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Paediatrics > Elimination problem > Flashcards

Elimination problem Flashcards

Congenital disorders, vomiting, constipation, diarrhoea

1
Q

What is oesophageal atresia?

A

Blind ending oesophagus

Often occurs in conjunction with a tracheal oesophageal fistula (88%)

Occurs when there is failed division of the foregut into the trachea and oesophagus at 6 weeks gestation

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2
Q

How many births does oesophageal atresia/ tracheal oesophageal fistula affect?

A

1 in 3500

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3
Q

Clinical features of oesophageal atresia/ tracheal oesophageal fistula

A

May be suspected antenatally: causes polyhydramnios

Neonates will have saliva pooling in mouth with bubbles in nose

Choking/ dusky episodes when feeding as milk spills into lung

Narrow fistula may be diagnosed in older child with recurrent chest infections

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4
Q

How is a diagnosis of oesophageal atresia/ TO fistula made?

A

Baby tries to feed: chokes or vomits

Made postnatally if NG tube cannot be placed

In isolated atresia there is no stomach bubble present on CXR - presence of bubble suggests there is also a TO fistula

Imaging used to diagnose: CXR

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5
Q

Management of oesophageal atresia/ TO fistula

A

Nil by mouth until surgery (within 24hrs)

Suction to remove saliva and prevent aspiration

Prognosis good, reflux can occur in later life

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6
Q

When do congenital anomalies of the GI tract/ liver occur?

A

During 1st trimester when separation of the foregut into the GI tract and resp system occurs

Separation usually occurs around week 6-10

Often diagnosed on antenatal scans

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7
Q

Difference between gastrochisis and exomphalos

A

Both are defects of the anterior abdominal wall

Gastrochisis = bowels escape to the right of the umbilicus and there is no covering of the bowel (escape the G)

Exomphalos: bowels herniate through the umbilicus, liver can also herniate, contents of the hernia are covered in perioteneum (can’t escape the O so are sealed within membrane)

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8
Q

What is gastrochisis?

A

Congenital anomaly of the gut

5/10,000 live births

Intestines herniate to the right of the umbilicus - not covered by peritoneum

Usually diagnosed @ 18-20 week scan

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9
Q

Risk factors for gastrochisis

A

Young maternal age

Smoking

Drug use

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10
Q

Management of gastrochisis

A

Immediate: cover bowel in bag/ clingfilm to protect

Long-term: surgery

Bowel is surrounded by a doughnut shaped support to prevent vascular occlusion

Good prognosis but some babies have prolonged feeding difficulty

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11
Q

What is exomphalos?

A

Affects 3/10,000

Bowel herniates through umbilicus, liver can also herniate

Contents are covered in peritoneum

Risk factors: maternal drug use and smoking

Common to find associated conditions: trisomies, Beckwith-Weidemann syndrome

Management = surgery

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12
Q

What is Beckwith Weidemann syndrome?

A

Condition which affects many parts of the body, classified as an overgrowth disorder - associated with presence of exomphalos as the gut grows too large for the abdomen

Children tend to grow larger than their peers but growth slows around age 8

Increased risk of cancer + non-cancerous tumours

Normal life expectancy

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13
Q

Discuss malrotation of the gut

A

Bowel is fixed in an abnormal position in the abdomen due to abnormal rotation of midgut

Small bowel sticks to posterior abdominal wall

1/2500 babies

Can be asymptomatic but can lead to volvulus

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14
Q

What is volvulus?

A

Where intestine twists around itself and mesentry

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15
Q

How do patients with malrotation present?

A

Can be asymptomatic

If volvulus has occurred: bilious vomiting, intermittent abdo pain

Upper GI contrast studies will show duodeojejunal flexure in abnormal position

Surgical emergency as volvulus can lead to necrotic bowel if the blood supply from mesentery is occluded

Bowel is fixated to correct position to remove risk of volvulus or other complications

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16
Q

Hirschsprung’s disease

A

Neural crest cells fail to migrate to bowel muscle

1/5000

Parasympathetic innervation of the distal colon is poor so the affected segment is always contracted which causes obstruction and gross dilation of the section above the affected area

Length of bowel affected varies: always affects internal anal sphincter, often involves sigmoid colon and 20% involve descending colon

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17
Q

Clinical features of Hirschsprung’s

A

Newborn who has failed to pass meconium within 48hrs

Distended abdomen

Vomiting

PR examination causes explosive passage of stool

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18
Q

Diagnosis of Hirschsprung’s

A

Abdo x-ray shows dilated loops of bowel

Rectal biopsy shows lack of ganglionic nerve cells

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19
Q

Management of Hirschsprung’s

A

Initial: rectal washout/ bowel irrigation

Definitive: surgery to remove affected segment of colon and anastamosis

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20
Q

Intestinal atresia

A

Blind ending passage due to abnormal embryology

Most common = duodenal atresia (30% associated with Down’s)

Causes biliosu vomiting if its after the hepatopancreatic duct because bile can’t go anywhere apart from up

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21
Q

How does intestinal atresia present?

