Gastro Flashcards
What is the definition of vomiting
physical act that results in the gastric contents forcefully brought up to and out of the mouth, aided by a sustained contraction of the abdominal muscles and the diaphragm at a time when the cardia of the stomach is raised and the pylorus is contracted.
What is the definition of regurgitation?
fortless expulsion of gastric contents (healthy infants and older children who eat in excess)
What is the definition of rumination?
frequent regurgitation of ingested food (largely behavioural)
What is the definition of possetting?
small volume vomits during or between feeds in otherwise well child
What are the 2 key sites in CNS implicated in the organisation of the vomiting reflex?
the vomiting centre (Medulla) chemoreceptor trigger zone (Floor of 4th ventricle)
What are the 5 key neurotransmitters involved in afferent feedback to these area?
histamine (H1receptors), dopamine (D2), serotonin (5-HT3), acetyl choline (muscarinic) and neurokinin (substance P).
What are the 5 key receptors of the vomiting centre and chemoreceptor trigger zone (CTZ)?
muscarinic (M1),
dopaminergic (D2),
histaminergic (H1),
5-hydroxytriptamine or 5-HT3(serotonin),
neurokinin NK1(substance P).
What are the 5 key precipitants of the vomiting centre and chemoreceptor trigger zone (CTZ)?
toxic material in the lumen of the gastrointestinal tract
visceral pathology
vestibular disturbance
central nervous system stimulation
toxins in the blood or cerebrospinal fluid (CSF).
What can be shown in a history for a child with GI issues?
bilious or non-bilious (helps to localize GI problems within the GI tract)
bloody or non-bloody (inflammation or damage)
projectile or non-projectile (specific diagnosis)
age of presentation
febrile or afebrile
nausea, abdominal pain, distension, diarrhoea, and constipation.
headache, changes in vision, polyuria, polydipsia and weight loss, to rule out increased intracranial pressure or DKA.
hydration status
What are red flags for gastroenterology problems in kids?
meningism, costovertebral tenderness, abdominal pain and any evidence of increased intracranial pressure.
What is involved in the examination for GI?
General: hydration, temperature, observations, weight loss, jaundice/pallor
Abdomen: distension, scars, tenderness, rigidity, bowel sounds
Neurological: Glasgow Coma Scale, meningism, neurological deficit
Plot growth
Assessment of hydration status
Evidence of infection
Presence of dysmorphic features, ambiguous genitalia or unusual odours
fontanelles, skin turgor, mucous membranes, and look for objective measures of stool and urine output
DDs of vomiting in infants and children in GI
GI Obstruction:
Pyloric stenosis
Malrotation with intermittent volvulus
Intestinal duplication
Hirschsprung disease
Antral/duodenal web
Foreign body
Incarcerated hernia
Other GI disorders:
Achalasia
Gastroparesis
Gastroenteritis
Peptic ulcer
Eosinophilic esophagitis/gastroenteritis
Food allergy
Inflammatory bowel disease
Pancreatitis
Appendicitis
Differential Diagnosis of Vomiting in Infants and Children – Non-GI
Neurologic
Hydrocephalus
Subdural hematoma
Intracranial hemorrhage
Intracranial mass
Infant migraine
Differential Diagnosis of Vomiting in Infants and Children – Non-GI
Infectious
Sepsis
Meningitis
Urinary tract infection
Pneumonia
Otitis media
Hepatitis
Differential Diagnosis of Vomiting in Infants and Children – Non-GI
Metabolic/endocrine
Galactosemia
Hereditary fructose intolerance
Urea cycle defects
Amino and organic acidemias
Congenital adrenal hyperplasia
Differential Diagnosis of Vomiting in Infants and Children – Non-GI
Renal
Obstructive uropathy
Renal insufficiency
Differential Diagnosis of Vomiting in Infants and Children – Non-GI
Toxic, Cardiac, Psychiatric
Toxic
Lead
Iron
Vitamin A and D
Medications: ipecac, digoxin, theophylline, etc.
