Gastro Flashcards
Explain Posseting, Regurgitation and Vomiting
Posseting = small amounts of milk which accompany the return of swallowed air
Regurgitation = Larger, more frequent losses
Vomiting = forceful ejection of gastric contents
Causes of Vomiting in infants?
Gastro-oesophageal reflux
Feeding problems
Infection ( gastroenteritis, respiratory tract, whooping cough, urinary tract, meningitis)
Dietary protein intolerances
Intestinal obstruction ( pyloric stenosis, atresia, malrotation, volvulus, hirschsprung disease)
Inborn errors of metabolism
Congenital adrenal hyperplasia
Renal Failure
Causes of vomiting in Preschool children
Gastroenteritis
Infection ( resp tract, urinary tract, meningitis, whooping cough)
Appendicitis
Intestinal obstruction ( intussusception, malrotation, volvulus, adhesions, foreign body)
Raised ICP
Coeliac Disease
Renal Faiure
Inborn erros of metabolism
Torsion of testes
Causes of vomiting in school-age children?
gastroenteritis
infection ( consider pyelonephritis, septicaemia, meningitis)
peptic ulcer
appendicitis
migraine
raised ICP
coeliac disease
renal failure
diabetic ketoacidosis
alcohol/drugs
cyclical vomiting syndrome
bulimia/anorexia
pregnancy
torsion of the testes
What are the two most common causes of chronic vomiting in infants?
Gastro-oesophageal reflux
Feeding problems (force feeding/ overfeeding)
If vomiting in infants occurs with other symptoms such as fever, diarrhoea, runny nose or cough, what should be considered?
Gastroenteritis or Resp tract infection
but also consider UTI and Meningitis
What should be excluded if an infant is projectile vomiting around age 2-7 weeks?
What should be excluded if it is bile-stained? What further assessments should be done?
Pyloric Stenosis
Intestinal obstruction ( intussusception, malrotation and a strangulated inguinal hernia)
Assess for dehydration and shock
What is the cause of gastro-oesophageal reflux in infants?
Inappropriate relaxation of the lower oesophageal sphincter as a result of functional immaturity
When does gastro-oesophageal reflux in infants normally resolve and why?
12 months
- maturation of the sphincter
- upright posture
- more solids in diet
What complications are associated with gatro-oesophageal reflux?
- Failure to thrive
- Oesophagitis
- Recurrent Pulmonary Aspiration (can lead to pneumonia, cough or wheeze)
- Dystonic neck posturing
- Apparent life-threathening events
Which infants are more likely to develop severe reflux?
Children with cerebral palsy
Preterm-infants (esp if they have bronchopulmonary dysplasia)
Following oesophageal atresia or diaphragmatic herna surgery
What investigations and management for gastro-oesophageal reflux?
Invest - nnormally clinical, however oesophageal pH monitoring can be used and endoscopy to idenitfy oesophagitis
Manage - parental assurance and thickening agents
- if bad can use H2 receptor antagonists and PPIs
- surgery considered in very bad cases
What happens as a consequence of severe vomiting due to pyloric stenosis?
hypochloraemic metabolic alkalosis
How can pyloric stenosis be diagnosed?
Examination - feed baby milk…..pyloric mass can be felt like an olive in the right upper quadrant
ultrasound examination also helpful
What must be done before a pyloromyotomy can be carried out?
Ensure that any fluid and electrolyte disturbances have been corrected
0.45% saline and 5% dextrose with potassium supplements
Then the pyloromyotomy procedure can be carried out
What can be some causes of sudden onset continuous crying in an infant?
- UTI
- Ear infection
- Fracture
- Torsion of Testis
- Meningitis
- Oesophagitis
- Coeliac disease
- Constipation
How does infant colic present?
Paroxysmal, inconsolable crying
drawing up of knees
excessive flatus
presents in 40% of babies and resolves by 4 months
If Infant Colic presents more severe and persistent that normal what could it be?
- Cow’s milk protein allergy
2. Gastro-oesophageal reflux
What are some less common causes of acute abdominal pain?
- lower lobe pneumonia may cause referred pain to abdomen
- primary peritonitis seen in patients with ascites (nephrotic syndrome/ liver disease)
- Can consider things such UTI and pyelonephritis
What is the commonest cause of childhood abdominal pain?
