Gastro

Question 1

What are the features of abdominal migraine and how is the acute attack treated/ how are they prevented?

Answer 1

Central abdo pain lasting >1hr
N&V, anorexia, pallor, headache, photophobia, aura

Acute treatment
-Quiet dark room
-Paracetamol
-Ibuprofen
-Sumatriptan

Preventative measures
Pizotifen (serotonin agonist) - main one used - withdraw it slowly
Propanolol
Cyproheptadine (antihistamine)
Flunarazine (CCB)

Question 2

What are the features of constipation

Answer 2

Less than 3 stools per week
Hard stools/ rabbit dropping
Straining/ painful
Abdo pain
Retentive posturing
Rectal bleeding
Faecal impaction- overflow soiling
Loss of sensation of needing to go

Question 3

What is encopresis

Answer 3

Faecal incontinence- not pathological until 4 yrs old
Sign of chronic constipation- loose stools leak out

Rarer causes of encopresis
-Spina bifida
-Hirschpring’s disease
-Cerebral palsy
-Learning disability
-Stress/ abuse

Question 4

What are some red flags relating to constipation in children

Answer 4

-Not passing meconium within 48 hrs birth - CF/ Hirschsprung’s disease

-Neuro signs in lower limbs- cerebral palsy/ spinal cord lesion

-Vomiting- obstruction/ hirschsprung’s

-Ribbon stool- anal stenosis

-Abnormal anus- anal stenosis, IBD, abuse

-Abnormal lower back/ buttocks- spina bifida, spinal cord lesion, sacral agenesis

-Failure to thrive- Coeliac, hypothyroid

-Severe abdo pain/ bloating- obstruction/ intussusception

Question 5

What is the management of constipation in children

Answer 5

1. Correct any reversible factors- high fibre diet and good hydration
2. Start laxatives (Movicol)
3. Faecal impaction may need a disimpaction regime- high doses of laxatives given first
4. Encourage toilet visits, bowel diary, star charts etc

Question 6

What are the features and management of GORD in children

Answer 6

In babies oesophageal sphincter is immature so stomach contents easily reflux- improves with growth

Chronic cough, hoarse cry, distress/ crying/ unsettled, reluctance to feed, pneumonia, poor weight gain

Management
Small frequent meals, burping regularly to settle milk, don’t overfeed, keep baby upright after feeds

If more severe
Gaviscon mixed with feeds
Thickened milk/ formula (anti reflux formula)
PPIs

Surgical fundoplication if very severe but this is rare

Question 7

What is Sandifer’s syndrome

Answer 7

Brief episodes of abnormal movements due to GORD in infants

Torticollis- neck twisting

Dystonia- arching back, unusual postures and twisting movements

Question 8

What are the features and management of pyloric stenosis

Answer 8

Thickening of the pyloric sphincter and narrowing of the pylorus- stops food from travelling from stomach to duodenum

Projectile vomiting
-First few weeks of life- thin baby, pale, failure to thrive
-Can see abdomen peristalsis and a firm mass in upper abdomen

Blood gas will show- Hypochloric metabolic alkalosis- the baby is vomiting hydrochloric acid from the stomach

Diagnosis
Made with abdo USS
Treatment- laparoscopic pyloromyotomy- widening pylorus

Question 9

What are the most common causes of viral gastroenteritis

Answer 9

Rotavirus
Norovirus

Question 10

What are the distinct features associated with E.Coli

Answer 10

Haemolytic uraemia syndrome
(Don’t use abx as this will increase risk of this)
Infected faeces, unwashed salads, contaminated water

Question 11

What are the distinct features of campylobacter jejuni

Answer 11

Travellers diarrhoea - most common type
Raw or poorly cooked poultry
Untreated water
Unpasteurised milk

Incubation period 2-5 days- symptoms resolve in 3-6
Abdo cramps, diarrhoea with blood, vomiting, Fever

Abx- Azithromycin and ciprofloxacin

Question 12

What are the distinct features of shigella

Answer 12

Faeces contaminating drinking water, swimming pools and food
Incubation period 1-2 days symptoms resolve in approx 1 week
Haemolytic uraemia syndrome
Bloody diarrhoea, cramps abdo pain, fever

Azithromycin and ciprofloxacin can be given if severe

Question 13

What are the distinct features of salmonella

Answer 13

Eating raw eggs/ poultry, contaminated food with infected animal faeces

12hrs to 3 days incubation period
Watery diaggoea with mucus/ blood
Abdo pain, voomiting
Antibiotics only if severe and do culture/ sensitivities first

Question 14

What are the distinct features of bacillus cereus

Answer 14

Fried rice left out
Food not put in fridge after cooking
Abdo cramping and vomiting within 5 hrs of ingestion
Watery diarrhoea
Symptoms resolve in 24 hrs

Question 15

What are the distinct features of yersinia entercolitica

Answer 15

Undercooked/ raw pork / urine and faeces of rabbits and rats
Usually affects children- watery bloody diarrhoea, abdo pain, fever, lymphadenopathy
Incubation 4-7 days and illness can last 3 weeks

Older children get right sided abdo pain- mesenteric lhymadenitis

Question 16

What are the distinct features of staphylococcus aureus toxin

Answer 16

Eggs, dairy and meat
Diarrhoea, perfuse vomiting, abdo cramps, fever
Symptoms start and settle within 12-24 hrs