Cardiac
Congestive heart failure
Vascular ring
Psychiatric
Munchausen syndrome by proxy
Child neglect or abuse
Self induced vomiting
Common Causes of Pediatric Vomiting by Age of Presentation Neonatal (0-2 days)
Duodenal or other intestinal atresia
-TEF (types A/C)
Common causes of vomiting in newborn 3 days - 1month
-Gastroenteritis
-Pyloric stenosis
-Malrotation +/- volvulus
-TEF (types B/D/H)
-Necrotizing enterocolitis
-Milk protein intolerance
-CAH
-IEM
Common causes of pediatric vomiting Infants 1-36 months
-Gastroenteritis
-UTI, pyelonephritis
-GER
-GERD
-Ingestion
-Intussusception
-Milk protein intolerance
Common causes of vomiting in children 36-12 years
-Gastroenteritis
-UTI
-DKA
-Increased intracranial pressure
-Eosinophilic esophagitis
-Appendicitis
-Ingestion
-Post-tussive vomiting
Adolescent vomiting 12-18
-Gastroenteritis
-Appendicitis
-DKA
-Increased intracranial pressure
-Eosinophilic esophagitis
-Bulimia nervosa
-Pregnancy
-Post-tussive vomiting
What investigations should be carried out?
Acute: U&E, stool virology, abdominal X-ray, surgical opinion, exclude systemic disease
Chronic: FBC, ESR/CRP, U&E, LFT, H pylori serology, Urinalysis, Upper GI endoscopy, Abdominal ultrasound, Small bowel enema, Brain imaging, test feed
Cyclic: amylase, lipase, glucose, ammonia
What are the consequences of vomiting?
Metabolic:
- Potassium deficiency
- Alkalosis
- Sodium depletion
Nutritional
Mechanical injuries to esophagus and stomach:
- Mallory-Weiss
- Boerhaave’s syndrome
- Tears of the short gastric arteries resulting in shock and hemopritoneum
Dental: erosions and caries
Oesophageal stricture, Barrett’s metaplasia, broncho-pulmonary aspiration, FTT, anaemia
Treatment of vomiting
Supportive - intravenous fluids, analgesia and antiemetics
Treat cause – medical or surgical
Pharmacological
Anti histamines used for vomiting
Look at slide 18 of Common gastroenterology problems
What are the warning S + S of GORD?
Bilious vomiting
GI bleeding
Persistently forceful vomiting
New onset of vomiting > 6 months
Failure to thrive
Diarrhoea
Constipation
Fever
Lethargy
Hepatosplenomegaly
Bulging fontanelle
Macro/microcephaly
Seizures
Abdominal tenderness or distension
Suspected metabolic syndrome
What is GOR
Gastroesophageal reflux (GOR):
the passage of gastric contents into the esophagus
with or without regurgitation or vomiting
What is GORD?
Gastroesophageal reflux disease (GORD):
the presence of troublesome symptoms and/or complications of persistent GOR.
What did separate pH studies show about the number of daily acid reflux episodes?
In separate pH studies, the number of daily asymptomatic acid reflux episodes, the number of daily episodes lasting >5 minutes, and the reflux index (percent of total time that esophageal pH is <4) were all higher in healthy infants than in the two older age groups [1-6].
Natural history of GER in children up to 2 years of age
41% of infants aged 3-4 months spit up most of their feedings
GER occurs in <5% of infants aged 13-14 months
Features of GORD in children
Faltering growth
Oesophagitis +/- stricture
Apnoea, ALTE, SIDS
Aspiration, wheezing, hoarseness
IDA
Seizure-like events, torticolis
Investigations for GORD
pH
Barium swallow and meal
Endoscopy
Others – Nuclear scintigraphy, tests on Ear, Lung and oesophageal fluids, USG, Combined multiple intraluminal impedance (MII)
‘PPI Test’
Management of GORD
Position
Thicken feeds
Change feeds
Drugs – antacid, H2 blocker, PPI
Surgery - fundoplication
If someone has an adverse food reaction which is immune mediated - what are the types of immune mediated adverse food reactions?
