Ch 13 - Gastroenterology Flashcards
Gastro-oesophageal reflux: RFs (3)
Mainly liquid diet
Mainly Horizontal posture
short intra-abdominal oesophageal length
Gastro-oesophageal reflux - features (5)
regurgitation/ vomitting difficulty feeding pain during/after feed aspiration apnoeic episodes putting on weight normally
Gastro-oesophageal reflux: Ix (3)
Clinical
24hr oesophageal pH monitoring: pH4 hrs
Endoscopy
Gastro-oesophageal reflux: management - conserative (3), medical (3), surgical (1)
Conservative - thickening agents e.g. nestargel/carobel, 30 degrees head up post feed, smaller more freq meals
Medical - Gaviscon, ranitidine, PPIs, domperidone
Surgical - if unresponsive to intensive medical treatment - Nissen’s fundoplication (fundus of stomach wrapped around intra-abdominal oesophagus)
Pyloric stenosis: Cause
Pyloric hypertrophy results in gastric outlet obstruction
Pyloric stenosis : Features (7)
age group 2-7 weeks
boys 4:1 with maternal FH
Vomiting (not bile stained) - becomes projectile eventually
hunger after vomiting - until dehydration leads to loss of interest
weight loss
hypocholraemic metabolic alkalosis (due to vomiting stomach contents) + hypokalaemia + hyponatremia
Pyloric stenosis: Ix (3)
Test feed (using milk) - may see peristalsis in abdomen Pyloric RUQ mass USS - if diagnosis still in doubt
Pyloric stenosis Management: (2)
First correct any fluid/electrolyte imbalance
Ramstedt’s pyloromyotomy - divide the hypertrophied muscle down to the mucosa
Crying - most imp cause: (1)
Colic: should resolve by 4 months of age; paroxysmal inconsolable crying + drawing up knees + passage of excessive flatus several times/day.
Acute appendicitis: features (5)
Colicky pain initally umbilical then localizes to RIF
Fever
anorexia
peritonitis - aggravated by movement
tenderness + guarding in RIF (mcburney’s point)
Acute appendicitis: Ix (2)
clinical
USS - may show thickened non-compressible appendix with increased blood flow
Acute appendicitis: management (2)
Appendicectomy; if guarding associated with perforation give IV fluids + ABs prior to surgery
If no peritonitis consider conservative management with delayed appendicectomy
Non-specific abdo pain + mesenteric adenitis features
NSAP - abdo pain self-resolves in within 48hrs +/- URTI & cervical lymphadenopathy
Mesenteric adenitis: preceding URTI > abdo pain (can only diagnose for sure if find children with large mesenteric LNs on laparscopy + normal appendix)
Intussusception: definition + age group
Invagination of proximal bowel into distal segment; commonly ileum into caecum via ileocaecal valve
Age - 3 months to 2 yrs
Intussusception: features (6)
Paroxysmal severe colicky pain
Pallor + drawing up of legs during episodes
Vomiting - bile stained
Abdo distension
‘Sausage shaped’ mass
‘Redcurrant jelly’ stool - blood-stained mucus
Intussusception: Ix (2)
USS - target like (doughnut) mass
AxR - Distended small bowel + no gas in distal colon/rectum
Intussusception: management (2)
IV fluid resusc > rectal air insufflation
surgery
Meckel Diverticulum: defintion + features (4)
Ileal remnant of vitello-intestinal duct (present at 2 yrs) Features: severe rectal bleeding Intussusception Volvulus around a band Diverticulitis which mimics appendicitis
Meckel diverticulum: Ix (1) & management (1)
Tecchnetium scan showing increased uptake by ectopic gastric mucosa
Surgical resection
Malrotation: definition
During foetal life if mesentery is not fixed, there can be incorrect positioning of intestingal components.
Ladd bands may obstruct duodenum ( so most common form of malrotation is where caecum stays high and fixed to the posterior abdo wall - it is fixed by these Ladd bands)
Volvulus may occur
Children present at 1-3 days of life (although can present later with bilous vomiting)
Malrotation: features (2 presentations)
Either features of obstruction alone - usually present with bilious vomiting
Or obstruction + compromised blood supply
Malrotation: Ix & management
Upper GI contrast study
Surgery - the malrotation isnt corrected as such, instead the mesentery is broadened + appendix removed
What is defined as recurrent abdo pain? (3)
Abdo pain affecting lifestyle > 3 months
A cause is identified in
Features of abdo migraine (4)
Abdo pain (midline)
headache
pallor + vomiting
FH of migraines
IBS: definition + features (4)
Diagnosis of exclusion! altered gut motility + altered perception of intra-abdo events
Features: abdo pain relieved by defacation, explosive stools, mucusy stools, cycles of constipation/diarrhoea, bloating, tenesmus
Peptic ulceration, gastritis & functional dyspepsia: cause (1), features (2), diagnosis (3)
H. pylori
Epigastric pain, relieved with food/milk
C13 breath test, stool test, urease detection
Peptic ulceration, gastritis & functional dyspepsia: Management (3)
Triple therapy: omeprazole +/- amoxicillin + clarithromycin/metronidazole
Functional dyspepsia - 3 features
Early satiety
post prandial vomiting
Delayed gastric emptying
Causes of gastroenteritis (6)
Rotavirus (developed countries)
Norovirus, adenovirus, coronavirus
Campylobacter (crampy abdo pain + bloody stool)
Shigella & salmonella (blood + pus in stool + pain)
Cholera
Dehydration: assessment (10)
Consciousness Fontanelle - sunken? sunken eyes Pale/mottled skin reduced cap refill Tachycardia Tachypnoea Oliguria sudden weight loss dry mucous membranes
Dehydration: grading (3)
None/ 10% of BW
Dehydration: Iso/hyponatremic vs hypernatremic dehydration
Iso/hypo - in developing countries due to malnourishment
Hypernatremic - fever/hot environment/ profuse low sodium diarrhoea: jittery movement, hyperreflexia, multiple small cerebral haemorrhages
Dehydration: complication of hyponatremic cases
this happens when children with diarrhoea drink lots of iso/hypotonic solution > means net loss of Na > H2O…so end up with hyponatremia. This means H2O moves from EC (plasma) into IC (cells) > brain swelling > convulsions.
