23 - Gastroenterology Flashcards
Coeliac’s disease has a prevalence of 1% in children (1:100). What is the pathophysiology of coeliac’s disease?
Autoimmune condition where exposure to gliadin fraction in gluten causes an immune reaction that creates inflammation in the small intestine
Autoantibodies (Anti-TTG and anti-EMA) are created in response to gluten that target the epithelial cells of the intestine and lead to inflammation
Usually in jejunum, causes atrophy of the intestinal villi so malabsorption
What are some associations with coeliac disease?
- Down’s syndrome
- Type 1 diabetes
- Thyroid disease
- Other autoimmune conditions e.g RA, Addison’s
How may coeliac disease present in a child?
Younger children tend to have GI symptoms but older children have extra GI symptoms. Can present at any age
- Asymptomatic
- Failure to thrive
- Diarrhoea/Steatorrhea
- Weight loss
- Abdominal pain
- Fatigue
- Mouth ulcers
- Anaemia secondary to iron, B12 or folate deficiency (in older children)
- Dermatitis herpetiformis
What are some differentials for coeliac’s?
Think of other malabsorption conditions
- Cystic fibrosis
- Inflammatory bowel disease
- Post – gastroenteritis
- Autoimmune enteropathy
- Eosinophilic enteritis
What genetic associations are found in coeliac’s and what auto-antibodies are found?
(image important)
Genetic
- HLA-DQ2 gene (90%)
- HLA-DQ8 gene
Auto-antibodies (ALWAYS TEST FOR TOTAL IGA TOO)
- Tissue transglutaminase antibodies (anti-TTG)
- Endomysial antibodies (EMAs)
- Deaminated gliadin peptides antibodies (anti-DGPs)
What investigations are done to diagnose coeliac’s disease?
Patient must remain on gluten diet during investigations for at least 6 weeks before as otherwise may not detect antibodies
- Total immunoglobulin A levels: to exclude IgA deficiency
- Anti-TTG antibodies (first choice)
- Anti-endomysial antibodies
- Endoscopy and intestinal biopsy: If positive serology. Crypt hypertrophy and villous atrophy
What are the indications for coeliac serology in children?
- Persistent unexplained abdominal or gastrointestinal symptoms
- Faltering growth
- Prolonged fatigue
- Unexpected weight loss
- Severe or persistent mouth ulcers
- Unexplained iron, vitamin B12 or folate deficiency
- Type 1 diabetes, at diagnosis
- Autoimmune thyroid disease, at diagnosis
- First‑degree relatives of people with coeliac disease
How is coeliac disease managed in children?
- Life-long gluten free diet
- Annual follow up to check for symptoms, diet compliance, development, growth and long term complications
What are some complications of coeliac’s disease if left unmanaged?
- Anaemia
- Osteoporosis
- Malignancy (Non Hodgkin Lymphoma, EATL, Small bowel adenocarcinoma)
- Infertility
What is the epidemiology and pathophysiology of GORD in children?
Only GORD if symptomatic, can be asymptomatic which is physiological called GOR
Epidemiology
- Occurs in 40% of infants in first 2 weeks as LOS still developing until 6 months
- 1% of children under 13 have it
Pathophysiology
- Low tone of lower oesophageal sphincter so reflux out of stomach to oesophagus
What are some risk factors for GORD in children?
- Prematurity
- Parental history of heartburn
- Obesity
- Hiatus hernia
- History of congenital diaphragmatic hernia
- History of congenial oesophageal atresia
- Neurodisability (eg. cerebral palsy)
How may GORD present in children?
Frequent effortless regurgitation of feeds is normal
- Chronic cough
- Hoarse cry
- Back arching
- Drawing knees to chest
- Excess crying or unsettled after feeding
- Reluctance to feed
- Pneumonia
- Poor weight gain
What are some differentials for GORD in infants?
If onset is >6 months of age or symptoms persist beyond 1 year then reflux is unlikely
- Pyloric stenosis: Frequent, forceful (projectile) vomiting in <2 month olds
- Intestinal obstruction: bile-stained vomit,
- Upper GI bleed: haematemesis
- Sepsis
- Raised ICP: rapidly increasing head circumference (>1cm per week), persistent headache and vomiting following periods of recumbence
- UTI
- CMPA
- Possetting
- Overfeeding
How is GORD investigated and managed?
