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Paediatrics > Abdominal Issues > Flashcards

Abdominal Issues Flashcards

1
Q

What is the most common cause of constipation in children

A

dietary

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2
Q

What advise to give parents with children with constipation

A
  • Increase fibre and fluid intake
  • Increase activity levels
  • If progressive give a laxative
  • non-punitive behavioural interventions
  • Health visitor to support parents
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3
Q

Causes of constipation in children

A 
dehydration
low-fibre diet
medications: e.g. Opiates
anal fissure
over-enthusiastic potty training
hypothyroidism
Hirschsprung's disease
hypercalcaemia
learning disabilities
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4
Q

Red flags for constipation in children - possible underlying condition

A
  • No meconium >48hrs
  • reported from birth/first few weeks of life
  • Ribbon stools
  • weakness in legs, locomotor delay
  • distension
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5
Q

Amber flags for constipation in children - possible underlying condition

A
  • faltering growth

- Possibilty of child maltreatment

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6
Q

What symptoms suggest faecal impaction

A
  • overflow soiling
  • Symptoms of severe constipation
  • faecal mass palpable in abdomen
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7
Q

Management of faecal impaction

A
  • 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
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8
Q

What advise to you give to bottle fed infants with constipation

A
  • give extra water in between feeds.
    gentle abdominal massage
  • bicycling the infant’s legs
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9
Q

What advise to you give to breast fed infants with constipation

A

constipation is unusual and organic causes should be considered

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10
Q

Passage of meconium after 48 hours is suggestive of what condition

A

Hirshprungs disease (50%)

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11
Q

What condition may be present in the FH of a child with Hirshsprungs disease

A

MEN 2A/B

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12
Q

Symptoms of intussuception

A
  • Colicky pain
  • diarrhoea and vomiting
  • sausage-shaped mass
  • red jelly stool
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13
Q

Common age range for intussuception

A

6-9 months

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14
Q

What is Hirshprungs disease - doctor

A

Absence of ganglion cells from myenteric and submucosal plexuses

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15
Q

What is Hirshprungs disease - patient

A

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

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16
Q

How do you diagnose Hirshupsrungs disease

A
  • rectal biopsy
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17
Q

What is the definitive management of Hirshsprungs Disease

A

removal of aganglionic segment of bowel

rectal wash outs initially

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18
Q

Complications of Hirshrpungs Disease

A

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.

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19
Q

What are the main features of mesenteric adenitis

A

Central abdominal pain and URTI

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20
Q

What is the management of mesenteric adenitis

A

Conservative management

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21
Q

Symptoms of NEC

A
  • abdominal distention
  • bloody stool
  • billios vomiting
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22
Q

What may you see on abdominal x ray in NEC

A
  • pneumatosis - bubbles in bowel wall
  • bowel wall thickening
  • free air indicates perf
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23
Q

Management of NEC

A
  • Nil by mouth
  • TPN
  • IV ABX 10 - 14 days - amp/gent
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24
Q

What is a Wilms tumour

A
  • nephroblastoma
  • one of the most common childhood malignancies
  • typically presents < 5 years of age, with a median age of 3 years old.
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25
Q

What are the features of a Wilm’s Tumour

A

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)

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26
Q

What is the management of a Wilm’s tumour

A

nephrectomy
chemotherapy
radiotherapy if advanced disease
prognosis: good, 80% cure rate

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27
Q

Features of an atypical UTI

A 
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.
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28
Q

How to collect a urine sample in children

A
  • clean catch is preferable
  • urine collection pads
  • cotton wool balls, gauze and sanitary towels are not suitable
  • invasive methods as last resort
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29
Q

Management of UTI in chlidren

A
  • <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
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30
Q

When should you consider antibiotic prophylaxis in UTI in children

A

If recurrent infections

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31
Q

What questions regarding stool should you ask

A
  • Frequency
  • Time of day
  • Consistency
  • Blood
  • Mucus
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32
Q

Red flags for vomiting

A
  • Blood/billious
  • Projectile vomiting
  • Abdo tenderness/distension
  • Blood in stool
  • Bulging fontanelle
  • Altered concious level
  • Fever >38
  • persistent
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33
Q

Differentials for abdo pain in children

A
  • Constipation
  • GORD
  • gastritis/duodenitis
  • Abdo migraine
  • SI dysmotility
  • Malabsorption
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34
Q