A

Commonly duodenal atresia

Bilious vomiting if after the hepatopancreatic duct

AXR: dilated loops of bowel proximal to atresia + classic double bubble (can also be seen on USS)

Double bubble occurs because there is dilation of the stomach and proximal duodenum due to atresia

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22
Q

What is biliary atresia?

A

Rare

Atresia of the common bile ducts or hepatic ducts

Bile is made but cannot reach small intestine so causes inflammation of the ducts and the liver

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23
Q

How does biliary atresia present?

A

Prolonged jaundice

Pale stool

Dark urine

Poor weight gain

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24
Q

How is biliary atresia diagnosed?

A

Bloods: raised conjugated bilirubin + deranged LFTs

USS: absence of biliary tree

Radioisotope scan will show absent excretion of radiolabelled bile from the liver

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25
Q

How is biliary atresia managed?

A

Hepato-portoenterostomy is performed

Aim is to enable bile to flow into small intestine

Not curative - many children need liver transplant

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26
Q

Approach to vomiting in a child

A
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27
Q

What are the most common causes of vomiting in children?

A
  1. Intestinal causes: reflux, pyloric stenosis, malrotation and obstruction, cow’s milk protein allergy
  2. Infection: UTIs can cause persistent vomiting in children
  3. Cerebral disorders: raised ICP
  4. Renal: failure, tubular acidosis
  5. Metabolic disorders: adrenal failure
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28
Q

Causes of bilious vomiting in a baby?

A

Blockage:

Malrotation

Intestinal atresia (commonly duodenal)

Meconium ileus

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29
Q

First thing to ascertain when a baby presents with vomiting

A

Bilious or non bilious

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30
Q

When baby presents with non-bilious vomiting, first thing to consider?

A

Projectile or not?

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31
Q

Non-bilious, projectile vomiting?

A

Pyloric stenosis

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32
Q

Baby has non-projectile vomiting and they are unwell - what are the possible diagnoses?

A

Infection

If they also have diarrhoea: probably gastroenteritis

If they do not have diarrhoea: possibly sepsis or meningitis

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33
Q

Baby has non-projectile vomiting, non bilious. What could it be?

A

No signs of raised ICP: reflux

Signs of raised ICP: space occupying lesion or hydrocephalus

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34
Q

Gastro-oesophageal reflux in a child

A

Non-forceful regurg of contents up the oesophagus, sometimes into mouth

- Babies have weak LO sphincters, have a liquid diet and are often supine = recipe for reflux

Physiological in infants but can be troublesome and cause FTT

More common in premature babies and those with neuro-developmental impairment, less common in older children and teenagers

35
Q

Symptoms of gastro-oesophageal reflux

A

Asymptomatic in most

Discomft: draing up legs during or after feeds, arched back, crying

Large vomits after feeding

FTT if severe

Common source of anxiety in parents

36
Q

Management of gastro-reflux in a child?

A

Reassurance is often all that is needed

Investigate if patient is not growing

Overfeeding is a common problem so ascertain how much child is having

If patient has neuro-developmental impairment they are at risk of aspiration so surgery may be needed

90% cases resolve by 1 year

  • Advise regarding position during feeds - 30 degree head-up
  • infants should sleep on their backs as per standard guidance to reduce the risk of cot death
  • ensure infant is not being overfed (as per their weight) and consider a trial of smaller and more frequent feeds
  • a trial of thickened formula (for example, containing rice starch, cornstarch, locust bean gum or carob bean gum)
  • a trial of alginate therapy e.g. Gaviscon. Alginates should not be used at the same time as thickening agents
    • NICE do not recommend a proton pump inhibitor (PPI) to treat overt regurgitation in infants and children occurring as an isolated symptom. A trial of one of these agents should be considered if 1 or more of the following apply:
  • Unexplained feeding difficulties (for example, refusing feeds, gagging or choking)
  • distressed behaviour
  • faltering growth
  • Ranitidine was previously used as an alternative to a PPI but was withdrawn from the market in 2020 as small amounts of the carcinogen N-nitrosodimethylamine (NDMA) were discovered in products from a number of manufacturers.
  • prokinetic agents e.g. metoclopramide should only be used with specialist advic
    *
37
Q