IgE mediated
Non-IgE mediated
Mixed IgE and non-IgE mediated
Cell mediated
What are some non-immune adverse food reactions
Pharmacologic
Metabolic
Toxic
Other
Features of CMPA
Most common (soya, wheat, egg, nut, fish)
Cow’s milk is composed of curds (casein) and whey
- Caseins 76 -86%
- Whey proteins 14 -24%
Associated with atopy, IgA deficiency and IgG subclass abnormalities
estimates of the prevalence of cow’s milk protein allergy (CMPA) vary from 2% to 7.5%
GI S + S of IgE-mediated food allergy
Angioedema of the lips, tongue and palate
Oral pruritus
Nausea
Colicky abdominal pain
Vomiting
Diarrhoea
GI S + S of non IgE mediated food allergy
GORD
Loose/ frequent stools
Blood in stools or mucus
Abdom pain
Infantile colic
Food refusal or aversion
Constipation
Perianal redness
Pallor or tiredness
Falterign growth
Skin symptoms and signs in food allergy
IgE - mediated
Pruritus
Erythema
Acute urticaria - localised or generalised
Acute angioedema
Non - Ige - mediated:
Pruritus
Erythema
Atopic eczema
Resp system S + S of food allergy
IgE - mediated
Upper respiratory tract symptoms (nasal itching, sneezing, rhinorrhoea or congestion [with or without conjunctivitis])
Lower respiratory tract symptoms (cough, chest tightness, wheezing or shortness of breath)
How do we diagnose and manage CMPA
Diagnosis – elimination diet
Management – Hydrolysed or AA feeds
Basic infant formula and breast milk contain whole proteins - what are these proteins
eHF - Extensively broken down – smaller peptides, Based on casein or whey, Less well recognised by immune system, First choice for mild to moderate (both IgE and non-IgE).
AAF - Based on amino acids, Infants who react to cow’s milk protein via breast fed (when they need to top-up or alternative), History of anaphylaxis, EoE, Severe GI or skin manifestations in conjunction with faltering growth, Reacting or refusing EHF (BSACI)
Hydrolysate formulas
Features of lactose intolerance
Lactase appears late in foetal life and falls after 3 years
Primary – rare
Late onset (oriental background) – common
Explosive watery stools, abdominal distension, flatulence, audible bowel sounds)
Stool chromatography, Lactose hydrogen breath test, Small bowel biopsy and elimination diet
Lactose free formula/Milk-free diet with calcium and Vitamin D supplements
What is the pahophysiology of (Secondary) Lactose intolerance?
The loss of physiological drive and an osmotic gradient causes unabsorbed sugar to build up in small bowel
This causes excess water
The unabsorbed sugar in the colon is broken down into short chain FA - the osmotic gradient and toxic effect on mucosa causes watery diarrhoea
What test is used for the Lactose intolerance
Breath hydrogen
What is constipation?
Infrequent passage of stool associated with pain and difficulty, or delay in defecation.
What is encopresis?
involuntary faecal soiling or incontinence secondary to chronic constipation.
How do we diagnose functional constipation ROME III criteria
Two or fewer defecations per week
At least 1 episode of faecal incontinence per week
Retentive posturing or stool retention.
Painful or hard bowel movements
Presence of a large faecal mass in the rectum
Large diameter stools that may obstruct the toilet
What is the pathogenesis of functional constipation
Painful defecation > Voluntary witholding > Prolonged fecal stasis - Reabsorbed fecal stasis - inc in size and consistency > more pain > Painful defecation
Red flags of constipation
Delayed passage of meconium
Fever, Vomiting, Bloody Diarrhea
Failure to thrive
Tight, empty rectum with presence of palpable abdominal faecal mass
Abnormal neurological exam
DDs of constipation
Hirschsprung’s disease
Anorectal malformations
Neuronal intestinal dysplasia
Spina bifida
Neuromuscular disease
Hypothyroidism
Hypercalcaemia
Coeliac disease
Food allergy/intolerance
Cystic fibrosis
Perianal group A streptococcal infection
Anal fissure
Pelvic/spinal tumours
Child sexual abuse
Drugs
What are the short and long term complications of constipation
Short term – no sequelae
Long term – acquired megacolon, anal fissures, overflow incontinence, behavioural problems
Investigations for constipation
Usually not necessary. Perform only if organic cause suspected, remain constipated despite medical treatment
T4/TSH, serum calcium, Coeliac Panel, Sweat test (if clinically indicated), AXR, anal manometry, rectal biopsy, spinal imaging (neurological cause)
Management of constipation
Explanation of normal bowel function
Diet/fluids and exercise
Behavioural advice
Toilet training advice
Simple reward schemes
Medication for constipation
Softener: lactulose, liquid paraffin
Bulking agent: Fybogel
Non-absorbed laxative irrigative: Movicol
Stimulant: Senna, Dulcolax
Enema
Anal fissure: anaesthetic cream +/- vasodilator
What is diarrhoea?
