DISORDERS OF THE GASTROINTESTINAL SYSTEM Flashcards
What is the symptom that characterises infantile colic?
Inconsolable crying
What is the differential diagnosis for inconsolable crying in an infant?
Infantile colic Gastro-oesophageal reflux Cow's milk protein allergy Otitis media Incarcerated hernia Urinary tract infection Intussusception
What is the management of infantile colic?
Rule out other differentials and then reassure parents. Infantile colic is a benign condition with a good prognosis, but it can be a risk factor for non-accidental injury.
Symptoms of gastro-oesophageal reflux in infants and children are normally mild and do not require treatment. What are the more severe complications of GORD in children?
Oesophagitis Aspiration pneumonia Failure to thrive Bronchiectasis Bronchospasm with wheezing
Which infants are most at risk of developing gastro-oesophageal reflux disease?
Preterm infants - especially those with chronic lung disease
Children with cerebral palsy
Infants with congenital oesophageal anomalies, eg after repair of a tracheo-oesophageal fistula.
What are the symptoms of oesophagitis in children?
Irritability
Pain after feeding
Blood in vomit
Iron deficiency anaemia
Is gastro-oesophageal reflux disease in children a clinical diagnosis or one made through investigations?
Mostly clinical although some investigations can aid in those where the diagnosis is unclear
What investigations might you do with a child in whom you suspected gastro-oesphageal reflux disease?
24 hour oesophageal pH monitoring in older children
Impedance study in infants
Barium studies
Endoscopy - indicated in children with suspected oesophagitis
How do we manage a mild case of gastro-oesophageal reflux disease?
Normally reassurance is all that is required and 95% will resolve by the age of 18 months. Remember to safety net
How do we manage of more severe case of gastro-oesophageal reflux disease?
Prokinetic medications - domperidone
PPI - omeprazole
H2 antagonists - ranitidine
Surgery is required in very severe cases
What is the most common cause of gastroenteritis in children in the UK?
Rotavirus
What are the bacteria that commonly cause gastroenteritis in children?
Shigella
Salmonella
Campylobacter sp
E. coli
What are the parasites that can cause gastroenteritis in children?
Entamoeba histolytica
Giardia lamblia
Cryptosporidium sp
What are the features of bacterial gastroenteritis as opposed to viral gastroenteritis?
Abdominal pain and blood or mucus in the stool is more suggestive of an invasive bacterial pathogen
High fever also suggests that viral aetiology is unlikely
What two surgical conditions must be ruled out with a child who presents with vomiting and/or diarrhoea before a diagnosis of gastroenteritis can be given?
Pyloric stenosis
Intussusception
What are the main concerns for a children with gastroenteritis?
Dehydration
What are some of the signs of clinical dehydration in a child?
Altered responsiveness Decreased urine output Dry mucous membranes Raised heart rate Raised resp rate
What are some of the sign that the dehydration has now moved into clinical shock?
Decreased level of consciousness Absent urine output Mottle skin Cold peripheries Low blood pressure Prolonged cap refill
If there is evidence of clinical dehydration (but not shock) in an infant or child, what amount of fluids should be added to the maintenance fluids?
50 mL/kg over 4 hours - orally with rehydration salts (ORS)
If there is evidence of clinical shock in an infant or child, what amount of fluid should be added to the maintenance fluids?
20 mL/kg of 0.9% saline rapidly and repeated if necessary. Then continue IV rehydration with 0.9% saline adding 100 mL/kg to maintenance requirements.
How do you calculate the maintenance fluids for a child?
100 mL/kg/24h for the first 10 kg
50 mL/kg/24h for the next 10 kg (10-20)
20 mL/kg/24h thereafter
What amount of maintenance fluid over 24 hours would be needed for a child that weighs 32 kg?
1740 mL
Who is more likely to suffer from pyloric stenosis?
Five times more common in boys
Normally affects infants between 2-8 weeks old
What are the clinical features of pyloric stenosis?