Question 17

What are the distinct features of Giardiasis

Answer 17

Faecal oral transmission
May not cause symptoms or may cause chronic diarrhoea
Treatment with metronidazole after stool microscopy

Question 18

What are the features and management of coeliac disease

Answer 18

Anti-TTG and Anti-EMA antibodies
Anti-DPG
Test for IgA antibodies- IgA deficiency- they have the condition but antibody test won’t show up as coeliac

Jejunal villous atrophy
* Link with type 1 diabetes*

Failure to thrive, weight loss, diarrhoea, fatigue, mouth ulcers, anaemia- iron B12 and folate deficiency, dermatitis herpetiformis

HLA-DQ2 gene

Diagnosis - must still have gluten in diet
Total IgA and TTG and EMA antibodies
Endoscopy and intestinal biopsy

Lifelong gluten free diet

Question 19

What are the features/ Management of Crohn’s disease

Answer 19

Crows NESTS
No blood or mucus
Entire GI tract
Skip lesions
Terminal ileum most affected and Transmural (full thickness inflam)
Smoking is a risk factor

Inducing remission
Steroids- Oral prednisone/ IV hydrocortisone
If doesn’t work add one of Azathioprine, mercaptopurine, methotrexate, infliximab

Maintaining remission
1st Azathioprine or Mercaptopurine

Others: Methotrexate, infliximab, adalimumab

Surgery- when disease only affects the distal ileum

Question 20

What are the features/ management of ulcerative colitis

Answer 20

CLOSEUP - UC
Continuous inflammation
Limited to colon and rectum
Only superficial mucosa affected
Smoking is protective
Excrete blood and mucus
Use aminosalicylates
Primary sclerosis cholangitis

Inducing remission
Mild/ moderate : Aminosalicylate (mesalazine oral or rectal)
Steroids (pred)
Severe: IV steroids
2nd line IV ciclosporin

Maintaining remission
Aminosalicylate (mesalazine)
Azathioprine
Mercaptopurine

UC only affects colon and rectum so can remove these and leave patient with an ileostomy or a J-pouch

Question 21

How do you test for IBD in children

Answer 21

Faecal calprotectin
Endoscopy- OGD and colonoscopy- gold standard

Monitor growth and pubertal development especially since they are often on steroids etc

Question 22

What are the features of biliary atresia

Answer 22

A section of the bile duct is narrow/ missing
Cholestasis- bile can’t be transported from the liver to the bowel
Conjugated bilirubin can’t be excreted in bile

Presents just after birth- jaundice- high conjugated bilirubin

Suspect in persistent jaundice lasting more than 14 days in babies or 21 days in premies

Investigate conjugated and unconjugated bilirubin

High levels of conjugated bilirubin will show that the liver can process bilirubin for excretion but excretion is not happening due to flow of bile

Management
Kasai portoenterostomy- attach small intestine to liver opening to clear conjugated bilirubin

Will probably need a full liver transplant

Question 23

What are the features and management of intestinal obstruction

Answer 23

Causes
Meconium ileus, Hirschsprung’s disease, oesophageal atresia, duodenal atresia, intussusception, imperforate anus, malrotation of intestines with a volvulus, strangulated hernia

Presentation
Persistent vomiting, billows
Abdo pain and distension
Failure to pass stols/ wind
Abnormal bowel stools- high pitched/ tinkly

Abdo X-ray- dilated bowel loops- absence of air in rectum

Management
NBM, NG tube, IV fluids and surgery

Question 24

What are the features of Hirschsprung’s disease and how is it managed?

Answer 24

nerve cells of myenteric plexus are absent in bowel and rectum - absence of parasympathetic ganglion cells at the end of the colon- can happen to the entire colon
Loss of peristalsis of the large bowel

Aganglionic section of the colon does not relax and becomes constricted - bowel obstruction proximal to this

Genetic association between
Down’s syndrome
Neurofibromatosis
Waardenburg syndrome (pale blue eyes, patches of white skin and hair, hearing loss)
MEN 2

Presentation
Delay in passing meconium
Chronic constipation since birth
Abdo pain and distension
Vomiting
Poor weight gain

Surgical removal of the aganglionic section of bowel
Rectal biopsy to show lack of ganglionic cells

Question 25

What are the features of Hischsprung-associated enterocolitis

Answer 25

Inflam and obstruction of the intestine
2-4 weeks of birth - fever, abdo distension, bloody diarrhoea, sepsis
Can lead to toxic megacolon
Urgent abx, fluid resus and decompression

Management
Ando x-ray
Rectal biopsy - absence of ganglionic cells

Question 26

What are the features and management of intussusception

Answer 26

Bowel telescopes into itself (folds inwards)
Narrows lumen- palpable mass in abdomen and obstruction - 6 months to 2 years
More common in boys

Associated with n
Viral illness, henoch Schonlein purpura, Cystic fibrosis, intestinal polyps, Meckel’s diverticulum

Presentation
Severe, colicky abdo pain
Pale lethargic unwell
Redcurrant jelly stool
RUQ mass- sausage shaped
Vomiting
Intestinal obstruction

Management
USS / contrast enema for diagnosis
Therapeutic enemas- used to reduce intussusception
Surgical reduction