Change in the consistency of stools (loose or liquid), and/or
increase in the frequency of evacuations (typically >3 in 24 hours), with or without fever or vomiting which lasts less than 7 days and not longer than 14 days.
What are the infectious causes of diarrhoea?
(1) Viruses
(a) Rotavirus: 25-40%
(b) Calicivirus: 1-20%
(c) Astrovirus: 4-9%
(d) Enteric-type adenovirus: 2-4%
(e) Norwalk-like virus:?
(2) Bacteria
(a) Campylobacter jejuni: 4-8%
(b) Salmonella: 3-7%
(c) Escherichia col: 2-5%
(d) Shigella: 1-3%
(e) Yersinia enterocolitica: 1-2%
(f) Aeromonas hydrophilia: 0-2%
(g) Clostridium difficile: 0-2%
(3) Parasites
(a) Giardia Lamblia: 1-3%
(b) Cryptosporidium: 1-3%
Acute diarrhoea features
Other infections: otitis media, tonsillitis, pneumonia, septicaemia, UTI, meningitis
Allergy/food hypersensitivity reactions
Drugs
Hemolytic uraemic syndrome
Surgical causes: pyloric stenosis, intestinal obstruction, appendicitis, Intussusception
AGE features
204 of 1000 consultations with general practitioners in children under 5 are for gastro enteritis
annual hospital admission rate in this group is about seven per 1000 children
Presentation of AGE
Diarrhoea +/- bloody stools (dysentry)
Fever +/- vomiting
Dehydration and reduced consciousness
Examination of AGE
Assess for dehydration (<5% no reliable findings)
The best clinical indicators >5% dehydration are prolonged capillary refill, abnormal skin turgor and absent tears
Assessment and mgmt of dehydration
Look at slide 53 of common gastroenterology problems
What are the signs of non clinically detectable dehydration
Alert and responsive
Skin colour changes
Warm extremities
Eyes not sunken
Moist mucous membranes
Normal heart rate
Normal breathing patterns
Normal periphery pulses
Normal CRT
Normal skin turgor
Normal BP
Symptoms of non clinically detectable dehydration
Appears well
Alert and responsive
Normal urine output
Skin colour unchanged
Warm extremities
Clinical dehydration signs
Alert and responsive
Skin colour changes
Warm extremities
Eyes sunken
Dry mucous membranes
Tachy
Tachypnoea
Normal periphery pulses
Normal CRT
Reduced skin turgor
Normal BP
Clinical dehydration symptoms
Appears unwell
Alerted responsiveness
Decreased urine output
Skin colour unchanged
Warm extremities
Signs of clincal shock of dehydration
Decreased level of consciousness
Pale or motted skin
Cold extremities
Tachy
Tachypnoea
Weak peripheral pulses
Prolonged CRT
Hypotension
Symptoms of clinical shock
Decreased levels of consciousness
Pale or mottled skin
Cold extremities
Management of hydration in Gastroenteritis
Look at slide 54 of common gastroenterology problems
When should you perform stool microbiology for Gastroenteritis
Suspect septicaemia
Blood or mucus in stool
Child immunocompromised
When should you consider performing stool microbiology in gastroenteritis
Travel
diarrhoea not improved in 7 days
Uncertain about gastroenteritis
Investigations for Gastroenteritis
Blood tests are not necessary in simple gastroenteritis but measure serum electrolytes including glucose if:
severe dehydration
intravenous fluid therapy required
symptoms and/or signs suggesting hypernatraemia
altered conscious state
co-morbidity of renal disease or on diuretics
ileostomy
Other treatments of gastroenteritis
Antibiotics – bacterial GE complicated by septicaemia or systemic infections or immunocompromised and malnourished patients