Ix
- No investigation if feeding and gaining weight
- Rule out other causes e.g urine dipstick
Mx
- Conservative (advice on keeping baby upright, burping after feeds, thickened formula)
- Medical (Infant gaviscon, omeprazole)
- Surgical in severe cases (fundoplication)
What is the medical management for GORD in infants?
- Alginate mixed with water and feed (Gaviscon)
- If not resolved with this in 2 weeks then trial PPI (Omeprazole)
If GORD is severe, what investigation is done before fundoplication?
- Barium Meal
- Endoscopy
Only do fundoplication if failure to thrive or apneas
What are some complications with GORD?
90% of infants will spontaneously resolve within the first year of life as they change diet and start to sit upright
- Reflux oesophagitis
- Recurrent aspiration pneumonia
- Recurrent acute otitis media (>3 episodes in 6 months)
- Dental erosion (especially in children with neurodisability)
- Apnoea
- Apparent life-threatening events (ALTE): apnoea, colour change, change in muscle tone, choking and gagging
What is Sandifer’s syndrome?
Brief episodes of abnormal movements associated with GORD in infants. The infants are usually neurologically normal
- Torticollis: forceful contraction of the neck muscles causing twisting of the neck
- Dystonia: abnormal muscle contractions causing twisting movements, arching of the back or unusual postures
Tends to resolve as reflux resolves but refer to rule out infantile spasms and seizures
What are some red flags that point away from GORD to another diagnosis?
- Frequent, forceful (projectile) vomiting
- Bile-stained (green or yellow-green) vomit
- Abdominal distension, tenderness, or palpable mass
- Blood in vomit
- Bulging fontanelle or altered responsiveness (for example lethargy or irritability)
- Rapidly increasing head circumference (more than 1 cm each week); persistent morning headache and vomiting worse in the morning
- Blood in the stool
- Chronic diarrhoea
- Dysuria
- Appearing unwell or fever
- Onset of regurgitation and/or vomiting after 6 months of age or persisting after 1 year of age
What is important to ask in the history if you suspect GORD?
Feeding history
When should a baby with GORD be admitted?
- Haematemesis
- Maleana
- Dysphagia
What are the differences between UC and Crohn’s, both being forms of IBD with periods of exacerbation and remission?
NESTS
UC-CLOSE UP
How does IBD tend to present in children?
- Poor growth
- Diarrhoea
- Abdominal pain
- Bleeding
- Weight loss
- Anaemia
- Fever
What are some extra-intestinal manifestations of IBD in children?
- Finger clubbing
- Erythema nodosum
- Pyoderma gangrenosum
- Episcleritis and iritis
- Inflammatory arthritis
- Primary sclerosing cholangitis (UC)
What investigations are done for IBD in children?
- Blood tests for anaemia, infection, thyroid, kidney and liver function. A raised CRP indicates active inflammation
- Faecal calprotectin
- Endoscopy (OGD and colonoscopy) with biopsy: gold standard
- Imaging with ultrasound, CT and MRI can be used to look for complications such as fistulas, abscesses and strictures
How is IBD generally managed in children?
- Any child presenting with symptoms of IBD should be referred to secondary care for specialist assessment and management with MDT
- Monitor growth and pubertal development especially when treated with steroids. Get dietician input
- Inducing remission during flares and maintaining remission
What is the medical management for Crohn’s?
Inducing Remission
- Steroids: First line e.g. oral prednisolone or IV hydrocortisone).
- Immunosupressants: if above doesn’t work
Maintaining Remission
- First line: Azathioprine or Mercaptopurine
- Second Line: Methotrexate, Infliximab, Adalimumab
When should children with Crohn’s be referred for surgery?
- If just affects distal ileum then resect
- Surgery can also be used to treat strictures and fistulas secondary to Crohn’s
What is the medical management for UC?
Inducing Remission
Mild to moderate disease
- First line: aminosalicylate (e.g. mesalazine oral or rectal)
- Second line: corticosteroids (e.g. prednisolone)
Severe disease
- First line: IV corticosteroids (e.g. hydrocortisone)
- Second line: IV ciclosporin
Maintaining Remission
- Aminosalicylate (e.g. mesalazine oral or rectal)
- Azathioprine
- Mercaptopurine
What surgery can be done for UC?
