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Toni's Paeds > Gastro > Flashcards

Gastro Flashcards

1
Q

What are the features of conjugated hyperbilirubinaemia?

A 
prolonged/persistent neonatal jaundice (at >2wks)
pale stools
dark urine
bleeding tendency
failure to 
*liver pathology*
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2
Q

What is biliary atresia?

A

1/14000
progressive destruction / absence of extrahepatic biliary tree and intrahepatic biliary ducts
-> chronic liver failure + death without surgery

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3
Q

How might biliary atresia present?

A

mild conjugated jaundice
failure to thrive
hepatomegaly +- splenomegaly

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4
Q

How would you diagnose biliary atresia?

A

LFTs no help
fasting abdo US: may sho contracted/absent gallbladder
radioisotope scan TIBIDA: good liver uptake no excretion into bowel
liver biopsy: extrahepatic biliary obstruction
confirmation on operative cholangiography at laparotomy: fails to outline a normal biliary tree

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5
Q

How do you manage biliary atresia?

A

surgical bypass of fibrotic ducts
hepatoportoenterostomy: Kasai procedure - loop of jejenum anastamosed to cut surface of porta hepatis allowing drainage of any remaining patent ductules
surgery before 60 days = 80% success - bile drainage
if unsuccessful: liver transplant

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6
Q

What are complications of the Kasai procedure?

A

cholangitis
malabsorption of fats and fat soluble vitamins
progression to cirrhosis and portal htn -> liver transplant

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7
Q

What is a choledochal cyst?

A

cystic dilatations of the extrahepatic biliary system
present in infancy with cholestasis
present in older children with abdo pain, palpable mass, jaundice or cholangitis

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8
Q

How would you diagnose and treat choledochal cysts?

A

diagnose on US or radionuclide scanning
surgical excision of cyst with a Roux-en-Y anastamosis ot the biliary duct
complications incl: cholangitis
2% risk malignancy in any part of biliary tree

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9
Q

What are the causes of neonatal hepatitis syndrome?

A 
congenital infection
alpha1-antitrypsin deficiency
galactosaemia
tyrosinaemia -T1
CF
inborn errors of metabolism
errors of bile acid synth
PFIC
intestinal failure assoc liver disease - assoc with TPN
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10
Q

How do infants with neonatal hepatitis syndrome present?

A 
prolonged neonatal jaundice
hepatic inflammation
IUGR
hepatosplenomegaly at birth
giant cell hepatitis on biopsy
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11
Q

What is alpha 1 antitrypsin deficiency?

A 
AR 1/2-4000
Chr 14 protease inhibitor
liver disease assoc with PiZZ phenotype
estimate level in plasma
50% -> liver disease req transplant
emphysema may develop in adult life
avoid smoking!!!
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12
Q

What is galactosaemia?

A

1/40000
poor feeding, vomiting, jaundice + hepatomegaly when fed milk
untreated -> liver failure, cataracts + developmental delay
can be rapidly fatal due to G-ve sepsis -> shock + DIC
screening: galactose in urine
diagnosis: measure galactose-1-phosphate-uridyltransferase in RBCs
galactose free diet prevents progression
ovarian failure and learning difficulties may occur later

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13
Q

What are inborn errors of bile acid synthesis?

A

neonatal cholestasis + normal GGT
screen for elevated cholenoic bile acids in urine
diagnosed on mass spectrometry of urine for bile acids
treatment = ursodeoxycholic acid

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14
Q

What is Progressive Familial Intrahepatic Cholestasis?

A

disorders of bile transporter defects caused by recessive mutations in different genes
presents with jaundice, pruritus, diarrhoea, failure to thrive, rickets, liver disease
low GGT#some req transplant

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15
Q

What is Alagille syndrome?

A

AD
intrahepatic biliary hypoplasia with severe pruritus + failure to thrive
triangular facies, skeletal abnormalities, congenital heart disease, renal tubular disorders, defects in the eye
variable prognosis
50% survive without liver transplant

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16
Q

How does viral hepatitis present?

