Abdominal Issues Flashcards
What is the most common cause of constipation in children
dietary
What advise to give parents with children with constipation
- Increase fibre and fluid intake
- Increase activity levels
- If progressive give a laxative
- non-punitive behavioural interventions
- Health visitor to support parents
Causes of constipation in children
dehydration low-fibre diet medications: e.g. Opiates anal fissure over-enthusiastic potty training hypothyroidism Hirschsprung's disease hypercalcaemia learning disabilities
Red flags for constipation in children - possible underlying condition
- No meconium >48hrs
- reported from birth/first few weeks of life
- Ribbon stools
- weakness in legs, locomotor delay
- distension
Amber flags for constipation in children - possible underlying condition
- faltering growth
- Possibilty of child maltreatment
What symptoms suggest faecal impaction
- overflow soiling
- Symptoms of severe constipation
- faecal mass palpable in abdomen
Management of faecal impaction
- Movicol Paediatric Plain: escalating dose regimen
- Add stimulant laxative if no relief after 2 weeks
- inform families that disimpaction treatment can initially increase symptoms of soiling and abdominal pain
- continue medication at maintenance dose for several weeks after regular bowel habit is established, then reduce dose gradually
What advise to you give to bottle fed infants with constipation
- give extra water in between feeds.
gentle abdominal massage - bicycling the infant’s legs
What advise to you give to breast fed infants with constipation
constipation is unusual and organic causes should be considered
Passage of meconium after 48 hours is suggestive of what condition
Hirshprungs disease (50%)
What condition may be present in the FH of a child with Hirshsprungs disease
MEN 2A/B
Symptoms of intussuception
- Colicky pain
- diarrhoea and vomiting
- sausage-shaped mass
- red jelly stool
Common age range for intussuception
6-9 months
What is Hirshprungs disease - doctor
Absence of ganglion cells from myenteric and submucosal plexuses
What is Hirshprungs disease - patient
The bowel passes faececs by a squeezing motion, in this condition a part of the bowel is missing the nerve cells that cause this squeezing leading to a build and potentially a blockage of faeces in the bowel
How do you diagnose Hirshupsrungs disease
- rectal biopsy
What is the definitive management of Hirshsprungs Disease
removal of aganglionic segment of bowel
rectal wash outs initially
Complications of Hirshrpungs Disease
Soiling and incontinence (<1%)
Persisting constipation (~ 10%)
Leakage of the anastomosis.
Enterocolitis - one study reported an incidence of 12%[26].
Stricture of the resected segment - a late complication.
Late intestinal obstruction - possibly due to adhesions.
What are the main features of mesenteric adenitis
Central abdominal pain and URTI
What is the management of mesenteric adenitis
Conservative management
Symptoms of NEC
- abdominal distention
- bloody stool
- billios vomiting
What may you see on abdominal x ray in NEC
- pneumatosis - bubbles in bowel wall
- bowel wall thickening
- free air indicates perf
Management of NEC
- Nil by mouth
- TPN
- IV ABX 10 - 14 days - amp/gent
What is a Wilms tumour
- nephroblastoma
- one of the most common childhood malignancies
- typically presents < 5 years of age, with a median age of 3 years old.
What are the features of a Wilm’s Tumour
abdominal mass (most common presenting feature)
painless haematuria
flank pain
other features: anorexia, fever
unilateral in 95% of cases
metastases are found in 20% of patients (most commonly lung)
What is the management of a Wilm’s tumour
nephrectomy
chemotherapy
radiotherapy if advanced disease
prognosis: good, 80% cure rate
Features of an atypical UTI
Seriously ill Poor urine flow Abdominal or bladder mass Raised creatinine Septicaemia Failure to respond to treatment with suitable antibiotics within 48 hours Infection with non-E. coli organisms.