Persistent, projectile non-bilious vomiting
Child remains hungry and therefore eager to feed post vomiting
Weight loss
Constipation
Mild jaundice
Dehydration
How is pyloric stenosis diagnosed?
Clinical diagnosis, made by palpating a hypertrophied pylorus during a test feed.
Peristaltic waves may be visible - ultrasound can be used to help diagnosis
What might be seen on the blood gas of an infant with pyloric stenosis?
Hypochloraemic hypokalaemic metabolic alkalosis
Why does pyloric stenosis cause hypokalaemia?
The loss of acid from the stomach leads to alkalosis, therefore the kidney hold onto hydrogen ions at the expense of potassium
How do you manage pyloric stenosis?
Correction of fluid and electrolyte balances
Surgery - Ramstedt’s procedure
What is intussusception?
A life threatening condition in which one segment of bowel telescopes into an adjacent distal part of the bowel causing a mechanical blockages and reduced blood supply
What is the peak age at which infants are most likely to develop intussusception?
6-9 months
Where in the bowel does intussusception most commonly occur?
Just proximal to the ileocaecal valve - ileum invaginates into caecum
What are the clinical features of intussusception?
Paroxysmal severe colicky abdominal pain in which the infant draws up the legs and becomes pale
Vomiting - sometimes bile stained
Redcurrent jelly stool - late sign
Sausage shaped mass in right upper quadrant
What investigations would you do in a child in whom you suspected intussusception?
Ultrasound to look for sausage shaped mass
Barium or air enema
How would you manage an infant with diagnosed intussusception?
Most cases can be reduced using an air enema, but if this fails surgery is required.
What are the surgical parts of the differential for acute abdominal pain in an infant or child?
Appendicitis Intussusception Volvulus Strangulated hernia Ovarian torsion
What are the medical parts of the differential for acute abdominal pain in an infant or child?
Mesenteric adenitis Gastroenteritis Constipation Urinary tract infection Lower lobe pneumonia Diabetic ketoacidosis Henoch-Schonlein purpura Sickle cell crisis
What are the clinical features of appendicitis?
Central abdominal pain that moves to right iliac fossa over a period of hours
Pain increases in severity
Aggravated by movement
Fever Tachycardia Dehydration Loss of appetite Guarding in a toxic child
What investigations might be useful if there is diagnostic uncertainty in a child with acute abdominal pain?
Urine dip
FBC
Chest x-ray
Abdominal ultrasound
How do you manage a child with confirmed appendicitis?
Conservative management during the acute episode with appendectomy carried out 6 weeks later unless there are complications.
What are the complications of appendicitis?
Peritonitis
Septicaemia
Appendix abscess
Appendix mass
What is mesenteric adenitis and what are the features?
Non-specific inflammation of mesenteric lymph nodes which provokes a peritoneal reaction causing acute abdominal pain which mimics appendicitis. It often accompanies a viral illness and therefore other signs and symptoms include fever, headache, pharyngitis and cervical lymphadenopathy.
How would you manage someone with mesenteric adenitis?
Because diagnosis is almost one of exclusion, the patient should be observed for a while and investigated to rule out appendicitis. Management once diagnosed is conservative as it is self-limiting.
How does the presentation of coeliac disease differ in children from adults?
In adults the classic presentation is diarrhoea (often steatorrhea) with abdominal pain and bloating. In children, these features are not always present and they may instead present with failure to thrive, fatigue, vomiting, diarrhoea or constipation, iron or folate deficiency anaemia and even amenorrhoea in a slightly older girl.
What is the test of choice to confirm coeliac disease?
IgA tissue transglutaminase (tTGA) serological test of choice. If this is positive, then biopsy showing flattened mucosa is needed to confirm.
How do you manage someone with coeliac disease?
Strict gluten free diet
Support from a dietitian
Lifelong follow up of all associated conditions
What are the conditions associated with coeliac disease?
Thyroid disease
Pernicious anaemia
Increased risk of small bowel cancer (especially lymphoma)
Osteoporosis
What is affected in Hirschsprung’s disease?
