Pediatric Examination and Board Review (76 page)

(E) A and C

9.
What nutritional therapies can be employed to treat this child?

(A) high-residue diet

(B) high-protein diet

(C) diet of elemental formula

(D) gluten-free diet

(E) none of the above

10.
The child in the original vignette undergoes a colonoscopy that demonstrates pancolitis with erythema, edema, and granularity. The patient’s diagnosis could be

(A) ulcerative colitis

(B) Crohn disease

(C) pseudomembranous colitis

(D) A and B

(E) A, B, or C

11.
The patient with pancolitis has a perinuclear antineutrophil cytoplasmic antibody (pANCA). Her diagnosis is

(A) ulcerative colitis

(B) Crohn disease

(C) autoimmune colitis

(D) A and B

(E) A, B, and C

12.
First-line treatment of this moderately severe case of inflammatory bowel disease includes

(A) aminosalicylate

(B) steroids

(C) A and B

(D) no medications are needed because 20-30% of patients have a spontaneous remission

(E) Remicade

13.
The patient in question 11 begins treatment and returns with severe abdominal pain, fever, and continued colitis. Evaluation should begin with

(A) abdominal ultrasound

(B) abdominal CT

(C) repeat colonoscopy

(D) barium enema

(E) observation

14.
The risk of the patient from question 11 developing colon cancer in her life is

(A) higher than in the general population, and screening should begin after 10 years of active disease

(B) so high that prophylactic colectomy is recommended after 10 years of active disease

(C) the same as the general population. Medications to treat the disease have improved in the last decade so there is no longer any increased risk

(D) only high in those patients who have liver disease in addition to bowel disease

(E) about 20%

15.
Based on the laboratory values in question 6, the liver disease in a patient with ulcerative colitis most likely is

(A) autoimmune hepatitis

(B) sclerosing cholangitis

(C) gallstones

(D) cholangiocarcinoma

(E) primary biliary cirrhosis

16.
If a child has abdominal pain throughout the day that also wakes the patient at night, heme-positive stool, a physical examination with no abdominal tenderness, and a fissure noted on the rectal examination, your next step would be

(A) screening studies including a urinalysis, CBC, erythrocyte sedimentation rate

(B) reassurance and treatment for the fissure

(C) colonoscopy to ensure there is no additional pathology

(D) stool cultures

(E) blood for pANCA

17.
The laboratory studies for the patient in question 16 are listed below:

Other symptoms that may occur in this patient are

(A) epigastric pain and nausea

(B) constipation

(C) right lower quadrant pain

(D) diarrhea

(E) all of the above

18.
Initial treatment for this disorder includes

(A) dietary change and reassurance

(B) medications

(C) further radiology or endoscopic testing

(D) referral to a gastroenterologist

(E) all of the above

ANSWERS

1.
(E)
This vignette describes symptoms that may reflect any of the listed diagnoses. Although hemepositive stools are less likely in irritable bowel syndrome compared with patients with inflammatory bowel syndrome, up to 35% of patients with irritable bowel syndrome report rectal bleeding. In this scenario, the red flags include pain in the middle of the night, blood in the stool, and the findings on physical examination.

2.
(A)
Without a history of antibiotic exposure,
C difficile
is an unlikely pathogen. The chronicity of the course makes bacterial enteritis unlikely. Giardia does not usually present with blood in the stool. Stool fungal cultures are of no value.

3.
(E)
Any of the pathogens listed can cause acute gastroenteritis with bloody stool, although none are particularly likely in this case. A possible exception is
E coli
O157. You would expect a history of antibiotic exposure with
C difficile,
but communityacquired cases without such exposure do occur.

4.
(C)
The most dangerous complication of an acute gastroenteritis with bloody stool is hemolytic uremic syndrome associated with
E coli
O157:H7. The laboratory findings of hemolytic uremic syndrome may present before the culture for
E coli
is positive. Those findings include renal insufficiency, hemolysis, thrombocytopenia, and, in severe cases, cerebral edema.

5.
(A)
The height and weight given are far below the fifth percentile for age. With the symptoms described you must be concerned that the patient has Crohn disease. Looking for signs of inflammation, anemia, and protein-losing enteropathy are the appropriate next steps. Although this patient could have celiac disease, detection of antigliadin IgG antibody is not the test of choice for celiac disease.

