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Gastro Flashcards

1
Q

What causes GOR?

A

Due to inappropriate relaxation of LOS (=functional immaturity)

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2
Q

What is the prognosis of GOR?

A

Common and usually gets better with time

Most resolve by 12m

If persistent, can be GORD

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3
Q

What are the RFs for GOR?

A
  • Premature
  • Neurological disorders
  • Short/straight intraabdominal length of the oesophagus
  • Supine position
  • Primarily milk diet
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4
Q

What conditions is GOR associated with?

A
  • Hiatus / diaphragmatic hernia
  • Oesophageal atresia
  • Cow’s milk intolerance
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5
Q

What are the S/S of GOR?

A

Typically develops before 8w

  • Difficulty / pain on swallowing
  • Vomiting / regurg after feeds
  • Gastric / abdo pain
  • Feeding avoidance, irritability, failure to thrive
  • Haematemesis
  • Apnoea
  • Intermittent stridor
  • Recurrent chest infections
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6
Q

What are the investigations for GOR?

A

Clinical diagnosis

+/- 24hr LOS pH monitoring (should remain mostly >4)
+/- OGD

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7
Q

When do you refer for GOR?

A

SAME DAY referral if:
Haematemesis, melaena or dysphagia

Assessment by paediatrician if:
RED FLAGS > unexplained distress, feeding aversion, no improvement after 1yo, faltering growth, unresponsive to medical therapy, suspected Sandifer’s Syndrome

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8
Q

What is the management for GOR?

A

Conservative

  • Position of feeds = 30-degree head-up
  • Infants should sleep on their back
  • Consider smaller and more frequent feeds
  • Trial a thickened formula

Medical

  • 1st line = trial alginate therapy e.g. Gaviscon (not used same time as thickening agents)
  • 2nd line = 4w trial of PPI/H2 antagonist e.g. omeprazole

(only done in certain circumstances)
- Unexplained feeding difficulties (refusing/gagging/choking)
- Distressed behaviour
- Faltering growth
- Consistent heartburn, retrosternal / epigastric pain

  • 3rd line = Prokinetic agents e.g. metoclopramide (with specialist advice)

+ Safety net

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9
Q

What are the complications of GOR?

A
  • Recurrent aspiration pneumonia
  • Unexplained epileptic seizure-like events
  • Inflammation
  • Dental erosion with neurodisability
  • Unexplained apnoea
  • Recurrent acute otitis media
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10
Q

What is pyloric stenosis?

A

Hypertrophy of the pyloric sphincter muscle causing gastric outlet obstruction

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11
Q

What are the RFs for pyloric stenosis?

A
  • More common in males
  • FHx
  • Associated with Turner’s Syndrome
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12
Q

When does pyloric stenosis present?

A

Presents at 2-4w (rarely presents up to 4m)

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13
Q

What are the symptoms of pyloric stenosis?

A

Progressive projectile vomiting

  • ~30mins after feed
  • Increases in frequency / forcefulness over time
  • Non-bilious
  • Infant hungry between feeds (‘hungry vomiter’)
  • Occasionally associated with coffee-ground vomiting secondary to gastritis or MW Tear

Also:

  • Constipation
  • Dehydration
  • Hunger > loss of interest in feeding > WL > depressed fontanelle > FTT
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14
Q

What are the signs of pyloric stenosis?

A

Palpable ‘olive’ mass in RUQ

Visible peristalsis from L to R in upper abdomen

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15
Q

What are the investigations for pyloric stenosis?

A

Test feed: observe for gastric peristalsis

Bloods: U&Es (hypochloraemic, hypokalaemic alkalosis > low Cl, H, K, Na)

USS abdomen: pyloric muscle diameter >3mm thickness and pyloric channel >8mm in length are diagnostic

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16
Q

What is the management for pyloric stenosis?

A

Preoperative = IV fluid resus and correct electrolyte imbalances

Surgery = Ramstedt pyloromyotomy

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17
Q

What is infant colic?

A

Common and benign set of symptoms seen in young infants

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18
Q

When does infant colic occur?