What is coeliacs Disease

A
  • 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
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35
Q

What are the symptoms of Coeliacs Disease

A
  • Diarrhoea
  • Failure to thrive
  • Anaemia
  • Abdo protrustion
  • Fatigue
  • Arthralgia
  • Eczema
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36
Q

What other diseases are associated with coeliacs disease

A
  • T1DM

- Hypothyroidism

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37
Q

Investigations for coeliacs disease

A
  • FBC: anaemira
  • IgA anti-tissue transglutaminase
  • Endomysial antibodies
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38
Q

What may you see on biopsy of the small intestine in coeliacs disease

A

villous atrophy

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39
Q

When you should begin testing for coeliacs disease

A

> 18 months

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40
Q

What are the differentials for malabsorption

A
  • Coeliacs disease
  • Cystic fibrosis
  • Post-enteritis entropathy
  • Giardia
  • Rotavirus
  • Short bowel syndrome
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41
Q

Management of gastroenteritis in a child

A
  • Fluid challenge
  • Cont breast/bottle feed
  • Avoid fruit juices and carbonated drinks
  • Consider ORT or NGT
  • IV fluid
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42
Q

What is the fluid challenge

A

1ml/kg every 5 mins

50ml/kg/4 hours

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43
Q

When is the rotavirus vaccination given

A
  • 8 & 12 weeks old
  • Start before 15 weeks
  • Finish before 32 weeks
    (prevents intussusception)
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44
Q

Diarrhoea advice to parents

A
  • Diarrhoea 5-7 days (stop 2 w)
  • Encourage hand washing
  • Nursery 48h after LAST stool
  • HSP: unwell/male/lethargy/rash
  • Safety net
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45
Q

What investigations should you consider with gastroenteritis

A
  • Stool microscopy
  • Blood culture if Abx started
  • U&Es
  • Glucose
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46
Q

When should a renal US be done in children

A
  • Hydronephrosis: obstruction of vesicoureteric reflux

- <6 months confirmed UTI or atypical UTI

47
Q

What is and when should a micturating cytogram be done

A
  • Identifies vesicourteric reflux, bladder abnormalities or post-urethral valve issues
  • <6 mo atypical or recurrent UTI
  • > 6mo and USS findings
48
Q

What is DMSA and when is it done

A
  • Identifies scarring of the kidney due to UTI

- Recurrent UTI or <3yrs with atypical UTI

49
Q

Pre-existing fetures that pre-dispose children to AKI

A
  • Underlying pathology everywhere
  • Malginancy
  • Dependance on others for fluids
  • medications
50
Q

When should you investigate a UTI

A
  • <6months for first UTI (US)
  • Recurrent/atypical UTI (US)
  • ? structural abnormalatie
51
Q

What is minimal change nephrotic syndrome

A
  • Loss of structure of podocytes allowing protein through

- Assoc with IgE production

52
Q

Symptoms of minimal change nephrotic syndrome

A
  • Swelling: eyes then lower limbs
  • Infections: Abs lost in urine
  • Frothy oligouria
  • Blood clots
  • Anorexia
  • Ascites
53
Q

What might you see in blood tests in minimal change nephrotic syndrome

A
  • Decreased albumin <25

- Urea and createnine usually normal

54
Q

What might you see in the urine in minimal change nephrotic syndrome

A
  • Proteinurea ?200
  • P:Cr >200
  • A:cr >30
55
Q

Causes of nephrotic syndrome

A
  • Glomerulosclerosis
  • Glomerulonephritis
  • Diabetes
  • Infections: HIV/Hep
  • Lupus
  • Sickle cell
  • Leukaemia
56
Q

What are the ALARM symptoms in chronic abdominal pain in children

A 
Involuntary weight loss
linear growth deceleration
GI blood loss
Significant vomiting
Chronic severe diarrhoea
Persistent right sided abdominal pain
FH of IBD
Unexplained fever
57
Q

What are the 2 age peaks of chronic abdominal pain in children

A

4-6 and 7-12

58
Q

What is the management of children with abdominal pain without ALARM symptoms

A

reassurance
family educations
encouragement of return to normal function

59
Q

What investigations would you do if patients were presenting with ALARM symptoms

A

FBC/CRP/ESR/U&Es/LFTs/Coeliac screen
urine analysis
stool M&C
faecal calprotectin

60
Q

What os the gold standard of diagnosing IBD

A

upper and lower GI endoscopies with serial mucosal biopsies

61
Q

What is the management of a child with a first presentation or a single inflammatory exacerbation of Crohn’s in a 12 month period?

