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Gastro Flashcards

1
Q

What is the definition of vomiting

A

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.

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2
Q

What is the definition of regurgitation?

A

fortless expulsion of gastric contents (healthy infants and older children who eat in excess)

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3
Q

What is the definition of rumination?

A

frequent regurgitation of ingested food (largely behavioural)

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4
Q

What is the definition of possetting?

A

small volume vomits during or between feeds in otherwise well child

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5
Q

What are the 2 key sites in CNS implicated in the organisation of the vomiting reflex?

A

the vomiting centre (Medulla) chemoreceptor trigger zone (Floor of 4th ventricle)

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6
Q

What are the 5 key neurotransmitters involved in afferent feedback to these area?

A

histamine (H1receptors), dopamine (D2), serotonin (5-HT3), acetyl choline (muscarinic) and neurokinin (substance P).

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7
Q

What are the 5 key receptors of the vomiting centre and chemoreceptor trigger zone (CTZ)?

A

muscarinic (M1),
dopaminergic (D2),
histaminergic (H1),
5-hydroxytriptamine or 5-HT3(serotonin),
neurokinin NK1(substance P).

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8
Q

What are the 5 key precipitants of the vomiting centre and chemoreceptor trigger zone (CTZ)?

A

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).

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9
Q

What can be shown in a history for a child with GI issues?

A

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

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10
Q

What are red flags for gastroenterology problems in kids?

A

meningism, costovertebral tenderness, abdominal pain and any evidence of increased intracranial pressure.

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11
Q

What is involved in the examination for GI?

A

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

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12
Q

DDs of vomiting in infants and children in GI

A

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

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13
Q

Differential Diagnosis of Vomiting in Infants and Children – Non-GI
Neurologic

A

Hydrocephalus
Subdural hematoma
Intracranial hemorrhage
Intracranial mass
Infant migraine

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14
Q

Differential Diagnosis of Vomiting in Infants and Children – Non-GI
Infectious

A

Sepsis
Meningitis
Urinary tract infection
Pneumonia
Otitis media
Hepatitis

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15
Q

Differential Diagnosis of Vomiting in Infants and Children – Non-GI
Metabolic/endocrine

A

Galactosemia
Hereditary fructose intolerance
Urea cycle defects
Amino and organic acidemias
Congenital adrenal hyperplasia

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16
Q

Differential Diagnosis of Vomiting in Infants and Children – Non-GI
Renal

A

Obstructive uropathy
Renal insufficiency

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17
Q

Differential Diagnosis of Vomiting in Infants and Children – Non-GI
Toxic, Cardiac, Psychiatric

A

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

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18
Q

Common Causes of Pediatric Vomiting by Age of Presentation Neonatal (0-2 days)

A

Duodenal or other intestinal atresia
-TEF (types A/C)

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19
Q

Common causes of vomiting in newborn 3 days - 1month

A

-Gastroenteritis
-Pyloric stenosis
-Malrotation +/- volvulus
-TEF (types B/D/H)
-Necrotizing enterocolitis
-Milk protein intolerance
-CAH
-IEM

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20
Q

Common causes of pediatric vomiting Infants 1-36 months

A

-Gastroenteritis
-UTI, pyelonephritis
-GER
-GERD
-Ingestion
-Intussusception
-Milk protein intolerance

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21
Q

Common causes of vomiting in children 36-12 years

A

-Gastroenteritis
-UTI
-DKA
-Increased intracranial pressure
-Eosinophilic esophagitis
-Appendicitis
-Ingestion
-Post-tussive vomiting

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22
Q

Adolescent vomiting 12-18

A

-Gastroenteritis
-Appendicitis
-DKA
-Increased intracranial pressure
-Eosinophilic esophagitis
-Bulimia nervosa
-Pregnancy
-Post-tussive vomiting

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23
Q

What investigations should be carried out?

A

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

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24
Q

What are the consequences of vomiting?