A

Typically occurs <3m
Resolves by 3-12m

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19
Q

What are the symptoms of infant colic?

A

Bouts of excessive crying
Pulling-up of the hands/legs
Often worse in the evening

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20
Q

What is the management of infant colic?

A

Sooth infant:

  • Hold with gentle motion
  • Optimal winding technique
  • White noise

Support:

  • Reassure parents it’s a common problem that should resolve by 6m
  • Self-help support group www.cry-sis.org.uk
  • Health visitor / family / friends

If persistent:

  • Consider cow’s milk allergy or reflux
  • Consider 1-2w trial of whey hydrolysate formula followed by 2w trial of anti-reflux tx
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21
Q

What is appendicitis?

A

Acute inflammation of the vermiform appendix, caused by obstruction of the lumen (faecolith, normal stool, infective agents, lymphoid hyperplasia)

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22
Q

What are the symptoms of appendicitis?

A

Colicky umbilical pain which then localises to RIF pain and becomes constant

  • Pain worse on movement / coughing (peritoneal inflammation)
  • Fever, nausea, vomiting, constipation, diarrhoea, anorexia, loss of appetite
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23
Q

What are the signs of appendicitis?

A
  • Reluctant to move
  • Percussion tenderness
  • Guarding in RIF (McBurney’s point)
  • Rovsing’s sign (RIF pain with palpation in LIF)
  • Tenderness against anterior rectal wall (rectal examination only if dx in doubt)
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24
Q

What are the investigations for appendicitis?

A

Tends to be clinical dx > do not delay treatment

  • Bloods (FBC, CRP, U&Es)
  • Urine dip (exclude UTI)
  • Pregnancy test (if female)
  • AXR / USS / CTAP > inflammation or dilatation of the appendix outer diameter to more than 6mm.
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25
Q

What is the management for appendicitis?

A

Surgical emergency > Immediate hospital admission

GAME:

  • G (group and save)
  • A (abx – IV amoxicillin or ceftriaxone with metronidazole)
  • M (MRSA screen)
  • E (do not eat or drink – NBM)
  • +IV fluids

Appendicectomy

  • (Laparoscopic preferred in uncomplicated appendicitis)
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26
Q

What is intussusception?

A

Invagination of one portion of bowel into the lumen of the adjacent bowel

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27
Q

What is the pathophysiology of intussusception?

A

Mesenteric constriction > venous obstruction > engorgement and oedema > bleeding from bowel mucosa > perforation > peritonitis and gut necrosis

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28
Q

When does intussusception present?

A

Usually 6-18m
Rarely <3m
More common in boys

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29
Q

What is the most common form of intussusception?

A

Most commonly ileum into caecum through ileocecal valve (ilio-colic)

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30
Q

What are the causes of intussusception?

A
  • Idiopathic
  • Post-gastroenteritis (enlarged Peyer’s patches)
  • Associated with CF, adenovirus, HSP, FAP, lymphoma
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31
Q

What are the symptoms of intussusception?

A
  • Paroxysmal abdominal colic pain (child will draw knees up into a ball)
  • Non-bilious > bilious vomiting (as intussusception becomes more established)
  • Red-currant jelly PR bleeding (late sign due to necrosis)
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32
Q

What are the signs of intussusception?

A

Sausage-shaped mass in RUQ
Abdominal distension

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33
Q

What are the investigations for intussusception?

A

1st line = Abdominal USS:

  • Target like mass / donut sign

2nd line = AXR: If perforation/obstruction suspected

  • Less air in RUQ and large bowel
  • Thickened wall (oedema)
  • Poorly defined liver edge
  • Dilated small bowel loops

Contrast enema: Not if unstable

  • Meniscus sign; coiled spring sign
  • Most specific and sensitive diagnostic test
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34
Q

What is the management for intussusception?

A

EMERGENCY, ABCDE approach

  • Drip and suck (NBM + NGT to decompress bowel, IV fluids)
  • Broad spectrum abx (clindamycin + gentamycin OR tazocin OR cefoxitin + vancomycin)

1st line: (no peritonitis, perforation or hypovolaemic shock)

  • Rectal air insufflation / contrast enema (with fluoroscopy guidance) under radiological control

2nd line: (if fails / peritonitis)

  • Surgical reduction
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35
Q

What is Meckel’s Diverticulum?