A

glucocorticoids - first line monotherapy

  • pred/methylpred
  • IV hydrocortisone
62
Q

What is the management of constipation in children without impaction

A
  1. Maintenace macrogol e.g. movicol

2. stimulant laxative e.g. docusate, senna or sodium picosulphate

63
Q

How does cows protein milk allergy present

A
  • faltering growth
  • worsening vomiting after feeds
  • discomfort after feeding
  • presents weeks to months
  • IgE mediated presentaiton - rash/facial swelling
64
Q

what is the management of cows protein milk allergy

A
  1. Paediatric dietician
  2. trial on extensively hydrolysed formula
  3. Trial of amino acid formula
65
Q

Risk factors of GORD

A
  • 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
66
Q

When does GORD usually present

A
  • 8 weeks

- usually resolves by 1 year

67
Q

Symptoms of GORD in an infant

A
  • 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
68
Q

Same day admission for babies with GORD if

A
  • Haematemesis (not caused by swallowed blood from a nosebleed or ingested from a cracked maternal nipple).
  • Melaena.
  • Dysphagia.
69
Q

Specialist referal for babies with GORD if

A
  • uncertain diagnosis or ‘red flag’ symptoms
  • Persistent faltering growth associated with regurgitation.
  • Suspected complications: recurrent aspiration pneumonia, or unexplained apnoeas.
70
Q

WHat is the management of GORD in breast fed infants

A

1-2 week trial of baby gaviscon

71
Q

WHat is the management of GORD in formula fed infants

A
  1. reduction of the volume of feeds
  2. more frequent feeds
  3. thickened feeds (for example Instant Carobel®)
  4. Gaviscon® Infant.
72
Q

What is the next step if gaviscon infant doesn’t work in babies with GORD

A
  1. continue bt stopped every 2 weeks to see if any improvement
  2. 4 week trial omeprazole/ranitidine
73
Q

What is Meckel’s Diverticulum

A
  • failure of the vitelline duct to obliterate during the fifth week of fetal development
  • most common congenital defect of small bowel
  • if symptomatic <2YO
74
Q

Signs and symptoms of Meckels diverticulum

A
  • Fresh PR blood
  • chronic constipation
  • abdo pain
  • Nausea/vomiting (signs of obstruction)
75
Q

What investigations should be completed if concerned of Meckel’s Diverticulum

A
  • FBC
  • Meckel’s scan - technetium 99 pertechnenate scan
  • Abdo XR
76
Q

What is the management of Meckel’s Diverticulum

A
  • if incidental finding - No Rx

- Surgery - excision of diverticulum

77
Q

What investigations should be carried out if suspecting IBD

A
  • FBC/ESR/CRP/U&Es
  • faecal calprotectin
  • Stool M&C
78
Q

How do you induce remission of Crohns disease

A
  1. glucocorticoid steroids (pred/methylpred)
  2. Add in azathioprine or mercaptopurine
  3. Methotrexate
79
Q

When do you consider enteral feeding in patients who are having remission induced for Crohns disease

A
  • concerns about faltering growth

- side effects of glucocorticoids

80
Q

What should you investigate for prior to starting azathioprine or mercaptopurine

A

TMPT activity

81
Q

Who should be started on methotrexate for Crohns

A
  • TMPT activity is deficient
  • > 2 inflammatory exacerbations in a 12-month period
  • the glucocorticosteroid dose cannot be tapered.
82
Q

How do you maintain remission in patients with Crohns disease

A
  1. azathioprine/mercaptopurine

2. methotrexate

83
Q

Who should use methotrexate to maintain remission with Crohns

A
  • 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).
84
Q

How do you manage mild/moderate proctitis in UC

A
  1. topical aminosalicyate/oral aminosalicyate (topical better)
  2. add in topical/oral steroid (4 weeks)
85
Q

How do you manage proctosigmoiditis and left sided disease in UC

A
  1. topical aminosalicyate
  2. high dose oral aminosalicyate/short course steroid
  3. Inflixmab
86
Q

