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Block 41 > Child with elimination problem > Flashcards

Child with elimination problem Flashcards

1
Q

Possesting

A

Non-forceful return of small amounts of milk in accompaniment of return of swallowed air (wind)
Occurs in nearly all babies from time to time

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2
Q

Regurgitation

A

Larger, more frequent returns or losses of milk, may indicate presence of GORD

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3
Q

Vomiting

A

Forceful ejection of gastric contents

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4
Q

Red flags in vomiting

A

Bile stained vomit - intestinal obstruction
Haematemesis
Projective vomiting - pyloric stenosis
Vomiting after paroxysmal coughing - whooping cough
Abdo pain
Abdo distension
Hepatosplenomegaly
Blood in stool - intussusception
Severe dehydration/shock
Bulging fontanelle or seizures
FTT

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5
Q

Causes of vomiting in infants

A

GORD
Feeding problems
Infection
Gastroenteritis
Mengingitis
Pyloric stenosis
Intussusception
Hirschsprung’s disease

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6
Q

Causes of vomiting in preschool children

A

Gastroenteritis
Infection
Respiratory tract/otitis media
Appendicitis
Intestinal obstruction
Raised ICP
Coeliac disease
Renal failure

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7
Q

Causes of vomiting in School-age or adolescents

A

Gastroenteritis
Infection
Peptic ulceration
Appendicitis
DKA
ED

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8
Q

Pyloric stenosis definition

A

Hypertrophy of pyloric muscle causing gastric outlet obstruction
Presents at 2-7w

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9
Q

S+S of Pyloric stenosis

A

Vomiting which increases in frequency and forcefulness over time
Hunger after vomiting until dehydration leads to a loss of interest in feeding
Weight loss

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10
Q

Diagnosis

A

Hypochloraemic metabolic alkalosis with low plasma sodium and postassium occurs as a result of vomiting
Feed test
Gastric peristalsis may be seen
Pyloric mass - feels like an olive
Stomach over distended with air
USS is helpful

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11
Q

Management of pyloric stenosis

A

Correcet any fluid and electrolyte disturbance with IV fluids
Once hydrated, acid-base balance and electrolytes are normal
Can treat with pyloromyotomy - involves division of hypertrophied muscle down to mucosa

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12
Q

RF for GORD

A

Predominantly fluid diet
Mainly horizontal posture
Short intra-abdominal length of oesophagus
Prematurity
FHx
Obesity
Neurodisability
Repaired congenital diaphragmatic hernia/oesophageal atresia

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13
Q

Severe reflux

A

More common in:
Children with CP or other neurodevelopment disorders
Preterm infants especially if there is co-existent bronchopulmonary dysplasia
Following surgery for oesophageal atresia or diaphragmatic hernia

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14
Q

S+S of GORD

A

Recurrent regurg
Vomiting
Putting weight normally
Otherwise well
Mess, smell and frequent changing of clothes can be frustrating for parents and carers

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15
Q

GORD investigations

A

Usually diagnosed clinically and no investigations are normally required
24h oesophageal pH monitoring to quantify degree of reflux
24h impedance monitoring
Endoscopy with oesophageal biopsies to identify oesophagitis
Contrast studies to exclude underlying anatomical abnormalities in GIT

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16
Q

Mx of GORD

A

Uncomplicated GORD - parental reassurance and adding thickening agents to feeds + positioning infant prone after feeds
Usually resolves within a year - increased length of oesophagus, increased strength of LOS, weaning
More significant - acid suppression - either H2RA (ranitidine) or PPIs (omeprazole)
Or drugs that enhance gastric emptying (domperidone)
Surgery reserved for those with complications or unresponsive to intestinal medical treatment or oesophageal strictures - Nissen Fundoplication

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17
Q

Intestinal obstruction S+S

A

Bile stained vomit - Bowel obstruction until proven otherwise
Colicky abdo pain
Vomiting = early feature
Abdo distension
Absolute constipation + pain = large bowel obstruction

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18
Q

Radiological features of bowel obstruction

A

SBO - 80% of all mechanical intestinal obstruction
Dilated loops of small bowel proximal to obstruction
Gas fluid levels if AXR if erect

LBO - 20% bowel obstructions
Colonic distension
Collapsed distal colon - few or no air-fluid levels in large bowel as water is reabsorbed
Rectum has little or no air

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19
Q

Mx of intestinal obstruction

A

Immediate stabilisation: NBM, wide bore NGT, IV fluids and AXR
Surgery to remove the obstruction

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20
Q

Encopresis

A

Very loose, smelly stool passed without sensation or awareness

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21
Q

RF for constipation and encopresis

A

Cerebral Palsy
Downs syndrome
ASC
Safeguarding including FII (fabricated or induced illness)

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22
Q

Complications of constipation and encopresis

A

Anal fissure
Haemorrhoids
Rectal prolapse
Megarectum - rectum so dilated there is no sensation
Faecal impaction and soiling requiring disimpaction regime - obstruction
Volvulus
Distress and psychosocial issues (miss school)

