverticulum itself or the adjacent ileum. Bleeding, perforation, or diverticulitis can occur. More seriously, the diverticulum can lead to volvulus of itself and of the small intestine, and it can also undergo eversion and intus¬susception. Diagnosis can be made by technetium scan, and treatment is by surgical excision. Barium studies do not readily reveal the diverticulum, nor do plain films.
A 15-year-old otherwise healthy boy presents with a complaint of intermittent abdominal distention, crampy abdominal pain, and excessive flatulence. He first started noticing these symptoms when he moved into his father’s house, and his stepmother insisted on milk at dinner every night. He has normal growth, has not lost weight, and has no travel history. Which of the following is the most appropriate diagnostic study to diag¬nose his condition?
a. Barium swallow and upper GI
b. Hydrogen excretion in breath after oral administration of lactose
c. Esophageal manometry
d. Stool pH
e. Serum lactose levels
b. Lactase is a disaccharidase localized in the brush border of the intestinal villous cells. It hydrolyzes lactose to its constituent monosaccharides, glucose, and galactose. Intestinal lactase levels are usually nor¬mal at birth in all populations: however, lactase deficiency is a common. genetically predetermined condition. Lactase activity is not readily in¬creased by the oral administration 01 substrate or the inclusion of lactose in the diet. The clinical symptoms of lactose malabsorption are due to the presence of osmotically active, undigested lactose, which may act to increase intestinal fluid volume, alter transit time, and produce the symp¬toms of abdominal cramps, distention, and occasionally, watery diarrhea. Bacterial metabolism of the non-absorbed carbohydrates in the colon into carbon dioxide and hydrogen may contribute to the clinical symptoms. Acquired lactase deficiency is often associated with conditions of the gastro¬intestinal tract that cause intestinal mucosal injury (e.g., sprue and regional enteritis). Diagnostic techniques for lactose intolerance include removal of the offending sugar, with a reproduction of symptoms upon reintroduction. Although the ingestion of even small amounts of lactose can be diag¬nostic if gastrointestinal symptoms occur, the measurement of breath hydrogen is more specific, as it is not affected by glucose metabolism or gastric emptying. Similarly, an acidic stool pH in the presence of reducing substances would be diagnostic. Direct measurement of enzyme levels combined with histologic evaluation helps to differentiate an acquired (sec¬ondary versus primary) lactase deficiency in which the intestinal histology is normal.
A 6-week-old infant is admitted to the hospital with jaundice. Her outpatient blood work demonstrated a total bilirubin of 12 mg/dL with a direct portion of 3.5 mg/dL. Which of the following disorders is most likely to be responsible?
a. ABO incompatibility
b. Choledochal cyst
c. Rh incompatibility
d. Gilbert disease
e. Crigler-Najjar syndrome
b. Obstructive jaundice (i.e., direct-reacting bilirubin greater than 20% of the total) requires inves¬tigation in all infants. Cystic fibrosis and alpha 1 antitrypsin deficiency should be considered in the diagnostic evaluation of any child with obstructive jaundice. Other diseases to be excluded are galactosemia, tyrosinemia, and urinary tract or other infections (including toxoplasmosis, cytomegalovirus, rubella, syphilis, and herpesvirus). Ultrasound examination to rule out choledochal cyst may be included with a HIDA scan to assess the patency of the biliary tree. Liver biopsy can assist in the diagnosis by providing a histologic diagnosis (e.g., hepatitis), tissue for enzyme activity (i.e., inborn error of metabolism), or tissue for micro¬scopic determination of storage diseases. ABO and Rh incompatibility could cause direct hyperbilirubinemia if there were brisk hemolysis at birth, which would then lead to inspissated bile syndrome. All of the other causes listed typically lead to indirect hyperbilirubinemia.
A 9-month-old is brought to the emergency center by ambulance.
The child had been having emesis and diarrhea with decreased urine output for several days, and the parents noted that she was hard to wake up this morning. Her weight is 9 kg, down from 11 kg the week prior at her 9-month checkup. You note her heart rate and blood pressure to be nomal. She is lethargic, and her skin is noted to be “doughy.” After confirm¬ing that her respiratory status is stable, you send electrolytes, which you expect to be abnormal. You expect the serum sodium to be
a. Low
b. Normal
c. high
c. The description is that of a child with hypernatremia (in this case, the child’s sodium was 170 meq/dL); the ”doughy” skin is often seen in hypernatremia. The extracellular fluid and circulating blood vol¬umes tend to be preserved with hypernatremic dehydration at the expense of the intracellular volume. Therefore, hypotension may not be observed, nor may the other signs of circulatory inadequacy that, are typical of isotonic or hypotonic dehydration. Signs suggesting involvement of the central nervous system (such as irritability or lethargy) are characteristic of hypertonic dehydration.
You are admitting to the hospital a 3-month-old infant who has been having poor feeding, emesis, and diarrhea for three days. In the emergency center, her electrolytes were found to be: sodium 157 meq/L, potassium 2.6 meq/L, chloride 120 meq/L, bicarbonate 14 meq/L, creatnine 1.8 meq/L, BUN 68 meq/L, and glucose 195 meq/L. She was given a fluid bolus in the emergency center and has subsequently produced urine. Which of the fol¬lowing is the most appropriate next step in her management?
a. Slow rehydration over 48 h
b. Continued rapid volume expansion with l/2 NS
c. Packed red blood cells
d. CT scan to evaluate for CNS tumor causing SIADH
e. Urinary electrolytes
a. Initial bolus therapy should have been with isotonic fluid such as normal saline or lactated Ringers solution. Slow correction of this hypernatremia (over 24 to 48 h) prevents significant fluid shifts and increased intracranial pressure. Hyperglycemia may be seen in hypernatremic dehydration due to decreased insulin secretion and cell sen¬sitivity to insulin; this is particularly important because increased serum glucose can cause the serum sodium to be falsely decreased. The story in the case is not consistent with SIADH. Blood products such as fresh-frozen plasma are not indicated, and rapid infusion of hypotonic solutions such as D10W and 1/2NS could cause rapid fluid shifts resulting in cerebral edema and death. Hypertonic (3%) saline is used in the event of seizures caused by rapid rehydration (or in children with hyponatremic dehydration and associated central nervous system symptoms), along with other measures typically used to reduce cerebral edema.
An 8-year-old boy is brought to your office with the complaint of abdominal pain. The pain is worse during the week and seems to be less prominent during the weekends and during the summer. The patient’s growth and development are normal. The physical examination is unre¬markable. Laboratory screening, including stool for occult blood, complete blood count, urinalysis, and chemistry panel, yields normal results. Which of the following is the best next step in the care of this patient?
a. Perform in upper Gl series
b. Perform CT scan the abdomen
c. Administer H2 blockers
d. Observe the patient and reassure the patient family
e. Recommend a lactose-tree diet
d. Recurrent abdominal pain is a common complaint occurring in at least 10% of school-age children. In children older than 2 years, less than 10% of cases have an identifiable organic cause. Manage¬ment of these children is difficult and frustrating for the physician and the family. Excessive testing and treatments are contraindicated. A thorough history and physical examination, including growth parameters, are fre¬quently helpful in separating organic from nonorganic causes of abdominal pain. Any signs or symptoms of organic causes should be pursued. If nothing in the history or physical examination is found, as is likely in the case described, reassurance of the children and family members is indi¬cated. Close follow-up for new or changing symptoms as well as further reassurance to the farmily is important.
