Abdo Pain- GI +Lliver

Question 1

What happens in lactose intolerance?

Answer 1

Due to intestinal disaccharidase deficiency.
Mostly transient phenomenon post gastroenteritis but can be congenital.

Accumulation of sugar–> watery diarrhoea + B production of organic acid, which excoriates perianal region.
Dx-
+ve test for reducing substance (lactose is amreducing sugar)

Tx- lactose free diet

Question 2

What happens in food intolerances?

Answer 2

Mostly immune mediated reactions, usually to proteins.
Common foods: cows milk, soya, wheat, fish, eggs, nuts.
Dx- when sx are relieved by removal of a food and recur on reintroduction.
More common in infants with atopy or IgA deficiency.

Usually present with protracted diarrhoea and failure to thrive.
Avoid food until 2 years. Most patients grow out of intolerance by then, so conduct dietary challange.

Cows milk protein intolerance can lead to protein-losing enteropathy and blood loss. Manage with casein- hydrolysate based formula as infants likely ro become intolerant to soya ( ⬆️ Al3+ content, less absorption)

Question 3

Coeliac disease- what happens? How do we treat it?

Answer 3

Malabsorption due to gluten mediated damage to the mucosa of proximal intestine causing atophy of the villi and loss of absorptive surfcace.
Familial predisposition + ascc with HLA DQ2

CF
F to thrive when gluten introduced, w/ abdo distention and buttock wasting. Diarrhoea, irritability, anaemia due to iron or folate deficiency.

Dx- specific IgA antigliadin or antiemdomysial Abs for screening.
Definately by flat mucosa on jejunal biopsy which inpeoves on a gluten free diet and recurs on gluten challange.m

Mx- diet free gluten for life. Assc w/ other autoimmune disorders and increase risk of small bowel lymphoma (probs reduced by gluten free diet)

Question 4

IBD on kids- what happens?

Answer 4

1/4 onset in childhoood
PC- bloody diarrhoea, Lower abdo pain, F to thrive or wt loss.

Crohns- steroids, elemental diet, immunosupressives, surgery.
UC- aminosalicylates, steroids, colectomy.

Question 5

GO reflux- what happens? How do we treat it?

Answer 5

Common in infants- functional immaturity of lower Oesophageal sphincter. Most- mild- regurgitation, no tx, resolves.
Can help by thickening feeds, early weaning, alginate and antacid meds + positioning head up.
Minority: preterm, CP, congenital oesophageal abnormalitites and chronic lung disease- may be severe- F to thrive, oesophagitis (irritability, pain after bleeding, blood in vomit) , aspiration pneumonia.
Tx
Prokinetic drugs - domperidone + drugs to reduce gastric acid secretion and surgery if severe (Nissen fundoplication) .

Dx- clinically but confirm +’asses severity by 24hrs ambulatory oesophageal monitoring, barium studies- anatomical abnormality)’
, endoscopy (if oesophagitis,), nuclear milk scan.

Question 6

Are worm infx common?

Answer 6

Threadworms are very commom

Young children may also get dog or cat worms

Question 7

Whats mesenteric adenitis?

Answer 7

Non specific inflammation of lymph nodes provokes a peritoneal reaction mimicking appendicitis.
Common, assc w/ fever, headache, pharingitis and cervical lymphadenopathy. May need obs in hosp due to difficult diagnosis so manage conservatively. If persists, may need surgical exploration.

Question 8

Whats toddlers diarrhoea?

Answer 8

Well thriving child with persistent loose stools. Due to maturational delay in intestinal mobility causing reduced transit time (not enough time for Na therefore H20 to be reabs) and undigested veggies.

Question 9

What happens in pyloric stenosis?

Answer 9

Persistent projective vomiting in a hungry baby w/ reduced stool output, visible peristalsis and palpable pyloric mass.
Typically boys between a few weeks -3M, often FHx.
Develop wt loss, consyipation, mild jaundice (no fats for bile to go to) , dehydration (no H2O abs)
❗️ risk of hypocholaraemic metabolic alkalosis (vomit acid, u lose ⬆️⬆️ H+) due to hypertrophy of smooth muscle of pylorous.