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23
Q

Presentation of constipation

A

Less than 3 stools a week
Hard stools, difficult to pass
Rabbit dropping stools
Straining and painful passage
Abdo pain
Retentive posturing
Rectal bleeding
Loss of sensation of need to open bowels

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24
Q

Causes of functional constipation

A

Habitually not opening bowels
Low fibre diet
Poor intake and dehydration
Sedentary lifestyle
Psychosocial problems such as a difficult home or school environment (safeguarding)

25
Q

Red flags for constipation

A

Not passing meconium within 48h (CF or Hirschprungs)
Onset from birth to few weeks of life - Hirschsprungs
Distension and vomiting
FHx of Hirschsprungs
Ribbon stool pattern - anal stenosis
Leg weakness or motor delay
Abnormal appearance of anus
Abnormal lumbosacral and gluteal region

26
Q

Amber flags for Constipation

A

FTT
Developmental delay
Coeliac
HYpothyroidism
CMPA
Safeguarding

27
Q

Mx of constipation primary care

A

Correct any reversible factors e.g high fibre diet and good hydration
Start laxatives - 1st line = movicol
Faecal impaction disimpaction regimen with high dose laxatives at first
Encourage and praise visiting toiler - bowel diary, scheduling visits and star charts
Foot stool - for positioning

28
Q

Mx of constipation secondary care

A

Manual evacuation
Polyethylene glycols via NG for whole gut lavage
ACE - anterograde colonic enema - enema through appendix or coecal junction
Psychosocial + behavioural therapies

29
Q

Disimpaction regime

A

Escalating dose of macgrocols (movicol/laxido)
If fails add stimulant (Senna)
If macrogol not tolerated use stimulant with lactulose/docusate
Avoid suppositories/enema in primary care

30
Q

Daytime enuresis

A

Lack of bladder control during the day in a child who is old enough to be continent (over age of 3-5)
Nocturnal enuresis is normally present

31
Q

Causes of enuresis

A

Lack of attention to bladder sensation - may be a developmental, psychogenic problem, may occur in otherwise normal children who are too preoccupied
Detrusor muscle instability: sudden, urgent urge to void which is induced by sudden bladder contractions
Bladder neck weakness
Neuropathic bladder - enlarged and fails to empty properly, assoicated w/ spina bifida
UTI
Ectopic ureter - constant dripping and child is always damp

32
Q

RF for enuresis

A

FHx
Males
Obesity
Developmental delay
Constipation
Faecal impaction
Psychological or behavioural disorders
Sleep apnoea and upper airway obstruction symptoms

33
Q

Investigations for enuresis

A

MCS urine sample
USS may show bladder pathology
XR of spine may show vertebral anomaly
MRI spine - tethering of cord

34
Q

Mx of enuresis

A

Affected children with no neuro cause - star charts, bladder training and pelvic floor exercises
Treat any constipation first , then daytime, then nighttime enuresis
Small portable alarm with pad in pants - activated by urine - can be used for lack of attention to bladder sensation
Anticholinergic drugs - oxybutynin - may be helpful if other measures fail, decrease bladder contractions

35
Q

Causes of secondary enuresis

A

Emotional upset
UTI
Polyuria from osmotic diuresis in DM or renal contracting disorder (e.g sickle cell disorder or CKD)
Faecal retention severe enough to reduce bladder volume and can cause bladder neck dysfunction

36
Q

Causes of nocturnal enuresis

A

Genetically determined delay in sphincter competence
Small children need to be stress free and have a measure of parental approval in order to learn night-time incontinence
Emotional stress can interfere and cause secondary enuresis
Underlying stress

37
Q

Mx of nocturnal enuresis

A

Explain problem is common and beyond control - parents should stop punitive procedures
Star chart - wet beds treated as matter of fact and not punished
>5y - alarm - rings when start weeing so get up and go toilet - reward system
Desmopressin - rapid/short term solution e.g camp
Recurs - restart desmopressin plus alarm

38
Q

Acute gastroenteritis

A

3 or more partially formed or watery stools per day foe less than 14 days

39
Q

Dysentry

A

loose stool with blood and mucus, pyrexia and abdo cramps

40
Q

Causes of gastroenteritis

A

Organisms or toxin related
Rotavirus - 60%
Campylobacter - severe abdo pain
Shigella/Salmonella produce dysenteric type of infection with blood and pus in stool, pain and tenesmus
Cholera and enterotoxigenic E. Coli infection - profuse, rapidly deteriorating diarrhoea

41
Q

Investigations for gastroenteritis

A

Usually none
Stool culture - if septic, blood or mucus, I.C child, recent travel not improved in 7 days
U&Es - creatinine, glucose if IV fluid needed or signs of hypernatraemia
Blood culture for abx

42
Q

Mx of gastroenteritis

A

Antidiarrhoeals not used - ineffective, may prolong bacteria can be S/E
Abx rarely needed - sepsis, extra-intestinal spread, malnourished or I.C
Abx for:
C. diff associated w/ pseudomembranous colitis
Cholera
Shigella
Giardiasis