Overfeeding babies

A

More common with bottle fed babies as its more difficult for baby to control milk flow

Causes wind, cramps, watery poo, foul smelling poo, sleep problems and irritability

38
Q

Pyloric stenosis

A

Male babies typically (4:1 M:F), hypertrophy of pyloric muscle

2-4/1000 live births

Typical presentation: 3-8 week old with projectile vomiting

Examination: hungry, dehydrated, poor weight gain, ripples across abdomen

Diagnosis: test feed causes projectile vomiting and peristalsis visible on abdomen, small lump palpable, bloods show hypochloraemic, hypokalaemic alkalosis due to vomiting, USS confirms diagnosis - shows thickened pylorus

Management: correct electrolytes, surgery - Ramstedt’s pyloromyotomy (pylorus is cut to widen abnormality)

Good prognosis, can reintroduce milk almost immediately

39
Q

Causes of abdominal pain in chidren

A

Appendicitis, intusussception, Meckel’s diverticulum, Mesenteric adenitis, constipation

40
Q

What symptoms of abdominal pain in a child would warrant further investigation?

A

Severe pain

Pain lasting a long time

Recurrent pain

41
Q

How can paediatric abdo pain be categorised?

A

Surgical causes: appendicitis, intussusception, hernia, testicular torsion

Infective: gastroenteritis, lower lobe pneumonia, UTI, mesenteric adenitis

Non-infective: constipation, coeliac disease, IBD, DKA, peptic ulcer, functional/ ‘non-organic’

42
Q

Appendicitis

A

Lumen of appendix occluded by faecoliths

Affects any age, 10% of all people during lifetime but most common during teens

Presentation: decreased appetite, central abdo pain which migrates to RIF, vomiting, fever (LESS SPECIFIC SYMPTOMS IN YOUNGER CHILDREN)

Examination: guarding and tenderness over RIF, rebound tenderness, rigidity associated with peritonitis if appendix has perforated

Diagnosis: waised WCC and CRP, USS showing inflamed appendix

Management: appendicectomy

43
Q

Intussusception

A

Invagination of bowel like a telescope, most commonly at terminal ileum which invaginates into caecum & takes mesentery with it

Pathophysiology: causes oedema, ischaemia and necrosis + perforation

Presentation: intermittent pain, drawing up legs, inconsolable crying, vomiting and pallor, palpable sausage-shaped mass, redcurrant jelly blood = late sign ⚠️

Investigations: USS shows target sign

Management: reduce by air enema (works in 70%), 30% need surgery

Air can cause or reveal perforation: surgery required

Recurs in 5%

If symptoms present for 24hrs+ or if suspicion of perforation surgery is needed due to high risk of necrosis

44
Q

Meckel’s diverticulum

A

Remnant of vitello-intestinal duct which connects yolk sac and gut during embryonic development

Affects 2% population - only 5% symptomatic as bleeding occurs within diverticulum

Presentation: fresh bleeding from rectum, melaena, low Hb, microcytic anaemia due to chronic bleeding, abdo pain, tenderness near umbilicus

Rule of 2s

  • M:F 2:1
  • 2yrs old = most common age
  • 2 feet from ileocaecal valve
  • 2 inches long
  • 2 cm wide

Diagnosis: USS or AXR may show blockage, radioisotope scan (Meckel’s scan) comfirms, faecal sample showing presence of blood, laparotomy

Management: surgery

45
Q

Mesenteric adenitis

A

Inflammation of the mesenteric LNs - common cause of abdo pain in children

Nodes enlerge due to infection (usually viral e.g. URTI)

Self-limiting, give pain relief

Pain can mimic appendicitis

46
Q

Non-organic abdominal pain in a child

A

Functional abdo pain

Poorly localised/ central abdo pain but all investgations are normal

Normal growth

Management: coping strategies

47
Q

Abdominal migraine

A

Poorly localised abdo pain, may be associated with vomiting, family hx of migraines

Pain usually resolves as child gets older but many develop migraines later on

48
Q

Consitpation in children: overview

A

Affects up to 30% of children

Often due to lack of fibre

Presentation: abdo pain, poor appetite, infrequent bowel opening, straining, hard & small stool

>> Pain can lead to child not wanting to use toilet >> makes situation worse

Soiling is common as liquid overflow bypasses blockage

Diagnosis: clinical, important to rule out FTT and underlying disease

Examination: mass in abdomen commonly LIF, inspect anal area for fissures, don’t do PR if suspecting constipation, neuro examination of legs to rule out spinal pathology

Management: advice re diet and fluid intake, laxatives/ laxitive disimpaction regimen before staring maintenance therapy

49
Q

What features of constipation might suggest underlying disease?