A

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

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25
Treatment of vomiting
Supportive - intravenous fluids, analgesia and antiemetics Treat cause – medical or surgical Pharmacological
26
Anti histamines used for vomiting
Look at slide 18 of Common gastroenterology problems
27
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
28
What is GOR
Gastroesophageal reflux (GOR): the passage of gastric contents into the esophagus with or without regurgitation or vomiting
29
What is GORD?
Gastroesophageal reflux disease (GORD): the presence of troublesome symptoms and/or complications of persistent GOR.
30
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].
31
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
32
Features of GORD in children
Faltering growth Oesophagitis +/- stricture Apnoea, ALTE, SIDS Aspiration, wheezing, hoarseness IDA Seizure-like events, torticolis
33
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’
34
Management of GORD
Position Thicken feeds Change feeds Drugs – antacid, H2 blocker, PPI Surgery - fundoplication
35
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
36
What are some non-immune adverse food reactions
Pharmacologic Metabolic Toxic Other
37
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%
38
GI S + S of IgE-mediated food allergy
Angioedema of the lips, tongue and palate Oral pruritus Nausea Colicky abdominal pain Vomiting Diarrhoea
39
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
40
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
41
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)
42
How do we diagnose and manage CMPA
Diagnosis – elimination diet Management – Hydrolysed or AA feeds
43
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
44
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
45
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
46
What test is used for the Lactose intolerance
Breath hydrogen
47
What is constipation?
Infrequent passage of stool associated with pain and difficulty, or delay in defecation.
48
What is encopresis?
involuntary faecal soiling or incontinence secondary to chronic constipation.
49
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
50
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
51
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
52
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
53
What are the short and long term complications of constipation
Short term – no sequelae Long term – acquired megacolon, anal fissures, overflow incontinence, behavioural problems
54
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)
55
Management of constipation
Explanation of normal bowel function Diet/fluids and exercise Behavioural advice Toilet training advice Simple reward schemes
56
Medication for constipation
Softener: lactulose, liquid paraffin Bulking agent: Fybogel Non-absorbed laxative irrigative: Movicol Stimulant: Senna, Dulcolax Enema Anal fissure: anaesthetic cream +/- vasodilator
57
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.
58
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%
59
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
60
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
61
Presentation of AGE
Diarrhoea +/- bloody stools (dysentry) Fever +/- vomiting Dehydration and reduced consciousness
62
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
63
Assessment and mgmt of dehydration
Look at slide 53 of common gastroenterology problems
64
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
65
Symptoms of non clinically detectable dehydration
Appears well Alert and responsive Normal urine output Skin colour unchanged Warm extremities
66
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
67
Clinical dehydration symptoms
Appears unwell Alerted responsiveness Decreased urine output Skin colour unchanged Warm extremities
68
Signs of clincal shock of dehydration
Decreased level of consciousness Pale or motted skin Cold extremities Tachy Tachypnoea Weak peripheral pulses Prolonged CRT Hypotension
69
Symptoms of clinical shock
Decreased levels of consciousness Pale or mottled skin Cold extremities
70
Management of hydration in Gastroenteritis
Look at slide 54 of common gastroenterology problems
71
When should you perform stool microbiology for Gastroenteritis
Suspect septicaemia Blood or mucus in stool Child immunocompromised
72
When should you consider performing stool microbiology in gastroenteritis
Travel diarrhoea not improved in 7 days Uncertain about gastroenteritis
73
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
74
Other treatments of gastroenteritis
Antibiotics – bacterial GE complicated by septicaemia or systemic infections or immunocompromised and malnourished patients Probiotics No antiemetics/anti-motility drugs
75
Features of hypernatremia dehydration
Unusual and serious Irritable with doughy skin Water shifts from intracellular to extracellular Rehydration should be slow
76
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
77
Features of Crohn's disease
Mouth to anus Transmural inflammation Discontinuous Granuloma Rectal sparing Fissures, fistula, abscesses and strictures Perianal disease
78
Features of UC
Colon only affected Mucosal inflammation Continuous No granuloma No rectal sparing Abscesses and strictures rare Primary sclerosing cholangitis
79
Differences between paediatric and adults IBD
Slide 63 of common gastroenterology problems
80
Growth in IBD
Poor growth Delayed puberty Reduced Final adult height Catch up growth Persistent poor growth - only sign of disease activity
81
How do we diagnose IBD
Clinical evaluation Biochemical Endoscopic Radiological Histological Nuclear medicine
82
Interventions for Crohn's disease
EEN Corticosteroids (Prednisolone/Budesonide) Aminosalicylates (Topical & Oral) Antibiotics Immunomodulators (Azathioprine, methotrexate) Biologics (Infliximab, Adalimumab) Surgery Parenteral nutrition
83
Approach to 1st line therapy for UC
Mild to moderate: Induction- Aminosalicylates Remission-Aminosalicylates Moderate to severe: Induction- Corticosteroids Remission- 6 MP/ Azathioprine
84
DDS for abdominal pain
Acute – appendicitis, intussusception, pancreatitis, cholecystitis, pneumonia… Chronic
85
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.
86
Organic causes of abdominal pain
GORD Peptic ulcer disease H pylori infection Food intolerance Coeliac disease IBD Constipation UTI Dysmenorrhoea Pancreatitis Hepato-biliary disease
87
Functional disorders of childhood
Several functional gastrointestinal disorders of childhood are recognizable . Functional dyspepsia Irritable bowel syndrome (IBS) Functional abdominal pain Abdominal migraine Aerophagia
88
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
89
Look at slide 73
90
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
91
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
92
Goals of Treatment/Management 2
Secondary goal - Relief of symptoms Pharmacologic Cognitive Therapy Relaxation Massage/PT/OT/Exercise

3A Paediatrics (19 decks)

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