Dx- clinically by feeling hypertrophic pylorous during test feed. (Olive, RUQ) . USS can confirm.

Corrct dehydration + electrolyte imbalance first.
Then manage surgically by Ramsteudt’s procedure- divide musculature.

Question 10

What happens in constipation?

Answer 10

Simple-
Febrile illnes or dehydration cause hard stool. -> discomfort or pain on defaecatinh and maybe anal fissure leading to retention of faeces. Rectal capacity imcreases leading to further retention and increased discomfort in a vicious cycle. May get overflow incontenence as child gets used to full rectum.
❗️ need to empty rectum first.
Tx- improve diet, encourage regular toileting and giving stool softeners e.g lactulose, or if severe
Drugs to increase intestinal mobility - senna, picosulphate.

Organic causes- Hirschprungs, hypercalcaemia, hypothyroidism.

Question 11

‼️❌❌ what are the red flags in a vomitting child?

Answer 11

Bile stained vomit- intestinal obstruction
Haematemesis- oesophagitis, peptic ulceration, oral/ nasal bleed
Projectile vomiting in first life weeks- pyloric stenosis
Vomiting at the end of paroxysmal coughing- whioping cough (pertussis)
Abdominal tenderness/abdo pain on movement- surgical abdo
Abdo distention- intestinal obstruction, strangulated inguinal hernia
Hepatosplenomegaly- chronic liver disease
Blood in stool - intussusception, gastroenteritis( salmonella, campylobacter)
Severe dehydration, shock: severe gastroenteritis, systemic infx (UTI), meningitis) ,DKA
Bulging fontanelle or seizures- raised ICP

F to thrive- Gastro-oesophageal reflux, coeliac disease, chronic gastrointestinal conditions.

Question 12

Vomittimg in infants- causes?

Answer 12

Common chronic causes- gastro-oesophageal reflux and feeding problems e.g. Force feeding or overfeeding.

If transient w/ other sx-fever, diarrhoea or runny nose, cough, most likely to be gastroenteritis or resp tract infx, but consider UTI and meningitis!!

If projectile at 2-7 weeks exclude pyloric stenosis.

If bile stained- exclude intestinal obstruction, esp intussusception, malrotation and strangulated inguinal hernia.
Asses for dehydration and shock.

Question 13

What are some common gastro oesophageal reflux complications?

Answer 13

F to thrive from severe vomiting
Oesophagitis- haematemesis, discomfort on feedinh or heartburn, iron deficiency anaemia.
Recurrent pulmonary aspiration- recurrent pneumonia, cough or wheeze, apnoea in preterm infants.

Dystonic neck posturing- sandifier syndrome
Apparent life threatening events- ALTE

Question 14

What are some vomiting causes in infants?

Answer 14

❗️GORD, Feeding problems, infx. –
gastroenteritis, resp tract/ ottitis media, whooping cough, urinary tract, meningitis.
❗️Dietray protein intolerances, intestinal obstr
↪️ pyloric stenosis, duodenal atresia + other sites. Intussusception, malrotation, volvulus, duplication cysts, strangulated inguinal hernia, Hischspurg disease.
‼️
Inborn errors of metabolism, congenital adrenal hyperplasia, RF.

Question 15

Causes of vomiting in preschool kids- causes?

Answer 15

Gastroenteritis, infection…Appendicitis, intestinal obstruction, (adhesions, foreign boddy-bezoar) , ⬆️ ICP, coeliac disease, RF, inborn errors of metabolism, torsion of the testes :(

Question 16

Causes of vomit in schl age and adolescents-?

Answer 16

GAstroenterits, infx- pyelonephritis, septicaemia, meningitis
Peptic ulceration + H. Pylori infx
Appendicitis, migraine, raised ICP, coeliac disease, RF, DKA, alcohol/drug ingestion or meds
Cyclical vomiting syndrome
Bulimia/anorexa nervosa
Pregnancy
Torsion of testes

Question 17

GORD- what happens?

Answer 17

Otherwise fit kids, risk imcreased if neuromuscular probs or surgery to oesophagus or diaphragm.
Tx with upright positioning after feed, feed thickening (nestragel) , PPI, smts Nissens fundoplication.