A

Congenital diverticulum of the ileum along the antimesenteric border.

It is a remnant of the omphalomesenteric duct and contains ectopic ileal, gastric or pancreatic mucosa

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36
Q

What is the Meckel’s Diverticulum rule of 2?

A

Occurs in 2% of population
Is 2 feet from ileocecal valve
Is 2 inches long
Between 1-2yrs

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37
Q

What are the S/S of Meckel’s Diverticulum?

A
  • Usually asx
  • Intermittent painless massive PR bleeding (bright / dark red)
  • RIF abdominal pain mimicking appendicitis
  • Lethargy, pallor, FTT (anaemia)
  • May show bilious vomiting, dehydration, constipation
  • May be present in addition to intussusception, volvulus, or diverticulitis
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38
Q

What are the investigations for Meckel’s Diverticulum?

A

Bloods:

  • FBC (low Hb/Hct, leukocytosis)

Meckel’s scan (technetium-99m scan):

  • Increased uptake by gastric mucosa

CT/USS of abdomen:

  • Will allow diagnosis of complications e.g. intussusception, obstruction, diverticulitis

Consider: Mesenteric arteriography

  • May be used in more severe cases e.g. if transfusion required
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39
Q

What is the management of Meckel’s Diverticulum?

A

Asymptomatic:

  • Incidental imaging finding = no treatment required
  • Detected during another surgery = prophylactic excision

Symptomatic:

  • Surgery (ileal resection and primary anastomosis)
  • +/- blood transfusion if bleeding / haemodynamically unstable
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40
Q

What is a complication of Meckel’s Diverticulum?

A

Can develop an ulcer in the ileum

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41
Q

What is malrotation?

A

Failure of normal rotation of the small intestine around the superior mesenteric artery (SMA) during embryological development, predisposing to intestinal obstruction, volvulus, and ischaemia

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42
Q

What are the S/S of malrotation?

A

Asx and present at any age with volvulus

OR

Present in first few days of life with obstruction +/- compromised blood supply

  • BILIOUS VOMITING
  • Abdominal pain
  • Peritonism
  • Abdominal distension
  • Scaphoid abdomen (concave abdomen)
  • Tinkling bowel sounds
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43
Q

What causes bilious vomiting in a neonate?

A

Bilious vomiting in neonate is malrotation until proven otherwise

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44
Q

What are the investigations for malrotation?

A

UGI contrast scan: Diagnostic standard test

  • Malrotation = right-sided duodenum
  • Volvulus = cork-screw appearance

AXR: Done in ED

  • Distended stomach/duodenum, gasless abdominal field

Bloods:

  • FBC, ABG
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45
Q

What is the management of malrotation?

A

If signs of vascular compromise = SURGICAL EMERGENCY

  • Drip and suck
  • IV broad spectrum abx (cefazolin)
  • Ladd Procedure
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46
Q

What is IBS?

A

Altered GI mobility and abnormal sensation +/- psychosocial stress and anxiety effect

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47
Q

What are the RFs for IBS?

A

FHx
Sx may be preceded by GI infection

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48
Q

What are the S/S of IBS?

A
  • Abdominal pain (often worse before/relieved by defecation)
  • Explosive loose or mucus stools
  • Bloating
  • Tenesmus
  • Constipation
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49
Q

What are the investigations for IBS?

A

FBC, ESR/CRP
Coeliac disease screen (TTG antibodies)

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50
Q

What is the management for IBS?

A

Supportive:

  • Reassurance of absence of organic disease
  • Encourage patient to identify sources of stress or anxiety in their lifestyle and any foods that may aggravate symptoms
  • Recommend adequate fluid intake

Psychological:

  • CBT
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51
Q

What is gastroenteritis?

A

Inflammation of the GI tract secondary to infection by an enteropathogen

52
Q

What organisms cause gastroenteritis?