The innervation of the bowel. There is an absence of ganglion cells in the myenteric and submucosal plexuses for a variable segment of the bowel extending from anus to colon. The aganglionic segment becomes narrow and contracted.
What are the clinical features of Hirschsprung’s disease in infants?
Delayed passage of meconium
Subsequent intestinal obstruction with bilious vomiting and abdominal distension
What are the clinical features of Hirschsprung’s disease in slightly older children?
Chronic severe constipation
Abdominal distension
Absence of faeces in the narrow rectum
What is the complications of Hirschsprung’s disease?
Enterocolitis
How do you definitively diagnosed Hirschsprung’s disease?
Barium enema showing lumen narrowing
Biopsy then shows lack of ganglion cells
How are patients with Hirschsprung’s disease managed?
They will need surgery. Colostomy followed by pull through procedure
What are the criteria for constipation in a child under the age of 1?
Suggested by 2 or more of the following:
- Fewer than 3 complete stools per week (Type 3 or 4 on Bristol stool chart)
- Hard large stool
- Rabbit droppings
- Distress on passing stool
- Straining
- Bleeding associated with hard stools
- Previous episodes of constipation
- Previous or current anal fissure
What are the criteria for constipation in a child older than 1 year old?
Suggested by 2 or more of the following:
- Fewer than 3 complete stools per week (Type 3 or 4 on Bristol stool chart)
- Overflow soiling (commonly very loose, very smelly, stool passed without sensation)
- ‘Rabbit droppings’ (type 1)
- Large, infrequent stools that can block the toilet
- Poor appetite that improves with passage of large stool
- Waxing and waning of abdominal pain with passage of stool
- Evidence of retentive posturing: straight legged, tiptoed, back arching
- Straining and bleeding
- Anal pain
- Previous episodes
- Anal fissures
What are the differential diagnoses for constipation in children?
Idiopathic - most common
Dehydration
Low-fibre diet
Medications: e.g. Opiates
Anal fissure
Over-enthusiastic potty training
Hypothyroidism
Hirschsprung’s disease
Hypercalcaemia
Learning disabilities
What are the red flags suggesting that constipation is not idiopathic and may be caused by an underlying disorder?
Reported from birth
Passage of meconium took more than 48 hours
‘Ribbon stools’
Faltering growth - Amber flag
Previously unknown or undiagnosed weakness in legs
Locomotor delay
Abdominal distension
Prior to starting treatment for idiopathic constipation in a child, what must first be assessed?
Must check for fecal impaction
What are the signs of fecal impaction?
Symptoms of severe constipation
Overflow soiling
Faecal mass palpable in abdomen - PR must only be done by a paediatric specialist
How do we treat fecal impaction in a constipated child?
1st line - Polyethylene glycol 3350 + electrolytes (Paediatric Movicol)
2nd - Increase dose
3rd line - Add stimulant eg Senna
If Movicol not tolerated use either Senna or Senna plus lactulose
Need to warn parents that initially soiling and abdominal pain may get worse
What is the maintenance therapy for constipation in a child?
Very similar to treatment for child with fecal impaction just with smaller doses:
1st line - Polyethylene glycol 3350 + electrolytes (Paediatric Movicol)
2nd - Increase dose
3rd line - Add stimulant eg Senna
If Movicol not tolerated use either Senna or Senna plus lactulose
For how long would you continue maintenance therapy for constipation in a child?
Continue medication at maintenance dose for several weeks after regular bowel habit is established, then reduce dose gradually
How do we treat infants who have not yet been weaned off milk who are showing signs of constipation?
Bottle fed:
- Give extra water in between feeds
- Try gentle abdominal massage and bicycling the infant’s legs
Breast fed:
- Consider other causes are constipation is very unusual
How do we treat infants who are either in the process of being weaned or who have recently been weaned off milk who are showing signs of constipation?
Offer extra water, diluted fruit juice and fruits
If not effective consider adding lactulose
