Constipation / Diarrhoea / IBD Flashcards
What is acute - intermediate diarrhoea
<1 week or <3 weeks
What is chronic
> 3 weeks
Always investigate
What causes acute
Gastroenteritis = most common
Intussception
NEC
What causes chronic
CMPI Toddler Coeliac IBD Lactose intolerance Post gastritis lactose intolerance Pancreatic disease - CF / Schwan Hyperthyroid IBS Obstruction Constipation + overflow
What is the mechanism behind diarrhoea
Active secretion e.g. infection
Osmotic diarrhoea e.g. malabsorption
Motility disorder = toddler / IBS / constipation
What is toddler’s diarrhoea
Common cause
Stools vary and contain undigested food
Child well
What does nocturnal defection suggest
Organic pathology
What is important if child has diarrhoea
Height and weight
Dehydration
What is secretory diarrhoea and what causes
Large volume due to toxin production - Cl via CFTR
Infection
Gastroenteritis
IBD
What is osmotic and what causes
Small volume Large osmotic gap and water moves to equilibrate Malabsorption Pancreatic - CF Hepatobiliary Allergy Coeliac
How do you Rx osmotic
Stops when remove offending agent
How do you differentiate
Stop trigger in osmotic
Osmotic = large osmotic gap and small vol
Secretory = high electroyte and pH
What is Schwaman Diamond
Pancreatic and bone marrow dysfunction
What is most common cause of gastroenteritis
Rotavirus
What are other causes of gastroenteritis
Adenovirus Enterovirus Norovirus E.coli Cambylobacter Shigella Salmonella Giardiasis Amoebiasis
What should you beware of / have to report
E.coli 0157
Cholera
What is Ddx
Sepsis Local infection - UTI Surgical causes DKA All causes of diarrhoea Obstruction if no fever
How does gastroenteritis present
Diarrhoea 5-7 days and resolves 2 week
Vomit 1-2 days and resolves 3 day
Fever
Cambylobacter
Bloody
Very high fever
Red flags
What are red flags
High fever Tachypnoea Altered consciousness Stiff neck Bloody stool Bile vomit Severe abdo pain or distension
What increases risk of dehydration
<1 LBW >6 stools 24 hours >3 vomit 24 hours Malnutrition Not tolerating fluid
Hx
Food Travel Contact Sexual Medication Bowel
How do you Dx
Clinical if well
When do you do stool culture
Red flag Septicaemia Blood / mucous Immunocompromised Foreign travel \+7 days Uncertain
What are complications
Dehydration = common Electrolyte imbalance - Hypokalaemia Paralytic ileus Transient lactose intolerance IBS Ketoacdisois if persistent
Moderate signs of dehydration
Unwell / lethargic
Decreased urine
Pale
Cold
What are signs of shock
Decreased consciousness Sunken eyes Dry membrane Decreased fontanelle Decreased turgur Tachycardia Weak pulses Prolonged CRT Hypotension
How do you treat
Fluid replacement
Oral if no dehydration
ORS (diorite) - 50ml /kg 4 hourly
IV if shock - 4,2,1
What do you do once rehydrated
ORS every watery stool
What are signs of hypernatraemic dehydration
Increase tone Hyper-reflexia Convulsion Drowsy Coma
How do you treat
Isotonic to rehydrate over 48 hours
Decrease Na <0.5mol / l /hour
DDX of coeliac in children
CMPI
GORD
Intolerance
Iron deficiency anaemia
What is constipation and other symptoms
<3 stools per week Hard and large or Rabbit dropping Large stool in rectum or palpable per abdomen Overflow soil >1 episode
Other Sx Distress on passing = constipation or ano-rectal Rectal bleeding Poor appetite / pain - improves when pass Abdo distension Irritable Lack of energy Withholding behaviour
Can present like appendicitis
What are idiopathic causes of constipation / RF
Idiopathic = most common
Low fibre
Dehydration
Excessive milk
RF Diet Withholding stool Change to daily routine Not enough exercise FH
What are other causes
Intercurrent illness Spinal cord lesion = always do LL neurology Opiates Hypothyroid Hypercalcaemia Hirschprung Meconium ileus Imperforate anus Obstruction Anal stenosis Gut atresia CMPI Coaliec IBD Sexual abuse
What is physiological cause
Constipation Hard / large stool Followed by pain when passing Avoidance / fear Child withholds Leads to fissure Megarectum -> soiling as sphincter open UTI
What are RED FLAGS
From birth - no stool >48 hours Occur in first few weeks after birth Ribbon stool - anal stenosis Faltering growth / FTT Neuro signs e.g. leg weakness Motor delay Acute, severe abdominal pain + vomting Distension No associated with diet change
What are symptoms of faecal impaction
Severe constipation
Mass
Overflow
How do you Dx constipation / impaction
Abdominal exam + anus
Weight + height
LL neurology / spine for dimples - spina bifida
X-Ray
What is important in Hx
How often How hard Previous episode Fissure / painful movement PR bleed Soiling? Withholding behaviour Toilet training Diet / appetite Daily activity Any worries Medication Rx tried Development
How do you treat 1st line
Increased fluid and fibre Decrease milk Toilet = pleasant Regular toilet Reward good behaviour Pharmacologicla = 2nd line
What is pharmacological Rx
Movicol (isotonic) = 1st line
Senna (stimulant) = after 2 weeks if stool now soft
Lactulose (osmotic) = if stool hard
- Not useful as need to drink loads and children don’t
What do you do after
Continue laxatives for several weeks then decrease dose
When is constipation unusual
Breast feeding
What is rare in children
Haemorrhoids
What is IBD in children
More severe
More extensive
What is important
Maintaining growth
U.C
Proctitis rare
Pancolitis common
Chron’s
Malabsorption - b12 may be only Sx
Upper GI / pan enteric more common
What are biochemical disturbances
Raised ESR / CRP Anaemia Thrombocytosis Leucocytosis Low albumin
How do you Dx
Exclude infection FBC, U+E, CRP, LFT Blood and stool culture Coeliac -ve Thyroid -ve Raised calprotectin Endoscopy MRI / barium meal if inconclusive
What is gold standard test
Endoscopy
How do you treat
Nutrition - supplement FODMAP Elemental feeding = 85% remission and healing Anti-inflammatory Immune suppression Biologics Steroids = last ditch
What immune suppression
Azathioprine - not in UC
Methotrexate
Cyclosporin
Biologic
Infliximab (anti-TNFa)
What is impotant
Maintain growth and development
When do you do surgery
Poor growth
No puberty
Unresponsive to medical Rx
What are consequences
Poor growth / puberty Colon cancer Haemorrhage Electrolyte Toxic dilatation and megacolon Obstruction Perforation
What are SE of steroid
Infection Weight gain Appetite Moon face Adrenal gland failure Poor growth
If failure to pass stool first 72 hours
Hirshprung
CF - meconium ileus
Imperforate anus
Constipation + FTT
Coeliac
IBD
CF
Hypothyroid