A
  • ROTAVIRUS
  • Campylobacter jejuni
  • Shigella / Salmonella
  • Cholera / E. coli
  • Protozoan
  • Adenovirus
53
Q

What are the S/S of gastroenteritis?

A
  • Vomiting
  • Diarrhoea (sudden change to loose-stools)
  • Fever
  • Abdominal pain
  • Anorexia
  • Dehydration

+/- shock (increased risk if <6m, >2 vomits in 24hrs, >5 diarrhoeal stools in 24hrs, cannot tolerate extra fluids, malnourished)

54
Q

What are the investigations for gastroenteritis?

A

Bloods: FBC, U&Es, LFTs

Stool: MC&S (if this reveals a causative organism, seek specialist advice regarding abx treatment)

AXR (can exclude other causes)

55
Q

What is the management for gastroenteritis?

A

Shocked/haemodynamically compromised:

  • Resuscitation fluids

CANNOT meet fluid requirements enterally + clinical signs of dehydration:

  • Replacement fluids

CANNOT meet fluid requirements enterally + NO clinical signs of dehydration:

  • Maintenance fluids

CAN meet fluid requirements enterally:

  • Encourage oral intake / NG feeding
  • Do not give sugary / carbonated drinks

Safety net:

  • D usually 5-7d, most stop within 2w
  • V usually 1-2d, most stop within 3d
  • Advice on preventing spread and follow-up
  • Do not give anti-diarrhoeals to <5yrs
56
Q

What is Crohn’s Disease?

A

Form of IBD, commonly affecting the terminal ileum and proximal colon, but may be seen anywhere from mouth to anus

57
Q

Where does the inflammation occur in Crohn’s?

A

Inflammation occurs in all layers (transmural inflammation), down to the serosa (why pts are prone to strictures, fistulas, and adhesions)

58
Q

What are the S/S of Crohn’s?

A
  • Abdominal pain - RLQ (most common sx in children)
  • Diarrhoea (most common sx in adults) > may be bloody in Crohn’s colitis
  • Weight loss, lethargy, growth failure, delayed puberty
  • Perianal disease > skin tags or ulcers
  • Uveitis
  • Arthralgia
  • Erythema nodosum
59
Q

When does Crohn’s present?

A

Typically presents in late adolescence or early adulthood

60
Q

What are the investigations for Crohn’s?

A

Bloods = raised inflammatory markers, low B12 + vit D

Faecal calprotectin = raised

Colonoscopy and biopsy = non-caseating epithelioid cell granulomata, discontinuous/patchy inflammation with skip lesions

Histology = inflammation in all layers from mucosa to serosa, goblet cells, granulomas

Small bowel enema = strictures (Kantor’s string sign), proximal bowel dilation, ‘rose thorn’ ulcers, fistulae

61
Q

What is the management of Crohn’s?

A

Conservative:

  • Education on features and flare ups
  • Support - www.crohnsandcolitis.org.uk
  • Stop smoking
  • Careful with NSAIDs and COCP (increased risk of relapse)

Inducing remission:
1st line = Exclusive Enteral Nutrition (EEN) (effective in 85-100% of patients)

  • Whole protein modular diet (excessively liquid) for 6-8w
  • May need NGT if child struggles to drink that much
  • (Products easily digested, replaces WL)

2nd line = CS e.g. prednisolone

Maintaining remission:

  • 1st line = mercaptopurine or azathioprine (cannot be given with TPMT mutation, cannot have live vaccines, must have pneumococcal and influenza vaccines)
  • 2nd line = Methotrexate (immunosuppressant) if fail to respond to azathiprine
  • Also - CS e.g. Budesonide, biologic therapies e.g. infliximab

Surgery:

  • For complications (obstruction, fistula, abscess, severe localised disease unresponsive to treatment)
62
Q

What are the complications of Crohn’s?

A
  • Small bowel cancer
  • Colorectal cancer
  • Osteoporosis
  • Abscess formation
  • Fistulas
63
Q

What is UC?

A

Form of IBD. Inflammation always starts at the rectum, never spreads beyond ileocecal valve and is continuous

64
Q

What are the S/S of UC?

