6I. T Gastro paeds Flashcards
Investigation - pyloric stenosis
Ultrasound to visualise thickened pylorus
Blood gas pyloric stenosis
Hypochloric, hypokalaemic metabolic alkalosis
Management pyloric stenosis
laparoscopic pyloromyotomy
known as Ramstedt’s pyloromyotomy
What type of jaundice causes dark urine and pale stools
In obstructive jaundice (both intrahepatic cholestasis and extrahepatic obstruction) the serum bilirubin is principally conjugated. Conjugated bilirubin is water soluble and is excreted in the urine, giving it a dark colour (bilirubinuria).
target like mass abdo scan
intussception
acute cyclical colicky abdominal pain and ‘currant jelly” stools. It may also present with vomiting, which in later stages may become bilious, but this is a rare and late feature
intussception
A 9-day-old pre-term neonate stops tolerating his cow’s milk feeds given by the nurses in the special care baby unit. He vomited after the most recent feed and the nurse noticed bile in the vomit. Stools are normal consistency but the last stool contained fresh red blood. On examination he is well hydrated but his abdomen is grossly distended and an urgent abdominal x-ray is requested. X-ray shows distended loops of bowel with thickening of the bowel wall
NEC
A father brings his 16-day old baby presents to the emergency department. The baby is visibly jaundiced and distressed, and the father explains the baby has not been feeding well since yesterday. Examination reveals hepatomegaly and splenomegaly. A newborn jaundice screen indicates no infection, normal thyroid function tests, raised conjugated bilirubin, liver transaminases and bile acids. The urine is negative for reducing substances
biliary atresia
a baby with a history of untreated prolonged jaundice becomes less responsive, floppy, drowsy, poor feeding
kernicterus
Travellers diarrhoea
Develops 2 to 5 days after:
Raw or improperly cooked poultry
Untreated water
Unpasteurised milk
Abdominal cramps
Diarrhoea often with blood
Vomiting
Fever
Cambylobacter jejuni
Abx if rf such as heart failure or HIV:
azithromycin or ciprofloxacin
Gastroenteritis symptoms soon after eating leftover fried rice that has been left at room temperature. It has a short incubation period after eating the rice before symptoms occur, and they recover within 24 hours.
Bacillus cereus
eating raw or undercooked pork can cause this infection. It is also spread through contamination with the urine or faeces of other mammal such as rats and rabbits.
watery or bloody diarrhoea, abdominal pain, fever and lymphadenopathy. Incubation is 4 to 7 days and the illness can last longer than other causes of enteritis with symptoms lasting 3 weeks or more.
Yersinia Enterocolitica
Infection may not cause any symptoms, or it may cause chronic diarrhoea.
Giardiasis
Metronidazole
Gastroenteritis spread through contact with infected faeces, unwashed salads or contaminated water.
E.coli 0157
Shigella
Both produce shiga toxin which can cause haemolytic uraemic syndrome
Gastroenteritis spread by eating raw eggs or poultry, or food contaminated with the infected faeces of small animals.
Salmonella
A 39 hour old neonate is brought to their GP by their parents. The child has not passed stool since being birthed at home and has started vomiting yellow/green liquid after feeding. On examination the childs stomach is grossly distended but with no palpable masses.
hirschsprung’s disease
2-4 weeks of birth with fever, abdominal distention, diarrhoea (often with blood) and features of sepsis.
Hirschsprung-Associated Enterocolitis
A 4-day-old girl who was diagnosed prenatally with Down’s syndrome and born at 38 weeks gestation presents with bilious vomiting and abdominal distension. She is yet to pass meconium.
hirchsprungs disease
A 5-week-old infant is brought into the emergency department by his mother with vomiting after every feed. The vomit is non-bilious, large volume and projectile. His mother reports this was initially small amounts of vomit and infrequent, but has increased in volume and regularity over the past week. The infant appears keen to try feeding again after each vomiting episode
pyloric stenosis
“Diarrhoea usually non-bloody, Weight loss more prominent, Upper gastrointestinal symptoms, mouth ulcers, perianal disease, Abdominal mass palpable in the right iliac fossa”
crohns
“Bloody diarrhoea more common, Abdominal pain in the left lower quadrant, Tenesmus”
ulcerative colitis
“abdo pain relieved by defecation, change in bowel habit, bloating, mucus”
IBS
Management idiopathic constipation
- Movicol paediatric plain
- Add stimulant laxative eg senna
- Add lactulose or docusate if stools are hard
4. Continue medication at maintenance dose for several weeks after regular bowel habit is established, then reduce the dose gradually
Management GORD paeds
- a trial of thickened formula (for example, containing rice starch, cornstarch, locust bean gum or carob bean gum)
- a trial of alginate therapy e.g. Gaviscon. Alginates should not be used at the same time as thickening agents
- PPI if unexplained feeding difficulties (for example, refusing feeds, gagging or choking)
distressed behaviour
faltering growth - prokinetic agents e.g. metoclopramide should only be used with specialist advice
- If there are severe complications (e.g. failure to thrive) and medical treatment is ineffective then fundoplication may be considered
Sandifer’s Syndrome
This is a rare condition causing brief episodes of abnormal movements associated with gastro-oesophageal reflux in infants. The infants are usually neurologically normal. The key features are:
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
The condition tends to resolve as the reflux is treated or improves.
Investigation and management pyloric stenosis
USS to visualise thickened pylorus
laparoscopic pyloromyotomy - known as “Ramstedt’s operation
GORD investigation if severe
24 hour oesophageal pH monitoring
Associations hirschsprungs disease
3 times more common in males
Down’s syndrome
“failure to pass meconium, constipation since birth, failure to thrive, vomiting, abdominal distension, failure to thrive”
hirschsprungs disease
“reflux of feeds, non-bilious” “refusing feeds, distress, pneumonia”
GORD
A 2-year-old child has a history of chronic constipation for the past year and chronic abdominal distention with vomiting for three months.
hirschsprungs
Investigations for hirschsprungs disease
abdominal x-ray (A plain abdominal x ray will demonstrate dilated loops of bowel with fluid levels and a barium enema can be helpful when it demonstrates a cone with dilated ganglionic proximal colon and the distal aganglionic bowel failing to distend.)
rectal biopsy: gold standard for diagnosis (The bowel histology will demonstrate an absence of ganglionic cells.)
management hirschsprungs disease
initially: rectal washouts/bowel irrigation
definitive management: surgery to affected segment of the colon
Hirschsprung-associated enterocolitis
Hirschsprung-associated enterocolitis (HAEC) is inflammation and obstruction of the intestine occurring in around 20% of neonates with Hirschsprung’s disease. It typically presents within 2-4 weeks of birth with fever, abdominal distention, diarrhoea (often with blood) and features of sepsis. It is life threatening and can lead to toxic megacolon and perforation of the bowel. It requires urgent antibiotics, fluid resuscitation and decompression of the obstructed bowel.
management meconium ileus
- PR contrast studies may dislodge meconium plugs and be therapeutic
- NG N-acetylcystine
- surgery
“failure to mass meconium, abdo distension, may or may not have obstructive symptoms”
meconium ileus
