7. GI major Flashcards
What are normal bowel movements for children?
-Around 3x a day for <6m
-1x a day for >3yrs
-Infrequent bowel movement is common in exclusively breastfed babies
-Passage of meconium is important to ask about
What features does constipation have in children?
-Infrequent passage of hard, pellet-like stools
-Excessive straining or painful defecation
-Overflow faecal incontinence
-<3 stools per week
-Chronic constipation = commonest at 2-4yrs
-Should be continent by age 2-3
What is faecal impaction?
-When there are no adequate bowel movements for days/weeks
-A large faecal mass becomes compacted in the rectum
-Leads to overflow soiling and symptoms of severe constipation
What is soiling?
-Faecal staining of underwear
-Results from leakage of liquid stool around impacted faeces (prolonged) - can be mistaken for diarrhoea
-Decreased urge to defecate due to loss of rectal sensation
What is encopresis?
-Involuntary passage of formed stools in inappropriate places (child is mature enough to be continent)
-May be due to overflow incontinence / sphincter disturbance / psychiatric illness
What risk factors are there for developing constipation?
-Low fibre diet, insufficient water intake
-Holding of stools
-Change in routine, lack of exercise
-Genetics
-Medication eg opiates
-Anal fissure
-Over-enthusiastic potty training
-Hypothyroidism, hypercalcaemia
-Learning disabilities, stress / psychiatric history
What red flags are associated with constipation?
-Issues from birth, failure to pass meconium
-Ribbon stools
-Abdominal distension
-Leg weakness
-Failure to thrive
-Perianal fistulae, abscesses, fissures
-Sacral dimple
-?Maltreatment
What causes idiopathic constipation?
-Cause of most cases
-Painful passage of hard stool causes anal fissure –> child holds in further stools to avoid pain
-Water reabsorbed from stool making it even harder to pass
What are the Rome criteria?
Fo diagnosis of constipation in children - requires at least 2 of the following at least once per week for at least 2 months:
-<3 defecations per week
->1 episode of incontinence per week
-Hx of stool retention
-Hx of painful / hard bowel movements
-Presence of large faecal mass in rectum
-Hx of large diameter stools that can block toilet
What is Hirschprung’s disease?
-Absence of ganglion cells in nerve plexus of bowel wall
-Associated with Down’s, more common in boys
-Diagnosed using barium enema / rectal biopsy, managed by surgical resection of affected area
-Presents in neonates with delayed passage of meconium and abdominal distension
-Can result in failure to thrive
-No Hx of faecal incontinence or fissure + empty rectum on examination (unlike in functional constipation
What are the different stages of management of constipation?
STAGE 1:
-Dietary ie fibre, increased water intake, limit squash + fizzy drinks
-Regular toileting
-Bowel diary
STAGE 2:
-Movicol for disimpaction and help with overflow
-Add lactulose if inadequate
-Consider manual evacuation under GA
STAGE 3:
-Maintenance laxatives / diet for 3-6m
STAGE 4:
-Vigilance, escalate treatment at first indications of recurrence
What are the clinical features of gastroenteritis?
-Diarrhoea lasting 5-7 days
-Vomiting lasting 1-2 days
-Fever, abdo pain
-Caused by rotavirus most commonly
–Less common = adenovirus, norovirus, salmonella, shigella
What are the clinical features of moderate dehydration (6-10%)
-Sunken eyes + fontanelle
-Decreased skin turgor
-Few wet nappies
-Dry mucous membranes
-Altered consciousness
-Tachycardia / tachypnoea
What are the clinical features of shock (>10%)?
-Decreased consciousness
-Cold extremities
-Pale / mottled skin
-Tachypnoea / tachycardia
-Low BP
-Prolonged CRT >5s
How do you calculate % fluid loss in dehydration?
-Body weight pre-illness X % body weight loss X 10
How should you manage gastroenteritis?
REHYDRATION
-Oral fluids 12ml/kg/h
-Oral rehydration solution 50ml/kg over 4h
-NG if cannot tolerate oral
-Ondansetron if vomiting
-IV fluid resus if in shock 20ml/kg saline
-Zinc
-Encourage breast feeding
What is the protocol for maintenance fluids for rehydration?
0.9% saline + 5% dextrose
-100ml/kg/24h if 0-10kg
-50ml/kg/24h if 10-20kg
-20ml/kg/24h if >20kg
What are the features of haemolytic uraemia syndrome?
-Low Hb, low platelets, raised urea
-Film will show schistocytes - fragmented red cells
-Bloody diarrhoea
-Associated with e.coli 0157 and shigella
-May require dialysis + blood transfusion – paediatric nephrology referral
What babies are most at risk of GORD?
-Preterm infants
-Cerebral palsy / Down’s
-Chronic lung disease
-NB reflux and colic are both common, benign and self-resolving
What causes GORD in infants?
-Lower oesophageal sphincter is abnormally relaxed, making it incompetent
-Non-forceful regurgitation of gastric contents
-Damage to gastric mucosa
How does GORD present in infants?
-Sleep disturbance
-Coughing
-Irritability
-Pain after feeding / resistance / arching
-Linked with apnoea
What complications can arise from GORD?
-Aspiration pneumonia
-Oesophagitis
-Bronchiectasis
-Failure to thrive
-Frequent OM
-Dystonic neck posturing
How is GORD managed?
-Small, regular feeds + wind baby during feeds
-Keep baby upright during feeds
-Sleep on back
-Add thickeners to feed / solids
-Gaviscon or omeprazole / ranitidine only if unexplained / faltering growth
-Metoclopromide can act as a prokinetic
-Nissen’s fundoplication done surgically if all else fails in cases of:
–Severe oesophagitis
–Recurrent apnoea
–Faltering growth
–Barrett;s oesophagus
–Extremely premature / neurodisability
What are some acute causes of vomiting?
-GI infection
-GI obstruction eg pyloric stenosis, atresia
-Adverse food reaction
-Raised ICP
-Poisoning
-Endocrine / metabolic
-Overfeeding