Acute Appendicitis
Symptoms of acute appendicitis?
anorexia
vomiting
abdo pain that starts centrally and moves towards right iliac fossa
Signs of acute appendicitis?
flushed face
oral fetor
low grade fever
abdo pain aggravated by movement
persistent tenderness with guarding in Mcburneys point
What is non-specific abdominal pain and mesenteric adenitis?
Abdominal pain which resolves in 24-48 hrs, often accompanied by an URTI and cervical lymphadenopathy
Identified during laparoscopy/laparotomy by large mesenteric nodes when the appendix is normal
What medical causes must be considered in older children and adolescents when presenting with abdominal pain?
Lower Lobe Pneumonia
Diabetic Ketoacidosis
Hepatitis
Pyelonephritis
When is intussusception in infants most common?
2-24 months
most common cause of intestinal obstruction
What are clinical features of intussusception?
paroxysmal, colicky pain with pallor, abdominal mass, redcurrant jelly stool
What imaging is used to diagnose intussusception? what would you see?
Abdominal X-Ray = distended small bowel and absence of gas in distal colon/rectum
Treatment options for intussusception?
IF there is NO peritonitis = rectal air insufflation and abdominal ultrasound to check response
If unsuccessful operative reduction
What is Meckel’s Diverticulum?
Ileal remnant of vitellointestinal duct
Anatomically how does malrotation occur?
If small bowel mesentery is not fixed at the duodenojejunal flexure or the ileocaecal region
How does volvulus due to malrotation present?
blood in gastric aspirate or stool
bilious vomiting
abdo pain
tenderness
What urgent investigation must be performed in any child presenting with bilious vomiting?
Upper GI contrast study
What is recurrent abdominal pain?
recurrent pain, sufficient to interrupt normal activities that last atleast 3 months
affects 10% school-age children
normally pain occurs around umbillicus
What investigations would you perform on a child presenting with recurrent abdominal pain?
Full Hx and Exam
- Perineum for anal fissures
- Check child’s growth
- Urine microscopy and culture (UTI)
4, Abdo USS (exclude gall stone and PUJ obstruction)
What is long-term prognosis for recurrent abdominal pain?
50% will resolve rapidly
25% will take months to resolve
25% will develop migraine, IBS or functional dyspepsia in adulthood
What is the most common cause of gastorenteritis in developed countries?
Rotavirus
also can be adenovirus, norovirus, calicivirus
While less common, how would a bacterial form of gastroenteritis present? what is the most common organism?
Blood in the stool
Campylobacter Jejuni
other bacteria : cholera & enterotoxigenic E.coli
What infections could be mistaken as gastroenteritis?
septicaemia, meningitis, resp. tract infection, otitis media, Hep. A, UTI
What surgical disorders could be mistaken as gastroenteritis?
pyloric stenosis, intussusception, acute appendicitis, Hirschsprung
What metabolic disorders could be mistaken as gastroenteritis?
diabetic ketoacidosis
What groups of children are at increased risk of dehydration?
- under 6 months of age
- born with low birthweight
- vomited 3 or more times in last 24 hours
- if they cant tolerate extra fluids
- if they have malnutrition
Why are infants at greater risk of dehydration?
- have greater surface area to weight ratio
- have higher basal fluid requiremnets
- immature renal tubular reabsorption
When can dehydration be detected clinically?
> 5% loss of bodyweight
> 10% loss = SHOCK
What is isonatraemic dehydration?
When losses of water are proportional to losses in sodium
How does hyponatraemic dehydration occurs? What complications can be caused by it?
When in isonatraemic dehydration the infant consumes water or hypotonic solution, causing increase in water but not sodium
This leads to extracellular water moving into cells. In the brain this increases it’s volume causing convulsions
Extracellularly, this loss of water further compounds the effects of shock
What causes hypernatraemic dehydration?
High insensible water loss ( high fever, hot dry environment,
Low-sodium diarrhoea
What are signs of hypernatraemic dehydration?
depression of fontanelle
decreased tissue elasticity
sunken eyes
*hard to diagnose in fat babies
What complications can arise from hypernatraemic dehydration?
Brain/cerebral shrinkage - jittery movements, increased muscle tone, hyperreflexia, seizures, small cerebral hemmorhage
Transient hyperglycemia in some babies
What are red flag symptoms of clinical dehydration?