- Panproctocolectomy: left with either a permanent ileostomy or something called an ileo-anal anastomosis (J-pouch)
What monitoring needs to be done for children with UC?
- Bone health
- Height and body weight plotted on growth chart
- Pubertal development
What is the definition of constipation in children and some of the causes for this?
Less than 3 stools per week or significant difficulty passing stool
- Idiopathic (most common, lifestyle issues e.g lack of fibre, dehydrated)
- Hirschprung’s
- CF
- Hypothyroidism
- Cow’s milk intolerance
- Anal stenosis
- Sexual abuse
What are some typical features in the history for constipation in children?
- Hard stools that are difficult to pass
- Rabbit dropping stools
- Straining and painful passages of stools
- Abdominal pain
- Holding an abnormal posture, referred to as retentive posturing
- Rectal bleeding associated with hard stools
- Overflow soiling
- Hard stools may be palpable in abdomen
What are some lifestyle factors in children that lead them to become constipated?
- Habitually not opening the bowels so lose sensation
- Low fibre diet
- Poor fluid intake and dehydration
- Sedentary lifestyle
- Psychosocial problems such as a difficult home or school environment
- Pain or anal fissure
What are some red flags in children when they have constipation that point away from a diagnosis of idiopathic constipation?
- Not passing meconium within 48 hours of birth: CF or Hirschsprung’s
- Neurological signs or symptoms: cerebral palsy or spinal cord lesion
- Vomiting: intestinal obstruction or Hirschsprung’s
- Ribbon stool: anal stenosis
- Abnormal anus: anal stenosis, IBD or sexual abuse
- Abnormal lower back or buttocks: spina bifida
- Failure to thrive: coeliac disease, hypothyroidism or safeguarding
- Acute abdominal pain and bloating: obstruction or intussusception
What are the general points of management in idiopathic constipation?
- Correct any reversible factors, e.g high fibre diet and good hydration
- Start maintenance laxatives
- Disimpaction regime if faecal impaction
- Good toilet habits e.g praise, toilet scheduling, star charts
What lifestyle changes can parents make for children with idiopathic constipation?
ERIC PROGRAMME
- High fibre diet
- High fluid intake
- Regular toileting e.g after meals, before bed
- Toilet positioning
- Exercise
- Praise for going to toilet
What is the disimpaction regime?
- Escalating doses of polyethene glycol 3350+electrolytes (Movicol)
- If no disimpaction after 2 weeks add a stimulant laxative
- Warn parents will make it worse before better and may have soiling
What are some examples of functional GI disorders in children?
Always be careful not to miss diagnoses like IBD, always recheck for them every few months, especially if growth issues
What is the pathophysiology of functional GI disorders in children and how can this guide our treatment?
Psychological intervention is important
What is the criteria for abdominal migraine in children?
May occur in young children before they develop traditional migraines as they get older
Episodes of central abdominal pain lasting more than 1 hour. Examination will be normal.
There may be:
- Nausea and vomiting
- Anorexia
- Pallor
- Headache
- Photophobia
- Aura
How does mesenteric adenitis present?
Diffuse central abdominal pain in the context of a previous URTI
US abdo will show enlarged mesenteric lymph nodes with a normal appendix.
Will improve spontaneously, appendicitis will not
What is oesophageal atresia?
- Blind-ending oesophagus
- Associated with tracheooesophageal fistula
- More common in trisomies – Downs/Pataus/Edwards
- VACTERL
How may oesophageal atresia present?
- Polyhydramnios
- Difficulty feeding
- Overflow saliva and blowing bubbles
- Choking and cyanotic spells
How is oesophageal atresia diagnosed and managed?
- Inability to pass a catheter into the stomach, X-rays show it coiled in the oesophagus
- Stop feeding and suck out any oesophageal pouch
- Primary surgical repair and look for other anomalies (50% have VACTERL)
What is gastroschisis and how is it managed?
Anterior abdominal wall defect to the side of the umbilicus with evisceration of the bowel and no covering of the bowel
Management
- Vaginal delivery may be attempted
- At delivery, cover exposed bowel in clingfilm, keep the baby warm and hydrated and aim to close the defect surgically as soon as possible, may be staged procedure
- Need TPN for few weeks
What is exomphalos and how is it managed?