A

Present since birth: may suggest congenital anomaly

Delayed passage of meconium: Hirschsprung’s or CF

FTT: coeliac disease, hypothyroidism, CF

Abnormal spine or weakness in legs: spinal abnormality e.g. spina bifida

50
Q

What might prompt investigation for hypothyroidism if child presents with constipation?

A

Lack of energy, feeling the cold, unusual weight gain

51
Q

Types of laxatives

A

Stimulant: senna + sodium picosulphate

Osmotic: lactulose

Macrogols: bulk the stool e.g. polyethylene glycol and electrolytes

52
Q

Typical stool frequency in children

A

Varies greatly but 3x day in <6 months then 1x day in those 3yrs+

53
Q

NICE guideline for constipation management in children

A

If faecal impaction present: polyethylene glycol + movicol paediatric plan - add stimulant laxative if not cleared after 2 weeks

This can initially worsen symptoms and soiling

Maintenance therapy: movicol paediatric plan, add stimulant laxative if no response, continue for several weeks after regular habit established then gradually reduce dose

Do not use dietary advice as 1st line but do offer advice

Consider behavioural interventions to encourage use of toilet

Consider asking health visitor to visit to support parents

54
Q

Management of constipation in a baby <6 months

A

Bottle fed: give water between feeds, massage belly and bicycle legs

Breast fed: v. unusual to be constipated so seek underlying cause

55
Q

Management of constipation in infants who are being weaned

A

Offer extra water and diluted fruit juice

Consider adding lactulose

56
Q

Most common cause of diarrhoea in children?

A

Infection - gastroenteritis

57
Q

Why is it important to know about a patients long-term bowel habit when taking a hx about diarrhoea?

A

Diarrhoea could occur following a period of constipation

58
Q

Condition that causes an accelerated transit time and resulting dirrhoea?

A

Hyperthyroidism

59
Q

Conditions that cause malabsorption in children

A

CF >> pancreatic insufficiency

60
Q

Gastroenteritis

A

Very common and affects almost all children at some stage

Mainly due to rotavirus - cases have dropped by 70% due to vaccine introduced in 2013

Viral causes much more common than bacterial

Highly contagious

Peak incidence 9-24 months

Course: diarrhoea and vomiting that usually settles after 24hrs, some become severely dehydrated and may need NG oral rehydration or IV fluids if unable to keep oral rehydration solution down

61
Q

What is toddler diarrhoea?

A

AKA peas and carrots condition

Child is thriving and has no abnormal clinical findings but has diarrhoea with presence of undigested food

Cause unknown, resolves without intervention but reduced intake of fructose in the form of fruit juice may help symptoms

62
Q

Coeliac disease in children

A

1/100, occurs when weaning or after (when gluten introduced)

Clinical features: bloating, poor weight gain, diarrhoea/ constipation, wasting of gluteal muscles, iron deficiency anaemia

Diagnosis: Anti-TTG antibodies high (may be falsely low if patient deficient in IgA or they havent eaten gluten recently), biopsy shows villous atrophy, bloods show endomysial antibody

Management: life-long gluten-free diet - risk of bowel malignancy if patients do not adhere to gluten-free diet

63
Q

When is a child defined as being obese?

A

Weight >98th centile for their age

64
Q

When is a child defined as being overweight?

A

BMI between 91st-98th centile

65
Q

Complications of obesity in children

A

HTN, insulin resistance, T2DM, sleep apnoea, orthopaedic problems and low self-esteem

66
Q

Management of childhood obesity

A

Education education education

Don’t encourage a child to lose weight, encourage them to live a healthy life and gow into their weight

67
Q

What is under-nutrition

A

Nutritional intake insufficient to meet the needs of the body e.g. growth and physiological function

Major problem in low income countries but also seen in higher income countries where nutritional insufficiency occurs due to chronic illness

Can be split into macro and micro nutrient deficiency

68
Q

Most common micro nutrient deficiencies in the UK?