A
  • Bloody diarrhoea
  • Abdominal pain – particularly LLQ
  • Urgency, tenesmus
  • Weight loss, growth failure
  • Erythema nodosum
  • Arthritis
65
Q

What are the complications of UC?

A
  • PSC
  • Enteropathic arthritis
  • Toxic megacolon
  • Haemorrhage
  • Perforation
  • Bowel cancer
66
Q

How is the severity of UC graded?

A
  • Mild = <4 stools/d, small amount of blood
  • Moderate = 4-6 stools/d, varying amounts of blood, no systemic upset
  • Severe = >6 blood stools/d, features of systemic upset (pyrexia, tachycardia, anaemia, raised inflammatory markers)
67
Q

How is the severity of IBD graded?

A

1. Paediatric CD Activity Index (PCDAI)
2. Paediatric UC Activity Index (PUCAI)
3. Truelove and Witts score

  • Severe = >65 points
  • Mild-Moderate = 10-64 points
68
Q

What are the investigations for UC?

A

Bloods:

  • FBC (anaemia, leukocytosis)
  • CRP/ESR
  • CMP (including LFTs)

Stool sample:

  • Test for c. Dif / other infective pathogens
  • Faecal calprotectin (raised)

Abdominal X-Ray:

  • Dilated loops with air-fluid level secondary to ileus
  • Free air = perforation
  • Toxic megacolon = transverse colon dilated to ≥6cm in diameter

Flexible sigmoidoscopy / Colonoscopy & Biopsy:

  • Continuous colitis extending from rectum proximally
  • Superficial inflammation (not beyond submucosa)
  • Loss of vascular marking
  • Diffuse erythema
  • Ulceration and psuedopolyps
  • Crypt abscesses
  • Depletion of goblet cells and mucin

Barium enema:

  • Loss of haustrations
  • Superficial ulceration, ‘pseudopolyps’
  • Long standing disease = colon is narrow and short (drainpipe colon)
69
Q

What is the management for UC?

A

Inducing remission:
(Topical > oral if no improvement after 4w)

  • 1st line: Topical/Oral aminosalicylates e.g. mesalazine
  • 2nd line: Topical/Oral CS e.g. pred, beclomethasone
  • 3rd line (steroid resistant): Oral tacrolimus
  • 4th line: Biological agents e.g. infliximab
  • 5th line (resistant disease): Surgery (colectomy with ileostomy or ileojejunal pouch)

Maintaining remission:

  • ASA (topical, topical + oral, oral)

Education / Support:

  • Regular screening for bowel cancer after 10yrs of dx
  • Crohn’s and Colitis UK
70
Q

What is the management of severe colitis?

A

EMERGENCY > Treated in hospital with MDT approach

  • 1st line = IV corticosteroids
  • 2nd line = IV ciclosporin (CS contraindicated or ineffective)
  • 3rd line = Surgery
71
Q

What is toddler diarrhoea?

A

Chronic, non-specific diarrhoea.
Most common cause of loose stools in preschool kids

72
Q

When does toddler diarrhoea occur?

A

6m-5y

73
Q

What are the S/S of toddler diarrhoea?

A
  • Varying consistency stools (well-formed to explosive and loose)
  • Stools often contain undigested food / vegetables
  • Child is well and thriving, normal examination
74
Q

What are the investigations for toddler diarrhoea?

A

Lab ix usually negative
Dietary ix may reveal high intake of apple juice

75
Q

What is the management for toddler diarrhoea?

A
  1. Increased fibre and fat in diet (whole milk, yogurts, cheeses)
  2. Avoid fruit juice / squash / milk
  3. Reassurance
76
Q

What is constipation?

A

Decrease in the frequency of bowel movements, characterised by the passing of hardened stools that may be large and associated with straining and pain

77
Q

What is the normal frequency of stools in children?

A
  • 1st week of life = 4 per day
  • 1yr = 2 per day
  • 4yrs = between 3 per day and 3 per week
78
Q

What can contribute to constipation?