43
Q

Mx of hypernatraemic dehydration

A

Difficult to manage
ORS
If IV fluids too quick - rapid reduction in plasma sodium conc. and osmolarity will lead to a shift in water = cerebral oedema - give fluid over 48h
Nutrition - developing countries can lead to malnutrition, may be zinc deficiency and supplementation may be helpful

44
Q

Advice to parents for gastroenteriris

A

Most managed at home
Contact HCP if dehydration sx develop
Child is not clinically dehydrated - drink plenty of fluids
Don’t drink fruit juices and carbonated drinks
Give ORS to increased risk
Advise that usual diarrhoea is 5-7d
Usual vomiting is 1-2d
Doesn’t resolve within time period contact HCP

45
Q

Importance of recognising UTI in children

A

Up to 50% have structurally abnormality in UT
Pyelonephritis may damage growing kidney by forming a scar, predisposing to HTN and CKD if scarring is bilateral

46
Q

S+S of UTI

A

classic tria: dysuria, frequency + loin pain in older children
fever
vomiting
lethargy
irritability
poor feeding
FTT
abdo pain
jaundice
haematuria
offensive urine

47
Q

Investigations for UTI

A

Clean catch urine is recommended
Not available: urine collection pads or invasive: catheter samples or suprapubic aspiration
Infants <3m referred to specialist + MCS sample
Use dipstick testing in children >3m + <3y

48
Q

Indications for culture

A

Suspect acute pyelonephritis
High to intermediate risk of serious illness
Infants under 3m
Positive for leukocyte esterase or nitrite
Infants + children with recurrent UTI
Infection doesn’t respond to treatment within 24-48h
Clinical sx + dipstick tests don’t correlate

49
Q

Mx of UTI in infants <3m

A

referral to paeds, treat with parenteral abx
use cephalosporin - cefotaxime or ceftriaxone
+ abx against listeria (amoxicllin)

50
Q

Mx of UTI in 3m-15y

A

Start abx if leukocyte esterase, nitrates or both are positive
Lower:
1. Trimethoprim/Nitrofurantoin
2. Nitrofurantoin/amoxicillin/cefalexin

Upper:
1. Oral: cefalexin/co-amoxiclav
1. IV: co-amoxiclav/cefuroxime/ceftraixone

51
Q

Mx of UTI pregnant women 12+

A
  1. Nitrofurantoin
  2. Amoxicillin/cefalexin
  3. Consult microbiologist
52
Q

S+S of dehydration

A

Unwell
Irritable/lethargic
Reduced U/O
Pale or mottled skin
cold extremities
sunken eyes
dry mucous membranes/skin turgor
tachycardia/tachypnoea
low BP
Slow crt

53
Q

Hyponatraemic dehydration

A

Children with diarrhoea drink large quanities of water = greater net loss of sodium than water, leading to fall in plasma sodium
Leads to a shift of water from extracellular to intracellular compartements
Increase in intracellular volume leads to a greater degree of shock per unit water loss

54
Q

Isonatreamic dehydration

A

total body deficit of sodium + water
losses of sodium + water are proportional and plasma sodium remains within normal range (isonatraemic)

55
Q

Hypernatraemic dehydration

A

More water loss than to sodium relatively and plasma sodium concentration increases
Occurs from high water losses
ECF becomes hypertonic with respect to ICF
Water shifts into ECF
Harder to spot as signs of ECF depletion are less per unit of loss
Dangerous as fluid is drawn out of brain and cerebral shrinkage within a rigid skull - jittery movements, increased muscle tone with hyperreflexia, altered consciousness, seizures and multiple, small cerebral haemorrhages

56
Q

Rehydration

A

ORS mainstay - correction of deficit, maintenance and ongoing losses
No dehydration - usual feeds/bottle, ORS supplement (if refuse/don’t like taste aren’t too dehydrated) no fruit juices or carbonated drinks

With signs but at home:
<5y 50ml/kg for deficit over 4h + maintenance ORS
>5y 200ml ORS after each loose stool plus normal fluid intake

Shock: IV therapy, rapid infusion of 0.9% sodium chloride solution

57
Q

Causes of chronic diarrhoea

A

Toddler diarrhoea - commonest cause of persistent loose stools per day for 4+ weeks
Coeliac disease
Lactose intolerance - primary (rare) and secondary (after acute gastroenteritis)
Functional GI disorders - toddler diarrhoea and IBS
IBD
Food allergy and intolerances
CF
Small intestinal bacterial overgrowth
Malignancy

58
Q

Toddler diarrhoea

A

Stools are varying consistency
Sometimes well formed and sometimes explosive and loose
Presence of undigested vegetables - “peas and carrots diarrhoea”
Affected children are gen. well
Underlying maturational delay in intestinal motility which leads to intestinal hurry
Usually grow out of it by 5, achieving foecal continence
Relieve symptoms can be achieved by making sure child’s diet has fat and fibre (slows gut transit)
Excessive consumption of fresh fruit juice can exacerbate

Block 41 (4 decks)

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