Inx only if diagnosis unclear or complications occur.

Question 18

What happens in pyloric stenosis?

Answer 18

Boys more. Hx with maternal fhx
Signs- visible gastric peristalsis, palpable abdo mass- feels like an ‘olive’ on gentle, deep palpation halfway b/w right ribcage and umbilicus on test feed (breast feeding) and possible dehydration.

Assc w/ hyponatraemia, hypokalaemia, hydrochlorawmic alkalosis.

Dx- confirm by UsS
Tx- surgery (pyloromyotomy) after dehydration and correction of electrolyte imbalance.

Question 19

Surgical causes of acute abdo?

Answer 19

Intrabdomen 
Acute appendicitis ‼️ COMMONEST
Intestinal obstr including intussusception 
Inguinal hernia
Peritonitis- ruptured appendix, pts w/ ascites from nephrotic syndrome or liver disease- if fluid leaks in peritoneum. 
Inflamed meckel diverticulum
Pancreatitis
Trauma

Question 20

Medical causes of acute abdo?

Answer 20

Non specific  abdo pain- . 
Gastroenteritis
Urinary tract( uncommon cause of abdo pain) - UTI, acute pyelonephritis, hydronephrosis, renal calculus- take urine sample to see if DM or liver disease. 
Henoch Schonlein purpura
DKA
Sickle cell disease
IBD
Hepatitis
Comstipatiom
Recurrent abdo pain of childhood
Psychological
Lead poisoning
Acute porphyria (rare) 
Unknown

Question 21

What are some extra abdominal causes of acute abdo pain?

Answer 21

URTI
Lower lobe pneumonia
Torsion of testes
Hip and spine

Question 22

What happens in acute appendicitis?

Answer 22

Uncommon in

Question 23

Acute abdo pain in older kids and adolescents??

Answer 23

Exclude med causes esp lower lobe pneumonia, DKA, hepatitis, pyelonephritis.
Check for strangulated inguinal hernia or torsion of testes.
To distinguish acute appendicitis and non spesific cause- close monitoring

Question 24

What happens in non specific abdo pain and mesenteric adenitis?

Answer 24

resolves in 24-48hrs- often accompined by URTI w/ cervical lymphadenopathy. - dx of mesenteris adenitis- only when on laparoscopy normal appendicitis but large mesenteric nodes found

Question 25

Why arent anti diarrhoeal drugs like loperamide, lomotil and entiemetics used in gastroenteritis?

Answer 25

Ineffective
May prolong excretiom of bacteria in stools,
SE
Add to cost unessesarily
Focus attention away fro, oral rehydration.

Question 26

Whats infantile colic?

Answer 26

Recurrent inconsolable crying accompanied by drawing up legs.
Common amd benign.
Usually resolves by 4M .

Question 27

When are antibiotics used in gastroenteritis?

Whats the main tx?

Answer 27

Not routinely, even if bacterial cause.
Only used if suspected or confirmed sepsis, extra intestinal spread of B infx, for :
Salmonella gastroenteritis

Question 28

What conditions can mimic gastroenteritis?

Answer 28

Systemic infx- septicaemia, meningitis
Local infx- RTI, otitis media, hep A, UTI
Surgical disorders- pyloric stenosis, intussusception, acute appendicitis, necrotising enterocolitis, Hirschsprung D.
Metabolic- DKA
Renal disorder- haemolytic uraemic syndrome

Other
Coeliac, cows milk protein intolerance, adrenal insufficiency.

Question 29

How does gastroenteritis presents? What might he the aetiology? What is a treatment?

Answer 29

10% present and 5% admissions.
PC: diarrhoea + vomitting,illness, abdo pain
blood or mucus in stools–> suggests invasive bacterial pathogen.
Usually mild + self-limiting.

Cause- usually viral ( esp developed countries rota virus-60%

Question 30

Gastroenteritis- what are the differences in developed and developing countries?

Answer 30

Developing:
Death: dehydration
Commonly caused by B from contaminated water and food,
Oral rehydration solution- saves lives

Developed:
Mostly viral but can be caused by campylobacter, shigella, salmonella.
Imfants! Susceptible - high Sa/V ratio
Dehydration assesed as non clinical, clinical and shocked according to sx.
Oral rehydration for most
IV fluids if shocked, ongoing vomiting or clinical deterioration.