A
  • Inadequate fluid intake
  • Reduced dietary fibre
  • Toilet training issues
  • Drugs
  • Psychosocial issues
  • FHx
  • Pain
  • Fever
79
Q

What are the symptoms of constipation?

A
  • <3 stools per week
  • Hard, large stool
  • ‘Rabbit droppings’ stool
  • Overflow soiling in children >1yr
80
Q

What RED FLAGS need to be excluded with constipation?

A
  • Hx of severe constipation, overflow soiling, faecal mass palpable = faecal impaction
  • Failure to pass meconium within 24hrs of life / gross abdominal distension = Hirschsprung’s disease
  • Abnormal LL neurology / deformity = Lumbosacral pathology
  • Sacral dimple above natal cleft or on spine = Spina bifida occulta
  • Perianal bruising or multiple fissures = sexual abuse
  • Perianal fistulae, abscesses, fissures = Crohn’s
81
Q

What AMBER FLAGS need to be excluded with constipation?

A

Faltering growth, developmental delay, concerns about wellbeing = systemic condition (Coeliac, hypothyroidism, CF)

82
Q

What is the management for constipation?

A

Red flags present = urgent referral to specialist, tx not initiated in primary care
Amber flags present = referral arranged, tx can be initiated in primary care

Advise:

  • Underlying causes have been excluded
  • Behavioural interventions (scheduled toileting, bowel habit diary, reward system)
  • Diet and lifestyle adjustments (adequate fluid intake)
  • Offer sources of info and support

Disimpaction Therapy:

  • Movicol Paediatric Plain, escalating dose for 2w
    If unsuccessful after 2wks, add:
  • Stimulant laxative e.g. senna
  • Followed by maintenance therapy until normal bowel patterns reestablished

Maintenance Therapy:

  • First-line: Movicol Paediatric Plain
  • Add stimulant laxative if no response / not tolerated
  • Add another laxative such as lactulose or docusate if stools are hard
  • Continue medication at maintenance dose for several weeks after regular bowel habit is established, then reduce the dose gradually

If medical evacuation not possible:

  • Enemas
  • Manual evacuation under anaesthetic
83
Q

What is Hirschsprung’s Disease?

A

AKA congenital aganglionic megacolon

  • Missing myenteric plexus and submucous plexus
  • Results in functional bowel obstruction

(Cluster of nerves missing, leads to blocked colon, causes it to enlarge)

84
Q

What is Hirschsprung’s Disease associated with?

A
  • More common in males
  • Down’s Syndrome
85
Q

What are the symptoms of Hirschsprung’s Disease?

A

Neonatal:

  • Failure/delay to pass meconium
  • Acute intestinal obstruction = abdominal distension, poor feeding, bilious vomiting
  • Severe life-threatening enterocolitis (C. diff)

Infantile:

  • Constipation
  • Abdominal distension
  • Intermittent abdominal pain and fever (during episodes of retained faeces)
  • Failure to thrive
86
Q

What are the signs of Hirschsprung’s Disease?

A

PR exam reveals sudden explosive passage of liquid/foul stools

87
Q

What are the investigations for Hirschsprung’s Disease?

A

1. AXR

  • Dilated bowel

2. Contrast (barium) enema

  • Most valuable INITIAL screening diagnostic test
  • Dilated distal segment and narrowed, aganglionic proximal segment

3. Suction full thickness rectal biopsy

  • GOLD STANDARD for definitive diagnosis
  • Absence of ganglion cells, large ACh+ve nerve trunks
88
Q

What is the management of Hirschsprung’s Disease?

A

Initial:

  • Rectal washouts / bowel irrigation
  • Neonates = broad spectrum IV abx, NGT decompression

Surgical:

  • Anorectal pull-through procedure
89
Q

What are the causes of an anal fissure?

A
  • Constipation
  • IBD
  • Sexual abuse / traumatic injury
90
Q

What are the S/S of an anal fissure?

A
  • Pain/crying with bowel movements
  • Bright red blood on stool / nappy
  • Fever, rashes, WL, diarrhoea
91
Q

What is the management of an anal fissure?