A

Vitamin D >> Rickets

Iron >> iron deficiency anaemia

69
Q

Discuss vitamin D deficiency

A

Needed for intestinal absorption of calcium and bone mineralisation

Some vitamin D is taken from the diet but the most is made in the skin following UV exposure

Lack of sun = lack of vitamin D = lack of calcium = lack of bone mineralisation

40% <5yrs are vitamin D deficient

Supplementation advised for pregnant/ breastfeeding women and children between 6 months - 5yrs who drink <500ml milk daily

Severe deficiency = Ricketts, seizures, cariodmyopathy

70
Q

What is Ricketts?

A

Caused by lack of vitamin D

Growth plates are poorly mineralised and bony deformity occurs

Bowed legs, rachitic rosary (beading along ribs due to expansion of costochondral junctions), tender + swollen joints (esp. ankles and wrists)

Can cause delayed walking, waddling gait, poor growth, softning of skull, symptoms of hypocalcaemia

71
Q

Vitamin K deficiency

A

Usually presents with bleeding

Newborn babeis have low vitamin K levels and breast milk is low in it so babies injected immediately after birth to prevent haemorrhagic disease of newborn

Older children may be at risk of vitamin K deficiency if they have liver disease/ malabsorption

72
Q

What is haemorrhagic disease of the newborn?

A

AKA vitamin K deficiency bleeding

Preents with intracranial haemorrhage

Vitamin K deficiency leads to the risk of blood coagulation problems due to impaired production of clotting factors II, VII, IX, X, protein C and protein S by the liver

Uncommon in developed countries due to IM injection after birth

73
Q

Zinc deficiency

A

Rare in healthy children but can occur in those with poor small intestine absorption e.g. Crohns

Causes poor growth, diarrhoea and impaired immunity

Acrodermatitis enteropathica = autosomal recessive condition leading to impaired absorption of zinc >> causes rash around mouth and perineum + alopecia + chronic diarrhoea + FTT in infancy

  • Responds well to zinc supplementation
74
Q

Causes of undernutrition in children

A

Inadequate intake: inadequate spply, anorexia, physical feeding difficulties e.g. cerebral palsy

Malabsorption

Excessive nutrient loss: diarrhoea

Increased metabolic demands: congenital heart disease, CF, hyperthyroidism

Consequences: lack of energy, increased susceptibility to illness and infection, poor growth, poor outcomes

75
Q

Main cause of acquired liver failure in children?

A

Hepatitis

76
Q

Typical picture of hepatitis in children

A

Acute hepatitis: non-specific symotms e.g. fever, diarrhoea, vomiting, flu-like, jaundice

20-30% have hepatosplenomegaly, bloods show raised liver enzymes

Generally self-limiting but can develop into liver failure

77
Q

Causes of hepatitis in children

A

Viral (A-E), EBV and CMV

Bacteria, fungal, parasitic

Drugs: paracetamol

Genetic: Wilson’s, a anti-trypsin deficiency, haemochromatosis

Autoimmune hep, lupus

78
Q

What is Reye’s syndrome?

A

Rare disease that causes liver damage associated with the use of aspirin in children >> hence aspirin not being prescribed to children unless for Kawasaki’s disease

79
Q

Cause of referred pain in abdomen of child?

A

Right lower lobe pneumonia

80
Q

Congenital diaphragmatic hernia

A

1/2000 newborns

Herniation of abdominal contents into chest cavity due t incomplete diaphragm formation

Consequences: lung hypoplasia, HTN, resp. distress shortly after birth

Most common = left side (85%) = Bochdalek hernia

Only 50% survive dspite intervention

81
Q

Investigation of choice for intussusception?

A

USS - shows a target-like mass

82
Q

What is Dance’s sign?

A

Empty RLQ due to intussusception seen on AXR

Mass may be felt in RUQ

83
Q

Complications of constipation

A

The longer the delay in treatment the longer it has to be treated for

  • Anal fissure
  • Haemorrhoids (rare in children)
  • Rectal prolapse
  • Megarectum
  • Faecal impaction and soiling
  • Volvulus
  • Distress and psychosocial issues
84
Q

Management of constipation

A
  • Children who have experienced pain when passing stools can adopt a retentive posture - straight legs on tiptoes with an arched back
  • Bowel habit diary - easier to manage if there is a clear picture
  • Rewards
  • Diet and lifestyle advice
  • Disimpaction regime: escalating dose of macrogol, if this fails add a stimulant e.g. senna. Avoid suppositories/ enemas in primary care
  • Secondary care: manual evacuation, polyethylene glycols via NG for whole gut lavage, antegrade colonic enema, psychological and behavioural therapies

Paediatrics (19 decks)

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