Question 31

What are some sx of clinical dehydration? What are the red flags (NICE) - risk of progression to shock?

Answer 31

🇦🇱 appears unwell, deteriorating
🇦🇱altered responsivness, eg irritable, lethargic
🇦🇱Sunken eyes
🇦🇱Tachycardia
🇦🇱Tachypnoea
🇦🇱Reduced skin turgor 
Decreased UO
Normal skin colour
Warm extremities
Dry mucus membranes
Normal peripheral pulses and cap refill
Normal blood pressure

Question 32

What is the clinical assesment of a shocked child?

Answer 32

Appears unwell, deteriorating, 
Decreased consciousnes level
⬇️ UO
Pale
Cold extremities, grossly sunken eyes + tearless, sunken frontanelle
Dry mucous membranes
Tachycardia
Tachypnoea
Weak peripheral pulses
Prolonged cap refill (>2s) 
Reduced skin turgor
Hypotesntion - indicates decompensated shock

Question 33

What are the red flags for constipation and what are the diagnostic concerns following?

Answer 33

🇦🇱F to pass meconium- Hirschsprung disease
🇦🇱F to thrive/ grow- Hypothyroidism, coeliac, other
🇦🇱Gross Abdo distention- Hirschsprung , other GI dysmobility.
🇦🇱Abnormal lower limb neurology or deformity e.g talipes or 2o urinary incontenece- Lumbosacral pathology
🇦🇱Sacral dimple above natal cleft, over spine- naevus, hairy patch, central pit, or spdiscoloured skin – spina bifida occulta

🇦🇱Abn appearance/ position/ patency of anus- abnormal anorectal anatomy

🇦🇱Perianal bruising or multiple fissures- sexual abuse

🇦🇱Perianal fistulae, abscesses or fissures- Perianal Crohns disease.

Question 34

Whats Hirschsprung disease? How dow er diagnose it!?

Answer 34

Abscence of myenteric + submucosal plexuses of rectum and variable colon distance.
PC: intestinal obstr in newborn followinh delay in passing meconium. In later life- chronic constipation, abdo distention + Growth F.
Diagnosis:
Suction rectal therapy- abscence of ganglion cells
Mx- colostomy + anastomosis.

Question 35

How do you manage non clinical dehydration?

Answer 35

PREVENT D
Continue breast feed
Encourage fluid intake to compensate for GI losses
Discourage fruit juices amd carbonated drinks
Oral Rehydration Solution (ORS) as a supplement fluid if an increased risk for dehydration

Question 36

How do you manage clinical dehydration?

Answer 36

ORS 50ml/kg over 4 hours, (often + small amounts)
Continue breast feeding
Give ORS by NG tube if vomiting
⬇️
If deteriorating or presistent vomitting/ or sx/signs of shock improve:
⬇️
IV therapy for redydration
Replace fluid deficit + give maintenance fluids
Fluid deficit : 100ml/kg (10% body wt) initially if shocked, 50ml if not.
0.9% NaCl solution +- 5% glucose solution.
Monitor:
Plasma electrolytes, urea, creatinine + glucose. Consider K IV.
Continue breast feed if possible
⬇️
After rehydration
Give full strength milk and reintroduce solid food. Avoid fruit juices and carbonated drinks
Parents: hand washing ! Towels used by infected child not to be shared. Do not return to kids facility until 48 hrs after last episode.

Question 37

How do you initially manage a shocked child?

Answer 37

Rapid infusion of 0.9% NaCl. Repeat if necessary.

If remains shocked consider ICU

Question 38

What are some uncommom causes of nutrient malabsortpion?

Answer 38

Cholesystic Liver disease or biliary atresia- bile salts not in duodenum- fat and fat soluble malabsorption result.

Lymphatic leakage or obstruction- chylomicrons (abs lipid) unable to reach thoracic duct + systemic circulation e.g. By intestinal lympangiectasia.