A

Conservative:

  • Increase dietary fibre
  • Increase fluid intake
  • Manage pain (simple analgesia)
  • Anal hygiene
  • Advise against stool holding

Medical (can be considered):

  • Topical GTN or diltiazem
  • Stool softeners e.g. polythene glycol or lactulose
  • Botox

Surgical:

  • Open lateral internal sphincterotomy
92
Q

What are the S/S of threadworms?

A
  • Asx in most cases
  • May experience perianal itching, particularly at night
  • Girls may have vulval sx
93
Q

What is a threadworm infection?

A

Infestation occurs after swallowing eggs that are present in the environment

94
Q

What are the investigations for threadworms?

A

Dx made by applying Sellotape to perianal area and sending it to the lab for microscopy to see the eggs

Most pts tx empirically

95
Q

What is the management of threadworms?

A

Children <6m = Hygiene measures alone (6w)

  • Hand washing
  • Cut fingernails regularly (avoid biting nails, scratching around anus)
  • Shower each morning
  • Change bed linen and nightwear daily for several days after tx
  • Thoroughly dust and vacuum

Children >6m = Single dose anti-helminth e.g. mebendazole to ENTIRE household

  • Dose repeated in 2w if infection persists
  • Rigorous hygiene for 2w
96
Q

What is lactose intolerance?

A

Inability to metabolise the carbohydrate lactose due to lactase deficiency

97
Q

What are the causes of lactose intolerance?

A

Congenital = autosomal recessive condition

Primary = natural non-persistence of lactase enzyme after early childhood

Secondary = damage to the intestinal brush border following gastroenteritis, Crohn’s, Coeliac

98
Q

What are the S/S of lactose intolerance?

A
  • Loose stools (frothy and explosive)
  • Bloating with lactose ingestion
  • Cramping abdominal pain
  • Flatus

Congenital: Infantile diarrhoea, FTT
Primary: GI sx increase with age due to progressive loss of lactase
Secondary: Preceding infective episode of diarrhoea

99
Q

What are the investigations for lactose intolerance?

A

Clinical diagnosis

  • Hydrogen Breath Test = earlier rise in exhaled H2 following CHO ingestion
  • Stools = acidic and contain undigested sugar
  • FBC = rule out secondary disease (anaemia, increased WCC)
100
Q

What is the management of lactose intolerance?

A

> > Dietician referral

Congenital:

  • Avoid milk and dairy products
  • Provide Ca and vit D supplements

Primary:

  • Experiment with diet > find lactose tolerance
  • Potential foods > high-fat dairy (lower lactose), hard cheeses, milk substitutes

Secondary:

  • Cut out dairy and allow gut time to heal (4-6w)
  • Ca and vit D supplements
  • Digestive enzymes can be taken in a capsule before eating lactose until gut heals
101
Q

What is coeliac disease?

A

Autoimmunity to gliadin (in gluten, wheat, barley, rye) > shorter villi and flat mucosa

102
Q

What are the S/S of coeliac disease?

A

> > Presents 8-24m after introduction of wheat-foods

  • Sx of malabsorption (diarrhoea, steatorrhoea, FTT, WL, abdominal distension/bloating)
  • Malnutrition (wasted buttocks, distended abdomen)
  • Anaemia
  • Fatigue, irritability
  • Can be asx
  • Dermatitis herpetiformis > itchy blisters on elbows, knees, face and buttocks
103
Q

What are the investigations for coeliac disease?

A

Serological testing:

  • IgA anti-tissue transglutaminase antibodies (anti-tTG) - most sensitive
  • IgA anti-endomysial cell antibodies (anti-EMA)

Bloods:

  • FBC, iron studies, vit B12/D/folate

Endoscopy & biopsy: (Confirmation of dx)

  • Subtotal villous atrophy
  • Crypt hyperplasia
  • Intra-epithelial lymphocytes (IELs)
  • Very young children = no histopathological confirmation

If dx unclear in <2yrs = gluten challenge to confirm at 6-7yrs

104
Q

What is the management of coeliac disease?