Dehydration: physiology of hypernatremic cases
in some cases the loss of H20 exceeds loss of Na e.g. low Na diarrhoea. Here the hypernatremia leads to drawing in of H2O from IC to EC…which means the clinical signs of dehydration are far less pronounced e.g. sunken fontanelle, sking rugor etc. Making it MUCH HARDER to detect clinically. Loss of water from brain cells causes atrophy - leads to jittery movements, altered consciousness etc.
Dehydration: management (3)
Clincal dehydration - ORS (oral rehydration solution)
if hypernatremic dehydration - (need to be careful as giving fluid will rapidly reduce osmolality and H2O will enter brain cells > cerbral oedema) should be done over 48hrs with correction in OSMOLALITY at
Post-gastroenteritis syndrome: what is it? diagnosis? managment (2)
Return of watery diarrhoea following introduction of normal diet (after having had gastroenteritis)
Happens in some cases, temporary lactose intolerance may have developed > which can be diagnosed by seing unasborbed sugars in stool POSITIVE CLINITEST
Manage with ORS & continued introduction of normal diet
Coeliac disease: definition
Malabsorptive disease due to gluten intolerance - specifically gliadin
Coeliac disease: features (5)
Failure to thrive abdo distension foul-smelling stools wasting of buttocks anaemia
Coeliac disease: Diagnosis (2)
Endoscopy - jejunal biopsy: subtotal villous atrophy + crypt hyperplasia
Anti-tTGA abs + anti endomysial + anti gliadin abs
Coeliac disease: management (1)
gluten-free diet
Toddler diarrhoea: defintion
Commonest cause of perisistent lose stools in preschool children; most grow out of symptoms by 5 yrs
Toddler diarrhoea: feaures (3)
Stools of varying consistency, well formed to explosive
undigested veggies in stools
children well + thriving
Toddler diarrhoea: management (2)
Adequate fat in diet - to slow transit
low fruit juice - esp those high in non-absorbaly sorbitol
Crohn’s Disease: Definition, Features (6)
Inflammatory disease of GIT from mouth to anus; most commonly distal ileum + prox colon
Features: oral lesions, perianal skin tags, arthralgia, fistulae, (abdo pain + diarrhoea), growth failure/ delayed growth, cobblestone mucosa, weight loss
Crohn’s Disease: Diagnosis (2 )
endoscopy - non-caseating epitheloid granulomata
Faecal calprotectin
Crohn’s Disease: Management (4)
Remission induction: nutritional therapy - whole protein modular feeds for 8 weeks, steroids if nutrition therapy ineffective
Remission maintenance: azathioprine, methotrexate, mercaptopurine; infliximab
Surgical - obstruction, fistulae, abscesses
Ulcerative colitis - definition, features (6)
Inflammatory bowel condition affecting only COLON; beigns at anus and moves proximally
Features - colicky abdo pain, bloody stools, erythema nodosum, weight loss, arthritis, erythema nodosum
Ulcerative colitis: diagnosis (2)
Endoscopy - confluent colitis from recctum proximally
Histology - mucosal inflammation, cryp damage and ulceration
Ulcerative colitis: management (4)
Mild - aminosalicylates e.g. mesalazine
Severe - systemic steroids(acute), azatioprine (maintain remission)
Confined to rectosigmoid - topical steroids
Surgical - colectomy + ileostomy/ileorectal puch (if severe disease)
Normal bowel movements in following ages: Week 1, year 1, breast fed
Week-1: 4/day
1 year: 2/day
breast fed: may not pass stools for days and still be healthy
Red flags of constipation: what do they indicate?
No meconium within first 48hrs of life
Failure to thrive
Gross abdo distension
abnormal lower limb neurology/ deformity
Sacral dimple above natal cleft, over spine; naevus
Abnormal anal appearance/ position/ patency
Perianal bruising/ multiple fissures
Perianal fistulae
1 - Hirschsprung disease 2 - Coeliac, hypothyroid 3 - Hirschsprung disease/ other GI dismotility 4 - lumbosacral path 5 - spina bifida occulta 6 - anatomical abnormality 7 - sexual abuse 8 - Crohn's disease
Hirschsprung disease: definition
Absence of myenteric nerve plexuses > narrow contracted bowel segment
Hirschsprung disease: features in neonates (4)
NO MECONIUM in first 24hrs
Billous vomiting
abdo
release of flatus/ liquid stool when finger withdrawn from DRE
Hirschsprung disease - features in late childhood (2)
Chronic constipation (but no soiling) Growth failure