How do you maintain remission in children with UC

A
  • topical aminosalicyaye

- topical and oral aminsalycate

87
Q

What is indeterminate colitis

A
  • subgroup of paediatric IBD
  • early onset in the first years of life
  • rapidly progressive to pancolitis.
  • overlapping features of Crohns + UC
88
Q

what must you rule out if a baby has billious vomits

A

intestinal obstruction

89
Q

What is the daily recommended feed for babies

A

150ml/skg

100mls/kg maintenance

90
Q

What are the complications of GORD

A

reflux oesphagitis
recurrent aspiration penumonia
otitis media
dental erosion

91
Q

what must you do in bottle fed babies before trialing them on gaviscon

A

STOP the thickener! Feed will become too think.

92
Q

Who should be trialed on a 4 week course of acid suppressing drugs?

A

overt regurgitation with unexplained feeding difficulties
faltering growth
Distressed behaviours

93
Q

What featues would warrant an upper GI endoscopy?

A 
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
94
Q

What features would warrant an oesophageal pH/impendence study

A 
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
95
Q

A UTI should be considered in infants with regurg if:

A

faltering growth
late onset >8w
frequent regurg and marked distress

96
Q

Features of non IgE cows milk protein allergy

A 
vomiting
failure to thrive
rash
proctocolitis
stars in first 4w of life
97
Q

What is infantile hypertrophic pyloric stenosis

A
  • gradual hypertrophy of pyloric muscular wall following the initiation of enteral feeding.
  • Can lead to obstruction of pyloric lumen
  • evolves over first few weeks
98
Q

presentation of infantile hypertrophic pyloric stenosis

A
  • recurrent, projectile, non-billious vomiting
  • hungary
  • constpated
  • 2-6 weeks (up to 12w)
  • M>W 4:1
  • loss of weight/poor gain
99
Q

What may you see on abdo examination in a patient with pyloric stenosis?

A
  • nothing
  • visible peristaltic waves
  • palpable pyloric mass during a ‘test feed’
100
Q

What is the investigation of choice to detect pyloric stenosis

A

abdo US diagnostic if:

  • muscle wall thickness >4mm
  • pyloric canal >17mm
101
Q

what would you expect on a blood gas in an infant with pyloric stenosis

A

hypocloraemic, hypokalaemic metabolic alkalosis

102
Q

What is the treatment for pyloric stenosis

A

Ramstedt pylormyotomy

103
Q

What is a congenital hernia

A

The diaphragm does not fuse properly in utero resulting in abdominal organs migrating into the chest cavity

104
Q

What are the 2 main issues associated with congeital hernia

A
  1. pulmonary hypertension
  2. pulmonary hypoplasia.
    - compounded by dysfunction of the surfactant.
    - Often associated with cardiac anomalies
105
Q

What are the 3 main types of congenital hernia

A
  1. Posterolateral Bochdalek’s hernia
  2. Anterior Morgagni’s hernia
  3. hiatus hernia
106
Q

What is Posterolateral Bochdalek’s hernia

A
  • 6 weeks gestation
  • Left sided: 85% - small and large bowel as well as solid organs
  • Right sided: Liver and large bowel herniates
  • bilateral uncommon
107
Q

What is Anterior Morgagni’s hernia

A
  • herniates through foramen of Morgagni
  • 3% of diaphragmatic hernias
  • often small
  • easily repaired via the laparoscope.
108
Q

What is a hiatus hernia

A

Essentialyl GORD

often functional as opposed to structural

109
Q

What may been seen prenatally on US that indicates a possible congenital diaphragmatic hernia

A
  • polyhydramnios
110
Q

What signs may be seen on delivery in a baby with a congenital diaphragmatic hernia

A
  • 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.
111
Q

What is the immediate management of baby born with a significant congenital diaphragmatic hernia

A
  • 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
112
Q

What would bloody dirrhoea with assoc. renal impairment suggest

A

haemolytic uraemic syndrome - check for E.coli 0157 on stool culture

113
Q

When to refer cows milk protein allergy to secondary care

A 
IgE mediated response
faltering growth with >1 GI symptoms
systemic reactions
severe, delayed reactions
significant atopic eczema + food allergies
persistent parental concern

Paediatrics (21 decks)

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