How to collect a urine sample in children
- clean catch is preferable
- urine collection pads
- cotton wool balls, gauze and sanitary towels are not suitable
- invasive methods as last resort
Management of UTI in chlidren
- <3 months refer immediately
- > 3 months but upper UTI consider admission
- > 3 months Lower UTI, antibiotics but return if no better in 24-48 hours
When should you consider antibiotic prophylaxis in UTI in children
If recurrent infections
What questions regarding stool should you ask
- Frequency
- Time of day
- Consistency
- Blood
- Mucus
Red flags for vomiting
- Blood/billious
- Projectile vomiting
- Abdo tenderness/distension
- Blood in stool
- Bulging fontanelle
- Altered concious level
- Fever >38
- persistent
Differentials for abdo pain in children
- Constipation
- GORD
- gastritis/duodenitis
- Abdo migraine
- SI dysmotility
- Malabsorption
What is coeliacs Disease
- Mainly affects small intestine
- Body has a reaction which makes it unable to digest gluten
- This includes barley, wheat and rye
- Can cause tummy pain, tiredness and weight loss
What are the symptoms of Coeliacs Disease
- Diarrhoea
- Failure to thrive
- Anaemia
- Abdo protrustion
- Fatigue
- Arthralgia
- Eczema
What other diseases are associated with coeliacs disease
- T1DM
- Hypothyroidism
Investigations for coeliacs disease
- FBC: anaemira
- IgA anti-tissue transglutaminase
- Endomysial antibodies
What may you see on biopsy of the small intestine in coeliacs disease
villous atrophy
When you should begin testing for coeliacs disease
> 18 months
What are the differentials for malabsorption
- Coeliacs disease
- Cystic fibrosis
- Post-enteritis entropathy
- Giardia
- Rotavirus
- Short bowel syndrome
Management of gastroenteritis in a child
- Fluid challenge
- Cont breast/bottle feed
- Avoid fruit juices and carbonated drinks
- Consider ORT or NGT
- IV fluid
What is the fluid challenge
1ml/kg every 5 mins
50ml/kg/4 hours
When is the rotavirus vaccination given
- 8 & 12 weeks old
- Start before 15 weeks
- Finish before 32 weeks
(prevents intussusception)
Diarrhoea advice to parents
- Diarrhoea 5-7 days (stop 2 w)
- Encourage hand washing
- Nursery 48h after LAST stool
- HSP: unwell/male/lethargy/rash
- Safety net
What investigations should you consider with gastroenteritis
- Stool microscopy
- Blood culture if Abx started
- U&Es
- Glucose
When should a renal US be done in children
- Hydronephrosis: obstruction of vesicoureteric reflux
- <6 months confirmed UTI or atypical UTI
What is and when should a micturating cytogram be done
- Identifies vesicourteric reflux, bladder abnormalities or post-urethral valve issues
- <6 mo atypical or recurrent UTI
- > 6mo and USS findings
What is DMSA and when is it done
- Identifies scarring of the kidney due to UTI
- Recurrent UTI or <3yrs with atypical UTI
Pre-existing fetures that pre-dispose children to AKI
- Underlying pathology everywhere
- Malginancy
- Dependance on others for fluids
- medications
When should you investigate a UTI
- <6months for first UTI (US)
- Recurrent/atypical UTI (US)
- ? structural abnormalatie
What is minimal change nephrotic syndrome
- Loss of structure of podocytes allowing protein through
- Assoc with IgE production
Symptoms of minimal change nephrotic syndrome
- Swelling: eyes then lower limbs
- Infections: Abs lost in urine
- Frothy oligouria
- Blood clots
- Anorexia
- Ascites
What might you see in blood tests in minimal change nephrotic syndrome
- Decreased albumin <25
- Urea and createnine usually normal
What might you see in the urine in minimal change nephrotic syndrome
- Proteinurea ?200
- P:Cr >200
- A:cr >30
Causes of nephrotic syndrome
- Glomerulosclerosis
- Glomerulonephritis
- Diabetes
- Infections: HIV/Hep
- Lupus
- Sickle cell
- Leukaemia
What are the ALARM symptoms in chronic abdominal pain in children
Involuntary weight loss linear growth deceleration GI blood loss Significant vomiting Chronic severe diarrhoea Persistent right sided abdominal pain FH of IBD Unexplained fever
What are the 2 age peaks of chronic abdominal pain in children
4-6 and 7-12
What is the management of children with abdominal pain without ALARM symptoms
reassurance
family educations
encouragement of return to normal function
What investigations would you do if patients were presenting with ALARM symptoms
FBC/CRP/ESR/U&Es/LFTs/Coeliac screen
urine analysis
stool M&C
faecal calprotectin
What os the gold standard of diagnosing IBD
upper and lower GI endoscopies with serial mucosal biopsies
What is the management of a child with a first presentation or a single inflammatory exacerbation of Crohn’s in a 12 month period?