A 
nausea, vomiting, abdo pain, lethargy, jaundice
large tender liver
splenomegaly in some
elevated liver transaminases
coagulation normal
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17
Q

Hep A in children

A

RNA virus
usually a mild illness
recover clinically and biochemically in 2-4wks
some may develop prolonged cholestatic hepatitis or fulminant hepatitis
chronic liver disease doesn’t occur
diagnosis confirmed by detecting IgM antibidy
no treatment
HNIG prophylaxis or vaccination for close contacts

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18
Q

Heb B in children

A 
DNA virus
causes acute and chronic liver disease
majority resolve spontaneously
perinatal HepB:
mostly asymptomatic
90% become chronic carriers
older children:
1-2% ->fulminant hepatic failure
5-10% become chronic carriers
anti-HBc= acute infection
HBsAg= ongoing infection
no treatment for acute infection
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19
Q

chronic Hep B in children

A

30-50% will develop chronic Hep B liver disease
of whom 10% progress to cirrhosis
long term risk = hepatocellular carcinoma

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20
Q

Hep B treatment

A

poor efficacy
Interferon:
effective for 50% infected horizontally, 30% perinatally
oral antiviral therapy effective in 23%

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21
Q

preventing HepB

A

antenatal screening of pregnant women: HbsAg
babies with +ve mothers to receive course of hep B vaccination
if mother has HBeAg also give hepBimmunoglobulin

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22
Q

Hep C in children

A

RNA virus
vertical transmission
rarely causes acute infection
2025% lifetime risk cirrhosis/hepatocellular carcinoma

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23
Q

EBV in children

A

usually asymptomatic

40% have hepatitis that may become fulminant

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24
Q

Acute liver failure (fulminant hepatitis) in children

A 
development of massive hepatic necrosis
loss of liver function
\+- hepatic encephalopathy
high mortality
mostly due to paracetamol OD and viral hepatitis
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25
Q

How does acute liver failure present?

A 
jaundice 
encephalopathy (irritability, confusion, drowsiness)
coagulopahy
hypoglycaemia
electrolyte disturbance
complications incl: cerebral oedema, haemorrhage, sepsis, pancreatitis
raised transaminases
abnormal coag
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26
Q

What is posseting?

A

non forceful return
small amounts milk
with return of swallowed air

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27
Q

What is regurgitation?

A

frequent
non forceful return
large amounts of milk
may indicate GORD

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28
Q

What is gastro-oesophageal reflux?

A

involuntary passage of gastric contents into the oesophagus

due to inappropriate relaxation of oesophageal sphincter due to functional immaturity

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29
Q

What increases risk of gastro-oesophageal reflux in infants?

A

mainly fluid diet
horizontal posture
short intra-abdo length of oesophagus

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30
Q

what are common symptoms of gastro-oesophageal reflux in infants?

A

recurrent regurgitation during 1st year
normal weight gain
otherwise well
spontaneous resolution by 12 months

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31
Q

What are the complications of gastro-oesophageal reflux?

A 
FTT from severe vomiting
oesophagitis
recurrent pulm aspiration
dystonic neck posturing
apparent life threatening event
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32
Q

When is severe reflux from gastro-oesophageal reflux seen?

A

children with cerebral palsy
preterm infants
following surgery for oesophageal atresia/diaphragmatic hernia

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33
Q

With an atypical history of reflux what investigations might be performed?

A

24hr oesophageal pH monitoring
to quantify degree of acid reflux
24hr impedence monitoring
endoscopy + oesophageal biopsy

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34
Q

How would you manage gastro-oesophageal reflux?

A

feed thickeners (nestargel, carobel)
30 degree head up prone position after feed
omeprazole or ranitidine

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35
Q

What is a Nissen fundoplication?

A

reserved for children suffering from complications of gastro-oesophageal reflux refractive
fundus wrapped around intra-abd oesophagus

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36
Q

What is pyloric stenosis?

A

hypertrophy of the pyloric muscle -> gastric outlet obstruction
2-7 wks
boys 4:1 girls

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37
Q

How does pyloric stenosis present?

A 
vomiting, incr freq and force->projectile
~ 1 month age
hunger after vomiting
weight loss
hypochloraemic metabolic acidosis
hyponatraemia, hypokalaemia
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38
Q

How would you go about confirming diagnosis of pyloric stenosis?

A

test feed
look for visible gastric peristalsis over the abdomen
pyloric mass in RUQ?
US if clinical examination is not conclusive

39
Q

How would you manage pyloric stenosis?

A

correct fluid/electrolyte disturbance
IVF: 0.45%saline + 5%dextrose with K supplements
Ramstedt’s pyloromyotomy: division of hypertrophied muscle down to mucosa
feed within 6hrs, discharge in 2 days

40
Q

What are the signs + symptoms of acute appendicitis?

A

central colicky abdo pain -> RIF
vomiting
anorexia

low grade fever
abdo pain aggravated by movement
guarding at Mc Burney’s point

41
Q

What investigations might confirm diagnosis?

A

generally none very helpful
US may support clinical findings
other imaging and bloods no use

42
Q

what are the complications of appendicitis?

A

appendix mass
abscess
perforation

43
Q

How would you manage appendicitis?