Appears unwell or deteriorating
Altered responsiveness (irritable, lethargic)
Sunken Eyes
Tachycardia
Tachypnoea
Reduced Skin Turgor
Also (reduced urine output, dry mucous membranes
What investigations should be carried out for gastroenteritis?
Stool Culture
U&Es
if Abx taken take a blood culture
What is management for a child who is clinically dehydrated?
Oral rehydration solution - fluid deficit replacement (50ml/kg) over 4 hours + maintenance fluids
IF keeps vomiting consider ORS by NG
What is management for a child who is in shock?
IV therapy - 0.9% NaCl
If patient improves
Replace fluid deficit :
If initially shocked give 100ml/kg
If not shocked give 50ml/kg
What is post-gastroenteritis syndrome?
Following gastroenteritis, introdcution of normal diet causes diarrhoea.
This is caused by lactose intolerance and diagnosed by a postive Clinitest, indicating non-absorbed sugar in the stool
To manage put them on ORS for 24 hrs then restart normal diet
What are 3 indications of malabsorption?
- Abnormal Stools
- Failure to thrive (in most)
- Specific nutrient deficiencies
What causes coeliac disease?
Gliadin component of Gluten
How does coeliac disease present?
Classically - failure to thrive, abdominal distension, buttock wasting, general irritability
More commonly these days - mild, non-speccific GI symptoms, anaemia (iron/folate), growth failure
What groups of children are at higher risk of coeliac disease?
Type 1 Diabetes
Autoimmune Thyroid
Down’s
1 degree relative with known disease
How do you diagnose Coeliac disease?
Gold Standard - biopsy = muscosal changes seen ;
1. increased intraepithelial lymphocytes
- villous atrophy
- crypt hypertrophy
What can help with toddler diarrhoea and what makes it worse?
fats can help
fruit juices high in non-absorbable sorbitol
What to consider if a child has diarrhoea and one of the following?
a) failure to thrive
b) following gastroenteritis
c) following bowel resection
d) otherwise well
a) coeliac or cow’s milk protein allergy
b) post-gastroenteritis lactose intolerance
c) cholestatic liver disease, exocrine pancreatic dysfunction, malabsorption
d) toddler diarrhoea
How does Crohn’s disease present?
Classically : abdominal, diarrhoea, weight loss
General : Fever, lethargy and weight loss
Extra-Intestinal : oral lesions, perianal skin tags, uveitis, arthralgia and erythema nodosum
It adolescents what can the symptoms of Crohn’s normally be mistaken for?
psychological problems/ anorexia
What would you use to diagnose Crohn’s and what would you expect to see?
Endoscopy - non-caseating epitheloid cell granulomata
in small bowel - narrowing, fissuring, muscosal irregularities and bowel wall thickening
How would you treat Crohn’s?
To achieve remission - normal diet replaced with whole protein modular feeds
For long-term treatment - immunosuppresants (azathioprine, mercaptoprine or MTX)
anti-tumour necrosis factor agents (infliximab/adalimumab)
*overnight ng/gastromy feeds may be needed for growth correction
Surgery - needed to remove obstruction, fistulae and abscess formation
How would Ulcerative Colitis present?
rectal bleeding, diarrhoea and colicky pain
weight loss and growth failure
extra-intestinal - erythema nodosum and arthritis
Diagnosis of Ulcerative Colitis?
Endoscopy
mucosal inflammation, crypt damage and ulceration
What form of UC is normally seen in children?
Pancolitis - 90% of children
in adults normally restricted to distal colon
Treatment for UC?
Aminisalicylates
Systemic Steroids (azathioprine)
Surgery - Colectomy
Why are regularly colonoscopic screenings required after diagnosis with UC?
adenocarcinoma risk
What is Hirschsprung diseasE?
absence of ganglioncells from myenteric and submucosal plexus in part of the large bowel
Which areas of the bowel are affected by Hirschsprung?
75% rectosigmoid
10% entire colon
How does Hirschprung’s disease present?
In neonatal period - intestinal obstruction and failure to pass meconium, abdominal distension and bile-stained vomiting
In later childhood - chronic constipation, abdominal distension w/o soiling and growth failure
- occasionally severe, life-threathening Hirschsprung enterocolitis sometimes due to clostridium difficile
Diagnosis of Hirschsprung’s?
Rectal biopsy (absence of ganglion cells)
Management of Hirschsprung’s?
Surgical - colostomy and anastomising normal innervated bowel