Probiotics
No antiemetics/anti-motility drugs
Features of hypernatremia dehydration
Unusual and serious
Irritable with doughy skin
Water shifts from intracellular to extracellular
Rehydration should be slow
Features of chronic diarrhoea
> 2 weeks
Continued infection with first pathogen
Infection with second pathogen
Post enteritis syndrome
Spurious
- constipation
Chronic non-specific diarrhoea
Food intolerance
Malabsorption
Features of Crohn’s disease
Mouth to anus
Transmural inflammation
Discontinuous
Granuloma
Rectal sparing
Fissures, fistula, abscesses and strictures
Perianal disease
Features of UC
Colon only affected
Mucosal inflammation
Continuous
No granuloma
No rectal sparing
Abscesses and strictures rare
Primary sclerosing cholangitis
Differences between paediatric and adults IBD
Slide 63 of common gastroenterology problems
Growth in IBD
Poor growth
Delayed puberty
Reduced Final adult height
Catch up growth
Persistent poor growth - only sign of disease activity
How do we diagnose IBD
Clinical evaluation
Biochemical
Endoscopic
Radiological
Histological
Nuclear medicine
Interventions for Crohn’s disease
EEN
Corticosteroids (Prednisolone/Budesonide)
Aminosalicylates (Topical & Oral)
Antibiotics
Immunomodulators (Azathioprine, methotrexate)
Biologics (Infliximab, Adalimumab)
Surgery
Parenteral nutrition
Approach to 1st line therapy for UC
Mild to moderate:
Induction- Aminosalicylates
Remission-Aminosalicylates
Moderate to severe:
Induction- Corticosteroids
Remission- 6 MP/ Azathioprine
DDS for abdominal pain
Acute – appendicitis, intussusception, pancreatitis, cholecystitis, pneumonia…
Chronic
What is the clinical definition of chronic and functional abdominal pain?
Chronic Abdominal Pain:
Long lasting, intermittent or constant that is functional or organic (disease)
Functional Abdominal Pain:
Abdominal Pain without evidence of disease/pathologic process.
Organic causes of abdominal pain
GORD
Peptic ulcer disease
H pylori infection
Food intolerance
Coeliac disease
IBD
Constipation
UTI
Dysmenorrhoea
Pancreatitis
Hepato-biliary disease
Functional disorders of childhood
Several functional gastrointestinal disorders of childhood are recognizable .
Functional dyspepsia
Irritable bowel syndrome (IBS)
Functional abdominal pain
Abdominal migraine
Aerophagia
Pathogenesis of abdominal pain
abnormal bowel reactivity to
physiologic stimuli (meal, gut distention, hormonal),
noxious stressful stimuli (inflammatory process),
psychological stressful stimuli (parental separation, anxiety)
Leading to the development of visceral hyperalgesia
Look at slide 73
Alarm symptoms or signs that warrant consideration of diagnostic testing in children with AP
Involuntary weight loss
Deceleration of linear growth
GI blood loss (visible or occult)
Significant vomiting (incl bilious, protracted, cyclical)
Chronic severe diarrhoea
Persistent right upper or lower quadrant pain
Unexplained fever
Family h/o IBD
Abnormal or unexplained physical findings
Goals of Treatment/Management 1
Primary goal - Return to normal function
Avoidance of reinforcement of pain behaviours
Distraction, providing attention, rest, identifying triggers for pain
Reassurance
Education to the family
Emphasize that there is no serious life threatening process/condition
Goals of Treatment/Management 2
Secondary goal - Relief of symptoms
Pharmacologic
Cognitive Therapy
Relaxation
Massage/PT/OT/Exercise