A

conservative: if no signs of peritonitits, IV abx, appendicetomy after a few wks
laparotomy: if symptoms progress
if signs of generalised guarding consistent with perforation: fluid resus and IV abx prior to laparotomy

44
Q

What is non-specific abdominal pain?

A

pain which resolves in 24-48hrs
less severe than appendicitis
often accompanied by URTI + cervical lymphadenopathy

45
Q

what is intussusception?

A

Invagination of proximal bowel into a distal segment
Mostly ileocaecal junction
Blood supply to telescoped bowel is compromised
-> ischaemia -> necrosis

46
Q

How does intussusception present?

A 
3 months - 2 years
paroxysmal colicky pain - screaming + drawing up legs
increasing lethargy
reduced feeding
vomiting - poss bile stained
sausage shaped abdo mass
redcurrent jelly stool
abdo distension
shock
47
Q

What are complications of intusussception?

A

hypovolaemic shock
bowel perforation ->
peritonitis + gut necrosis

48
Q

How would you manage intussusception?

A 
immed fluid resus
urgent reduction:
attempt rectal air insufflation in theatre 
75% success rate
if unsuccessful -> surgical reduction
49
Q

What is Meckel diverticulum?

A

2% have one: an ileal remnant of vitello-intestinal duct containing ectopic gastric mucosa or pancreatic tissue
most asymptomatic

50
Q

How would you expect a symptomatic Meckel diverticulum to present?

A 
severe rectal bleeding
neither bright red nor true melaena
volvulus around a band
diverticulitis 
technetium scan = incr ectopic gastric mucosa uptake
surgical resection req
51
Q

What is malrotation?

A

obstruction or obstruction + compromised blood supply
bilious vomiting in first few days of life -> urgent upper G contrast study
abdo pain + tenderness
urgent surgical correction
untwist volvulus and place in non-rotated position

52
Q

What is recurrent abdo pain?

A

pain sufficient to interrupt normal activities, lasts at least 3 months
oft peri-umbilical
likely due to either IBS, abdominal migraine, functional dyspepsia

53
Q

How would you manage recurrent abdo pain?

A

urine M, C + S

abdo US

54
Q

What imaging might confirm diagnosis of intussusception?

A

abdo XR

abdo US`

55
Q

What is IBS?

A

assoc with altered GI motility

abnormal sensation of intra-abdominal events

56
Q

How might IBS present?

A 
abdo pain relieved by defecation
explosive, loose, mucousy stool
bloating
feeling of incomplete defecation
constipation
57
Q

When might you suspect GI ulcer in a child?

A

recurrent abdo pain
wakes them at night
hx of ulceration in 1st degree rel

58
Q

What does H.pylori do and how is it identified?

A 
G-ve bacteria
causes nodular antral gastritis
produces urease
Clo test: Clabelled urea admin PO
or gastric/antral biopsy
59
Q

What does H.pylori eradication therapy comprise?

A

PPI: omeprazole/lansoprazole
amoxicillin
clarithromycin/metronidazolep

60
Q

What do you do if symptoms persist following eradication therapy?

A

upper GI endoscopy to look for pathology

if normal = functional dyspepsia

61
Q

What symptoms are associated with functional dyspepsia?

A

recurrent epigastric pain
early satiety
bloating
post prandial vomiting

62
Q

What is the most common cause of gastroenteritis in children living in developed countries?

A

rotavirus

63
Q

What symptoms might you see with Campylobacter gastroenteritis?

A

severe abdo pain

blood in stool

64
Q

What symptoms might you expect with Shigella gastroenteritis?

A

high fever
watery stools
blood + pus in stool
tenesmus

65
Q

Salmonella

A

?

66
Q

cholera

A

?

67
Q

What factors increase risk of hypovolaemic shock due to dehydration?

A

infant 6 diarrhoeal stools in 24 hrs
>3 vomits in 24 hrs
unable to tolerate fluids
malnutrition

68
Q

What is the likely cause of profuse diarrhoea in a child recently treated with broad spec abx?

A

pseudomembranous colitis
C-diff overgrowth
cdiff toxin identification in stool

69
Q

fever
bloody diarrhoea
high urea
haemolytic anaemia

A 
E.coli 0157
haemolytic uraemic syndrome
thrombocytopenia
treatment supportive
abx contraindicated
70
Q

What is transient lactose intolerance?

A

common sequelae of viral gastroenteritis
+ve clinitest: non-absorbed sugar in stool
24hrs oral rehydration solution then normal diet
?cut out lactose, then gradually reintroduce after a few months

71
Q

cows milk protein allergy

A

?

72
Q

What is coeliac disease?

A

gluten sensitive enteropathy
gliadin -> immunological response in proximal small intestine mucosa
villi-> shorter-> absent = flat mucosa

73
Q

What presentation would you classically expect with coeliac disease?