glucocorticoids - first line monotherapy
- pred/methylpred
- IV hydrocortisone
What is the management of constipation in children without impaction
- Maintenace macrogol e.g. movicol
2. stimulant laxative e.g. docusate, senna or sodium picosulphate
How does cows protein milk allergy present
- faltering growth
- worsening vomiting after feeds
- discomfort after feeding
- presents weeks to months
- IgE mediated presentaiton - rash/facial swelling
what is the management of cows protein milk allergy
- Paediatric dietician
- trial on extensively hydrolysed formula
- Trial of amino acid formula
Risk factors of GORD
- Premature birth.
- Parental history of heartburn or acid regurgitation.
- Obesity.
- Hiatus hernia.
- History of congenital diaphragmatic hernia (repaired) or congenital oesophageal atresia (repaired).
- Neurodisability - cerebral palsy
When does GORD usually present
- 8 weeks
- usually resolves by 1 year
Symptoms of GORD in an infant
- Distressed behaviour shown: by excessive crying, crying while feeding, and adopting unusual neck postures.
- Hoarseness and/or chronic cough.
- A single episode of pneumonia.
- Unexplained feeding difficulties.
- Faltering growth
Same day admission for babies with GORD if
- Haematemesis (not caused by swallowed blood from a nosebleed or ingested from a cracked maternal nipple).
- Melaena.
- Dysphagia.
Specialist referal for babies with GORD if
- uncertain diagnosis or ‘red flag’ symptoms
- Persistent faltering growth associated with regurgitation.
- Suspected complications: recurrent aspiration pneumonia, or unexplained apnoeas.
WHat is the management of GORD in breast fed infants
1-2 week trial of baby gaviscon
WHat is the management of GORD in formula fed infants
- reduction of the volume of feeds
- more frequent feeds
- thickened feeds (for example Instant Carobel®)
- Gaviscon® Infant.
What is the next step if gaviscon infant doesn’t work in babies with GORD
- continue bt stopped every 2 weeks to see if any improvement
- 4 week trial omeprazole/ranitidine
What is Meckel’s Diverticulum
- failure of the vitelline duct to obliterate during the fifth week of fetal development
- most common congenital defect of small bowel
- if symptomatic <2YO
Signs and symptoms of Meckels diverticulum
- Fresh PR blood
- chronic constipation
- abdo pain
- Nausea/vomiting (signs of obstruction)
What investigations should be completed if concerned of Meckel’s Diverticulum
- FBC
- Meckel’s scan - technetium 99 pertechnenate scan
- Abdo XR
What is the management of Meckel’s Diverticulum
- if incidental finding - No Rx
- Surgery - excision of diverticulum
What investigations should be carried out if suspecting IBD
- FBC/ESR/CRP/U&Es
- faecal calprotectin
- Stool M&C
How do you induce remission of Crohns disease
- glucocorticoid steroids (pred/methylpred)
- Add in azathioprine or mercaptopurine
- Methotrexate
When do you consider enteral feeding in patients who are having remission induced for Crohns disease
- concerns about faltering growth
- side effects of glucocorticoids
What should you investigate for prior to starting azathioprine or mercaptopurine
TMPT activity
Who should be started on methotrexate for Crohns
- TMPT activity is deficient
- > 2 inflammatory exacerbations in a 12-month period
- the glucocorticosteroid dose cannot be tapered.
How do you maintain remission in patients with Crohns disease
- azathioprine/mercaptopurine
2. methotrexate
Who should use methotrexate to maintain remission with Crohns
- needed methotrexate to induce remission
- have tried but did not tolerate azathioprine mercaptopurine for maintenance
- have contraindications to azathioprine mercaptopurine (deficient TPMT activity/ previous pancreatitis).
How do you manage mild/moderate proctitis in UC
- topical aminosalicyate/oral aminosalicyate (topical better)
- add in topical/oral steroid (4 weeks)
How do you manage proctosigmoiditis and left sided disease in UC
- topical aminosalicyate
- high dose oral aminosalicyate/short course steroid
- Inflixmab
How do you maintain remission in children with UC
- topical aminosalicyaye
- topical and oral aminsalycate
What is indeterminate colitis
- subgroup of paediatric IBD
- early onset in the first years of life
- rapidly progressive to pancolitis.