Short bowel syndrome
SI resection due to necrotising enterocolitis or cong abn-> nutrient, water, electrolyte malabsortpion

Loss of terminal ileum fx
Resection or Crohns- abscent bile acid and Vit B12 absorption

Exocrine pancreatic dysfuntion- e.g. Cystic fibrosis
Abscent Lipase, proteases and amylase– defective digestion of triglyceride , protein and starch (pan nutrient malabrosption).

Small intestinal mucosa disease
Loss of abs area- Coeliac
Specific enzyme defects- e.g. Lactase deficiency following gastroenterocolitis common in Black

Sp transport defects- e.g. Glucose- halactose malabsorption (severe life threateninh diarrhoea with first milk fed) 
Acrodermatitis enteropathica (Zn malabsorption + erythematous rash of mouth and anus).

Question 39

What do you think with chronic diarrhoea?

Answer 39

Infant + F to thrive, consider coeliac + cows milk protein allergy.

Following gastroenteritis, consider post-gastroenteritis syndrome + assc temporary lactose intolerance

Following bowel resection, cholestatic liver disease or exocrine pancreatic dysfunction, comsider malabsorption.

In an otherwise well toddler with undigested veggies in stool consider Toddlers diarrhoea.

Question 40

How does usually Crohns presents in adolescents and childern?

Answer 40

Growth F, puberty delayed.
Classical presentation(25%) :
Abdo pain, diarrhoea, wt loss. 

General ill health:
Fever, lethargy, wt loss.

Extra intestinal manifestations:
Oral lesions, perianal skin tags
Uveitis
Arthralgia
Erythema nodosum

Question 41

How would you manage constipation?

Answer 41

1. Faeces palpable per abdomen?
   NO
   Encouragment + close supervision- psy support of indicated (older)
   + balanced diet + sufficient fluids + maintenance laxatives.

YES
2. Macrogol laxative e.g. Polyethylene glucol + electrolytes (Movicol Paediatric Plain) -2weeks.
Passed stool spontaneously? Yes- balanced diet….
NO
3. Stimulant laxative (senna, picosulphate) +/- osmotic laxative (lactulose) … Success? Balanced diet
NO?
4. Consider enema (+/- sedation) or under manual evacuation under general anaesthetic by paediatric specialist.

Question 42

What GI causes might cause recurrent abdo pain?

Answer 42

IBS
Constipation
Non-ulcer dysplesia
Abdo migraine
Gastritis and peptic ulceration
IBD
Malrotation

Question 43

What gynae reasons might cause recurrent abdo pain?

Answer 43

Dysmenorrhoea
Ovarian cysts
PID

Question 44

What psychosocial fx might cause recurrent abdo pain?

Answer 44

Bullying, abuse, stress

Small proportion

Question 45

What hepatobility/ pancreatic probs might cause recurrent abdo pain? ANy urinary tract problems?

Answer 45

Hepatitis,
Gall stones
Pancreatitis

UTI, pelvic ureteric junction (PUJ) obstruction

Question 46

What SS suggest an organic disease?

Answer 46

Epigastric pain at night, haematemesis( duodenal ulcer)
Diarrhoea, wt loss, GrowthF, blood in stools (IBD)
Vomiting (pancreatitis)
Jaundice(liver disease)
Dysuria , 2o enuresis (UTI)
Bilous vomiting + Abdo distention (malrotation)

Question 46

What happens in malrotation?

Answer 46

PC 1-3 days of life- intestinal obstruction with Ladd bands obstructing duodenum or volvulus.
Might present at any age w/ volvulus causing obstructiom and ischaemic bowel.

CF:
Bilous vomiting, abdo pain, tenderness from peritionitis or ischaemic bowel.
Bilous vomit-❗️ urgent upper GI contrast study

Tx- surgical correction

Question 47

What hapoens in meckels diverticulim?

Answer 47

2%,

Question 48

What happens in intussusception?

Answer 48

3M -2Y
CF- colicky pain, paroxysmal, pallor, abdo mass, redcurrant jelly stools,
Shock❗️ imp complication- urgent tx
Reduction- attempted by rectal air insufflation (squeeze colon) unless peritonitis present.

Surgery required if reduction w/ air unseccesful or peritonitis present.