A

Remove all products containing wheat, rye and barley FOR LIFE

+ MDT approach

  • Dietician, child psychologist, school involvement, GP, paediatric gastroenterologist

+ Dietician referral

  • Regular checks of height, weight, and BMI
  • Review sx
  • Review adherence to diet
  • Consider blood tests

+ Support = Coeliac UK

  • Explain importance of sticking to diet (non-adherence > micronutrient deficiency > osteoporosis, EATL, hyposplenism)
105
Q

What is mesenteric adenitis?

A

Mesenteric lymph node inflammation associated with systemic illness and abdominal sx

106
Q

What are the causes of mesenteric adenitis?

A

Often follows recent viral infection

  • URT viruses most common cause
  • Can follow UTI
107
Q

What are the S/S of mesenteric adenitis?

A
  • Abdominal pain > central or RIF
  • Nausea
  • Diarrhoea
  • Decreased appetite
  • Infectious picture = fever, lymphadenopathy
108
Q

What are the investigations for mesenteric adenitis?

A
  • Laparoscopy: Large mesenteric lymph nodes (w normal appendix) = definitive
  • Bloods: FBC, U&Es
  • USS of RIF: May confirm dx
109
Q

What is the management of mesenteric adenitis?

A
  • Simple analgesia (sx resolve in few days, max 2w)
  • Safety net for increased pain, deterioration etc
110
Q

What are the RFs for an indirect inguinal hernia?

A
  • Male
  • Premature
  • Connective tissue disorders
111
Q

What is the main differential of an indirect inguinal hernia?

A

Hydrocele

112
Q

What are the S/S of an indirect inguinal hernia?

A
  • Scrotal sac enlarged, contains palpable loops of bowel, fluid (doesn’t always transilluminate) +/- pain
  • Swelling or bulge may be intermittent > can appear on crying / straining
113
Q

What would indicate an incarcerated indirect inguinal hernia?

A
  • Tender, firm mass
  • Vomiting
  • Unable to pass stool
  • Poor feeding
  • Erythematous/discoloured skin overlying
114
Q

What are the investigations for an indirect inguinal hernia?

A

Clinical dx

  • Determine type of hernia > examine supine and standing
115
Q

What is the management of an indirect inguinal hernia?

A

Urgent surgical correction = elective herniorrhaphy

  • <6w = within 2d
  • <6m = within 2w
  • <6y = within 2m
116
Q

What are the RFs for an umbilical hernia?

A
  • Afro-Caribbean
  • Down’s Syndrome
  • Mucopolysaccharide diseases
117
Q

What is the management for an umbilical hernia?

A

Common in newborns and often resolve by 12m

  • <1y = watch and wait
  • > 1y = surgical repair (large/symptomatic = 2-3yrs, small/asx = 4-5yrs)
118
Q

What are the S/S of an umbilical granuloma?

A

Wet, moist, leaks fluid

119
Q

What is the management of an umbilical granuloma?

A

Tx with salt

120
Q

What is gastroschisis?

A

Congenital defect in the anterior abdominal wall just lateral to the umbilical cord.

(Abdominal contents outside body, without peritoneal covering)

121
Q

What is the management for gastroschisis?

A
  • Vaginal delivery may be attempted
  • Newborns should go to theatre as soon as possible after delivery, e.g. within 4 hours
122
Q

What is omphalocele / Exomphalos?

A

The abdominal contents protrude through the anterior abdominal wall but are covered in an amniotic sac / peritoneal covering

123
Q

What is omphalocele / Exomphalos associated with?

A

Chromosomal abnormalities in 15% (Patau’s, Edwards, Down’s, Turner’s)

124
Q

What is the management of omphalocele / Exomphalos?

A
  • Caesarean section is indicated to reduce the risk of sac rupture
  • A staged closure should be started immediately, finishing at 6-12m
125
Q

What is encopresis?

A

Soiling of underwear with stool in children who are past the stage of toilet training (>4yrs)

126
Q

What causes encopresis?

A

Usually due to constipation overflow

127
Q

What is the management of encopresis?

A

Enquire about psych stressors, change in medications, food intolerances etc

Paeds (18 decks)

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