- overlapping features of Crohns + UC
what must you rule out if a baby has billious vomits
intestinal obstruction
What is the daily recommended feed for babies
150ml/skg
100mls/kg maintenance
What are the complications of GORD
reflux oesphagitis
recurrent aspiration penumonia
otitis media
dental erosion
what must you do in bottle fed babies before trialing them on gaviscon
STOP the thickener! Feed will become too think.
Who should be trialed on a 4 week course of acid suppressing drugs?
overt regurgitation with unexplained feeding difficulties
faltering growth
Distressed behaviours
What featues would warrant an upper GI endoscopy?
haematemesis/malaena dysphagia no improvement of regurg >1yo persistent faltering growth assoc with overt regurg feeding aversion + hx of regurg iron deficient anaemia - unexlpained ? Sandifers syndrome
What features would warrant an oesophageal pH/impendence study
suspected recurrent aspiration pneumonia unexplained nonepileptic seizurelike events Possible need for fundoplication ? Sandifer's syndrome unexplauned apnoeas Unexplained upper airway inflammation dental erosion assoc. with neuro disability frequent otitis media
A UTI should be considered in infants with regurg if:
faltering growth
late onset >8w
frequent regurg and marked distress
Features of non IgE cows milk protein allergy
vomiting failure to thrive rash proctocolitis stars in first 4w of life
What is infantile hypertrophic pyloric stenosis
- gradual hypertrophy of pyloric muscular wall following the initiation of enteral feeding.
- Can lead to obstruction of pyloric lumen
- evolves over first few weeks
presentation of infantile hypertrophic pyloric stenosis
- recurrent, projectile, non-billious vomiting
- hungary
- constpated
- 2-6 weeks (up to 12w)
- M>W 4:1
- loss of weight/poor gain
What may you see on abdo examination in a patient with pyloric stenosis?
- nothing
- visible peristaltic waves
- palpable pyloric mass during a ‘test feed’
What is the investigation of choice to detect pyloric stenosis
abdo US diagnostic if:
- muscle wall thickness >4mm
- pyloric canal >17mm
what would you expect on a blood gas in an infant with pyloric stenosis
hypocloraemic, hypokalaemic metabolic alkalosis
What is the treatment for pyloric stenosis
Ramstedt pylormyotomy
What is a congenital hernia
The diaphragm does not fuse properly in utero resulting in abdominal organs migrating into the chest cavity
What are the 2 main issues associated with congeital hernia
- pulmonary hypertension
- pulmonary hypoplasia.
- compounded by dysfunction of the surfactant.
- Often associated with cardiac anomalies
What are the 3 main types of congenital hernia
- Posterolateral Bochdalek’s hernia
- Anterior Morgagni’s hernia
- hiatus hernia
What is Posterolateral Bochdalek’s hernia
- 6 weeks gestation
- Left sided: 85% - small and large bowel as well as solid organs
- Right sided: Liver and large bowel herniates
- bilateral uncommon
What is Anterior Morgagni’s hernia
- herniates through foramen of Morgagni
- 3% of diaphragmatic hernias
- often small
- easily repaired via the laparoscope.
What is a hiatus hernia
Essentialyl GORD
often functional as opposed to structural
What may been seen prenatally on US that indicates a possible congenital diaphragmatic hernia
- polyhydramnios
What signs may be seen on delivery in a baby with a congenital diaphragmatic hernia
- Cyanosis soon after birth.
- Tachypnoea.
- Tachycardia.
- Asymmetry of the chest wall.
- Absent breath sounds on one side of the chest
- Bowel sounds audible over the chest wall.
- abdomen possibly feels ‘less full’ on palpation.
What is the immediate management of baby born with a significant congenital diaphragmatic hernia
- resuciatet head up in bowel sounds in chest
- endotracheal tube if required
- avoid bag/mask ventilation 0 fills bowels impairing lung function further
- orogastric tube
- gases/bloods
What would bloody dirrhoea with assoc. renal impairment suggest
haemolytic uraemic syndrome - check for E.coli 0157 on stool culture
When to refer cows milk protein allergy to secondary care
IgE mediated response faltering growth with >1 GI symptoms systemic reactions severe, delayed reactions significant atopic eczema + food allergies persistent parental concern