Abdominal contents protrude through the anterior abdominal wall but are covered in an amniotic sac formed by amniotic membrane and peritoneum
Associations
- Beckwith-Wiedemann syndrome
- Down’s syndrome
- Cardiac and kidney malformations
Management
- C-section to reduce the risk of sac rupture
- Staged repair with loose elastic bandage at 6-12 months, harder than gastroschisis
How may an infant with hepatitis present?
- Asymptomatic
- Jaundice
- Poor growth
- Splenomegaly
- Enlarged liver
What are some causes and how is hepatitis treated in children?
(image important)
- Vitamin supplements
- Phenobarbital to control seizures but also stimulates liver to excrete additional bile
- Hepatitis A virus usually resolves itself within six months
- If cirrhotic then liver transplant
What is the criteria for acute liver failure in children?
Rapid decline of hepatic function, jaundice, coagulopathy (INR >1.5) and hepatic encephalopathy in patients with no evidence of previous liver disease.
What are some causes of acute liver failure in children?
Viral and bacterial infections: CMV, EBV, Herpes, Parvovirus, Hep B/C
Metabolic disorders: mitochondrial disorder, galactosemia and tyrosinemia
Toxic hepatitis: mushrooms, acetaminophen, valproate or fluconazole
What is the management for acute liver failure in children?
General
- Daily IV Vit K
- Ranitidine IV or orally/NG
- Lactulose TDS to achieve BO 3-4x per day
- If signs of encephalopathy nurse with head elevated at 10-20 degrees
- If encephalopathy grade 3 or above requires ventilation and sedation
- Maintain circulating volume and avoid fluid overload
- Make sure fluids have glucose in to keep blood glucose >4.5
What are the criteria for liver transplant in children?
Always be thinking about encephalopathy
What are causes of diarrhoea in children?
(image important)
Diarrhoea usually lasts for 5-7 days and stops within 2 weeks. If >2 weeks it is chronic
- Sepsis
- Infections: Viral (Rotavirus), Parasitic, HUS
- IBS
- IBD
- Coeliac’s
- NEC
- Food intolerance (Cow’s milk)
- Toddler’s Diarrhoea (contains undigested food)
- Thyrotoxicosis
- Post gastroenteritis lactose intolerance
What is the most important thing to assess when a child has diarrhoea?
DEHYDRATION
Assess hydration status as normal, dehydrated or shocked
What children with diarrhoea are at risk of being dehydrated?
How is acute diarrhoea in children managed?
- Increased fluid intake: admit for IV fluids if clinically dehydrated
- Avoid antidiarrhoeals
- Avoid fruit juice and carbonated drinks
- Hygiene advice: hand washing, avoid nursery for 48 hours after last episode, do not go swimming
If a child has chronic diarrhoea what do you need to be considering?
- Coeliac’s
- Lactose intolerance
- Toddler’s diarrhoea (limit fruit juice)
- IBD
- IBS
- Parasitic infection
What are some causes of vomiting in children?
- Posseting: effortless and normal after feeds
- GORD
- Over-feeding (150mL/kg/day is normal)
- Pyloric stenosis (projectile, at ~8 weeks old)
- Any infection, eg UTI
- Adverse food reaction
- Infective gastroenteritis
- Pharyngeal pouch
- Raised intracranial pressure
- Intestinal obstruction
What are some general and specific red flags for vomiting in infants?
General: signs of dehydration e.g drowsy or floppy, dry mucous membranes and sunken eyes
Specific
- Projectile vomiting around 6-8 weeks of age
- Bile-stained vomit and abdominal distention:
- Bloody stool with vomiting
- Paroxysmal coughing to the point of vomiting
- Seizures/bulging fontanelle with vomiting: raised intracranial pressure
What are some medical causes of abdominal pain in children?
What are some surgical causes of abdominal pain in children?
- Appendicitis
- Intususseption
- Bowel obstruction
- Testicular torsion
What are some red flags for serious pathology behind abdominal pain in children?
- Persistent or bilious vomiting
- Severe chronic diarrhoea
- Fever
- Rectal bleeding
- Weight loss or faltering growth
- Dysphagia
- Nighttime pain
- Abdominal tenderness