A

malabsorptive syndrome: FTT, abdo distension, buttock wasting, abnormal stools, irritability
8-24 months

74
Q

How would you test for coeliac disease?

A

Ttg test: IgA tissue transglutaminase antibodies
endomysial antibodies
confirmation:
jejunal biopsy: mucosal changes and villous atrophy
gluten withdrawal: resolution of symptoms + catch up growth
gluten free for life!

75
Q

What is Toddler diarrhoea?

A

AKA chronic non-specific diarrhoea
persistent loos stools in otherwise well preschool children
undigested vegetables common
intestinal hurry due to maturational delay
spontaneous resolution by 5yrs for most

76
Q

What is short bowel syndrome?

A

nutrient, water + electrolyte malabsorption due to congenital abnormalities / resection following NEC

77
Q

What is Hirschsprung disease?

A

absence of myenteric plexus of rectum and variable distance of colon
= narrow contracted segment

78
Q

How does Hirschsprung usually present?

A

failure to pass meconium in first 24hrs
+ abdo distension + bilious vomiting
in later childhood: profound chronic constipation, abdo distension + growth failure

79
Q

How is Hirschsprung disease diagnosed?

A

suction rectal biopsy: absence of ganglion cells

anorectal manometry may indicate the extent of the constricted segment and aid surgery but not diagnose

80
Q

How is Hirschsprung disease managed?

A

colostomy

anastamosing normally innervated bowel to anus

81
Q

What is congenital diaphragmatic herniation?

A

1/3000, oft diagnosed on antenatal USS, 90% left sided
Loops of bowel in left hemithorax, mediastinal shift to right, no gastric bubble
Defect occurs during fusion of pleuro-peritoneal membranes to create diaphragm
Likely to cause hypoplastic left lung and malrotation of the bowel

82
Q

How might congenital diaphragmatic herniation present?

A

Tachycardia, tachypnoea, cyanosis
Asymmetry of chest wall
Absent breath sounds of left
Bowel sound audible on chest wall

83
Q

How is congenital diaphragmatic herniation treated?

A 
Stabilise
Correct and electrolyte disturbance of acidosis
Supportive treatment, may req vent
Delayed surgery
7-10 days
84
Q

How does duodenal atresia present?

A 
Hx polyhydramnios
Bile stained vomiting in first 24 hrs
No abdo distension
Normal meconium passage
Double bubble on abdo XR
1/3 with DA have Down syndrome 
Surgical repair req: duodeno-duodenostomy
85
Q

Typical signs of appendicitis

A 
Poorly defined umbilical pain -> RIF
Nausea
Anorexia
Vomiting
Low grade fever
Tenderness + guarding over Mc Burney's point
86
Q

Atypical signs of appendicitis

A

Loose stools: 10% due to pelvic/retrocaecal appendix
Urinary sx: pelvic appendix
V young children abdo pain may not be obvious

87
Q

Inguinal hernia

A

Commonly indirect
Due to patent processus vaginalis
More common in premature babies + males
Usually R sided due to delayed descent of R testes

88
Q

Volvulus

A 
Complete twisting of a loop of bowel around its mesenteric stalk
Assoc with malrotation of bowel
Commonly presents in neonatal period
Can present up to 12 months
Bilious vomiting + abdo pain
89
Q

What are characteristic histological findings in coeliac disease?

A

Partial -> total villous atrophy
Crypt hyperplasia + lengthening
Intraepithelial lymphocytes

90
Q

How is coeliac disease diagnosed?

A

tTGA IgA
EMA IgA
Gold standard: duodenal + jejunal biopsy at endoscopy

91
Q

Conditions associated with coeliac disease

A

Incr risk of enteropathy assoc T cell + non Hodgkin’s lymphoma
Vitiligo
Thyroid disease
Dermatitis herpetisformis

92
Q

What causes appendicitis?

A 
Obstruction of appendiceal opening into the caecum -> inflammation
Obstruction can be caused by:
Faecolith
Adhesions
Lymphoid hyperplasia
93
Q

What is mesenteric adenitis?

A

Inflammation of the mesenteric lymph nodes after a viral URTI
Vague central colicky abdo pain
Tachycardia, high fever, flushed appearance
Evidence of viral infection: lymphadenopathy/pharyngitis
Self limiting
Conservative management, avoid laparotomy

94
Q

Management of meconium plug in cystic fibrosis

A

Presentation: bile stained vomiting, abdo distension, no passage of meconium
Gastrograffin enema - unless peritonitic! CI
Seen in CF
Start prophylactic fluclox
Sweat test at 6 wks

Toni's Paeds (16 decks)

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