6.
(C)
A patient with iron deficiency anemia (low hemoglobin and low MCV), protein-losing enteropathy (low albumin), and increased inflammatory marker levels is likely to have Crohn disease. The best radiologic test would be an upper GI series with small bowel follow-through. Abdominal CT can also demonstrate small bowel disease

7.
(E)
The radiologic findings in a patient with Crohn disease is evidence of small bowel disease like strictures, bowel wall thickening, and fistulae. Transit through the GI tract may be delayed.

8.
(E)
In Crohn disease there is likely to be upper GI involvement (early satiety) and perianal disease (perianal abscess). Although there are some patients who have liver disease (RUQ pain), it is more likely to occur in a patient with ulcerative colitis. Skin rash is not a common feature of Crohn disease.

9.
(C)
Elemental formula is known to promote remission in patients with Crohn disease. The difficulty with this treatment is that the formulas have poor palatability and often require a nasogastric tube for infusion. Other recommendations include a lowresidue diet in patients with colitis.

10.
(D)
Crohn colitis and ulcerative colitis can look exactly the same on colonoscopy. Granulomas must be present on histology to make the diagnosis of Crohn’s. Serology can also assist in making the distinction. Pseudomembranous colitis is associated with
C difficile
infection. In pseudomembranous colitis there is a membrane or coating adherent to the mucosa that helps distinguish this entity from Crohn and ulcerative colitis.

11.
(A)
pANCA antibodies are specifically associated with ulcerative colitis.

12.
(C)
In a moderately severe case of inflammatory bowel disease (pancolitis), both steroids and aminosalicylates should be prescribed. Infliximab should be reserved for cases refractory to the above treatment.

13.
(B)
The most dangerous complication for a patient with ulcerative colitis is toxic megacolon. Risk factors for megacolon include drugs that interfere with intestinal motility, narcotics, antidiarrheal agents, and recent instrumentation. The megacolon can be seen on abdominal radiograph, but abdominal CT is a more sensitive and specific test. Treatment with bowel rest and antibiotics should be initiated when the diagnosis is suspected. Patients who do not respond to this conservative treatment may require colectomy.

14.
(A)
The risk for developing colon cancer depends on the extent of the colitis (pancolitis >left-sided colitis >proctitis) and the length of time it has been clinically apparent. The risk increases after 10 years. Patients with Crohn colitis are equally at risk for developing colon cancer.

15.
(B)
The most commonly associated liver disease in a patient with ulcerative colitis is sclerosing cholangitis (see
Figure 47-1
). The disease affects the biliary system. Therefore you would expect increased GGTP and alkaline phosphatase concentrations. Autoimmune hepatitis affects the hepatocytes, thereby causing an increased ALT and AST level. Gallstones are not associated with ulcerative colitis. Cholangiocarcinoma is a complication of longstanding sclerosing cholangitis, not an initial presentation of liver disease in an 11-year-old. Primary biliary cirrhosis is an adult liver disease.

FIGURE 47-1.
Sclerosing cholangitis. Endoscopic retrograde cholangiopancreatogram demonstrating diffusely narrowed intrahepatic bile ducts and one beaded area. (Reproduced, with permission, from Greenberger NJ, Blumberg RS, Burakoff R. Current Diagnosis & Treatment: Gastroenterology, Hepatology & Endoscopy. New York: McGraw-Hill, 2009: Fig. 52-1.)

16.
(A)
Although the patient has a normal abdominal examination, the presence of perianal disease and pain severe enough to be awakened is enough to order screening laboratory tests looking for inflammatory markers.

17.
(E)
The laboratory values in the table are all normal. It is unlikely for a patient with Crohn colitis or ulcerative colitis to have a normal hemoglobin, MCV, albumin, and erythrocyte sedimentation rate. Your conclusion is that this patient had irritable bowel syndrome, a variant of recurrent abdominal pain. About 10-15% of 4 to 16-year-old children have recurrent abdominal pain. The symptoms can include nonacid dyspepsia (epigastric pain and nausea), constipation, diarrhea, and migrating abdominal pain.

18.
(A)
Conservative therapy with dietary changes, particularly increasing dietary fiber and limiting lactose and high fructose corn syrup, is the first-line approach. In addition, reassurance about the benign nature of recurrent abdominal pain is crucial. Recognizing that the patient is in pain is important. You want to avoid overtesting, thereby contributing to the patient’s worry about the condition. Surgery is never necessary for irritable bowel syndrome.