Elimination problem Flashcards
Congenital disorders, vomiting, constipation, diarrhoea
What is oesophageal atresia?
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
How many births does oesophageal atresia/ tracheal oesophageal fistula affect?
1 in 3500
Clinical features of oesophageal atresia/ tracheal oesophageal fistula
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
How is a diagnosis of oesophageal atresia/ TO fistula made?
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
Management of oesophageal atresia/ TO fistula
Nil by mouth until surgery (within 24hrs)
Suction to remove saliva and prevent aspiration
Prognosis good, reflux can occur in later life
When do congenital anomalies of the GI tract/ liver occur?
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
Difference between gastrochisis and exomphalos
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)
What is gastrochisis?
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
Risk factors for gastrochisis
Young maternal age
Smoking
Drug use
Management of gastrochisis
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
What is exomphalos?
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
What is Beckwith Weidemann syndrome?
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
Discuss malrotation of the gut
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
What is volvulus?
Where intestine twists around itself and mesentry
How do patients with malrotation present?
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
Hirschsprung’s disease
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
Clinical features of Hirschsprung’s
Newborn who has failed to pass meconium within 48hrs
Distended abdomen
Vomiting
PR examination causes explosive passage of stool
Diagnosis of Hirschsprung’s
Abdo x-ray shows dilated loops of bowel
Rectal biopsy shows lack of ganglionic nerve cells
Management of Hirschsprung’s
Initial: rectal washout/ bowel irrigation
Definitive: surgery to remove affected segment of colon and anastamosis
Intestinal atresia
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
How does intestinal atresia present?
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
What is biliary atresia?
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
How does biliary atresia present?
Prolonged jaundice
Pale stool
Dark urine
Poor weight gain
How is biliary atresia diagnosed?
Bloods: raised conjugated bilirubin + deranged LFTs
USS: absence of biliary tree
Radioisotope scan will show absent excretion of radiolabelled bile from the liver
How is biliary atresia managed?
Hepato-portoenterostomy is performed
Aim is to enable bile to flow into small intestine
Not curative - many children need liver transplant
Approach to vomiting in a child
What are the most common causes of vomiting in children?
- Intestinal causes: reflux, pyloric stenosis, malrotation and obstruction, cow’s milk protein allergy
- Infection: UTIs can cause persistent vomiting in children
- Cerebral disorders: raised ICP
- Renal: failure, tubular acidosis
- Metabolic disorders: adrenal failure
Causes of bilious vomiting in a baby?
Blockage:
Malrotation
Intestinal atresia (commonly duodenal)
Meconium ileus
First thing to ascertain when a baby presents with vomiting
Bilious or non bilious
When baby presents with non-bilious vomiting, first thing to consider?
Projectile or not?
Non-bilious, projectile vomiting?
Pyloric stenosis
Baby has non-projectile vomiting and they are unwell - what are the possible diagnoses?
Infection
If they also have diarrhoea: probably gastroenteritis
If they do not have diarrhoea: possibly sepsis or meningitis
Baby has non-projectile vomiting, non bilious. What could it be?
No signs of raised ICP: reflux
Signs of raised ICP: space occupying lesion or hydrocephalus
Gastro-oesophageal reflux in a child
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
Symptoms of gastro-oesophageal reflux
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
Management of gastro-reflux in a child?
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
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Overfeeding babies
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
Pyloric stenosis
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
Causes of abdominal pain in chidren
Appendicitis, intusussception, Meckel’s diverticulum, Mesenteric adenitis, constipation
What symptoms of abdominal pain in a child would warrant further investigation?
Severe pain
Pain lasting a long time
Recurrent pain
How can paediatric abdo pain be categorised?
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’
Appendicitis
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
Intussusception
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
Meckel’s diverticulum
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
Mesenteric adenitis
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
Non-organic abdominal pain in a child
Functional abdo pain
Poorly localised/ central abdo pain but all investgations are normal
Normal growth
Management: coping strategies
Abdominal migraine
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
Consitpation in children: overview
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
What features of constipation might suggest underlying disease?
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
What might prompt investigation for hypothyroidism if child presents with constipation?
Lack of energy, feeling the cold, unusual weight gain
Types of laxatives
Stimulant: senna + sodium picosulphate
Osmotic: lactulose
Macrogols: bulk the stool e.g. polyethylene glycol and electrolytes
Typical stool frequency in children
Varies greatly but 3x day in <6 months then 1x day in those 3yrs+
NICE guideline for constipation management in children
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
Management of constipation in a baby <6 months
Bottle fed: give water between feeds, massage belly and bicycle legs
Breast fed: v. unusual to be constipated so seek underlying cause
Management of constipation in infants who are being weaned
Offer extra water and diluted fruit juice
Consider adding lactulose
Most common cause of diarrhoea in children?
Infection - gastroenteritis
Why is it important to know about a patients long-term bowel habit when taking a hx about diarrhoea?
Diarrhoea could occur following a period of constipation
Condition that causes an accelerated transit time and resulting dirrhoea?
Hyperthyroidism
Conditions that cause malabsorption in children
CF >> pancreatic insufficiency
Gastroenteritis
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
What is toddler diarrhoea?
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
Coeliac disease in children
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
When is a child defined as being obese?
Weight >98th centile for their age
When is a child defined as being overweight?
BMI between 91st-98th centile
Complications of obesity in children
HTN, insulin resistance, T2DM, sleep apnoea, orthopaedic problems and low self-esteem
Management of childhood obesity
Education education education
Don’t encourage a child to lose weight, encourage them to live a healthy life and gow into their weight
What is under-nutrition
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
Most common micro nutrient deficiencies in the UK?
Vitamin D >> Rickets
Iron >> iron deficiency anaemia
Discuss vitamin D deficiency
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
What is Ricketts?
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
Vitamin K deficiency
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
What is haemorrhagic disease of the newborn?
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
Zinc deficiency
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
Causes of undernutrition in children
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
Main cause of acquired liver failure in children?
Hepatitis
Typical picture of hepatitis in children
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
Causes of hepatitis in children
Viral (A-E), EBV and CMV
Bacteria, fungal, parasitic
Drugs: paracetamol
Genetic: Wilson’s, a anti-trypsin deficiency, haemochromatosis
Autoimmune hep, lupus
What is Reye’s syndrome?
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
Cause of referred pain in abdomen of child?
Right lower lobe pneumonia
Congenital diaphragmatic hernia
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
Investigation of choice for intussusception?
USS - shows a target-like mass
What is Dance’s sign?
Empty RLQ due to intussusception seen on AXR
Mass may be felt in RUQ
Complications of constipation
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
Management of constipation
- 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
