Gastro Flashcards
Bile stained vomit
Intestinal obstruction after the Ampulla of Vater
Projectile vomiting in the first weeks of life
Pyloric stenosis
Blood in stool
Gastroenteritis - Camplyobacter/Salmonella
Intussusception (red current jelly)
Causes of vomiting in neonates
Overfeeding
Gastro-oesophageal reflux
Necrotising enterocolitis
Obstruction - pyloric stenosis, vulvulas, malrotation (bilious vom)
Causes of vomiting in infants
Gastroenteritis
Other infections - Pertussis, UTI, meningitis, otitis media.
Dietary intolerance.
Intestinal obstruction - pyloric stenosis, intussusception, duodenal atresia, Hirschsprung disease.
Congenital adrenal hyperplasia.
Causes of vomiting in children and adolescents.
Gastroenteritis Infection - pyelonephritis, meningitis. H.pylori and peptic ulcer. Appendicitis Raised ICP (tumour) Diabetic ketoacidosis Bulimia Testicular torsion Coeliac.
Duodenal atresia
Blind ending in oesophagus which can have connecting fistula to the trachea (tracheo-oesophageal fistula).
Diagnosis can be made antenatally = small for gestational age, polyhydramnios.
Postnatally = respiratory distress, choking, poor feeding, unable to swallow, increased secretions, aspiration.
Unable to pass catheter into stomach.
Immediate surgical repair!
Causes of small bowel obstruction in neonates
Duodenal or ileum atresia or stenosis
Malrotation and volvulus (can lead to necrosis)
Meconium ileus (associated with CF)
Meconium plug
Causes of large bowel obstruction in neonates
Hirschsprung disease
Rectal atresia
Hirschsprung disease pathology and clinical features
Absence of myenteric nerve ganglia in rectum and can extend up to colon.
More common in males.
Continuous contractions = obstruction, neonate won’t pass faeces.
S+S = constipation, abdo distension, megacolon, vomiting, explosive passage of stools and gas.
Investigations and management of Hirschsprung
Rectal suction biopsy
Surgical excision of aganglionic section and colostomy.
Complications of Hirschsprung
GI perforation, enterocolitis, short-gut syndrome after surgical correction.
Malrotation and volvulus
Unfixed mesentery during embryonic rotation of the small bowel. Ladd bands cross duodenum.
Bilious vomiting, Epigastric distension, Blood in stools - necrosis in mid gut.
Contrast imaging and radiography.
Surgical correction via Ladd’s procedure.
Risk factors for necrotising enterocolitis
Low birth weight, PREMATURITY, mucosal injury, enteral feeding and bacterial colonisation.
Clinical features of necrotising enterocolitis
Abdo distension Abdo tenderness Blood PR Visibile intestinal loops Palpable abdo mass Shock
Investigations for necrotising enterocolitis
Pneumatosis intestinalis on AXR - gas in gut wall.
Management of necrotising enterocolitis
Nil by mouth
Stool cultures
ABx = cefotaxime + vancomycin.
Surgery if perforated or necrotic bowel.
Normal feeding amount
150ml/kg/day
Non-pathological vomiting in baby
Posseting - regurgitation of milk with gas.
Pyloric stenosis epidemiology
More common in males. Presents in 2-7weeks of age
Pathology og pyloric stenosis
hypertrophy of pyloric sphincter, outlet obstruction from stomach.
Clinical features of pyloric stenosis
Projectile vomiting.
Visible gastric peristalsis.
Palpable abdo mass.
Dehydration from vomiting and weight loss.
Low chloride, sodium and potassium ions and metabolic acidosis due to vomiting.
Investigations for pyloric stenosis
Test feed - visible peristalsis from left to right, pyloric olive shaped mass on palpation of right upper quadrant, USS.
Management of pyloric stenosis
IV fluids and electrolytes to rehydrate
Surgical pyloromyotomy.
Children at risk of severe gastro-oesophageal reflux
Neurodevelopmental pathologies e.g. cerebral palsy.
Preterm babies
Post surgery for oesophageal atresia.
Factors which make babies more at risk of GORD
Fluid diet
Immature lower oesophageal sphincter.
Mostly horizontal posture.
Short intra-ado length of oesophagus.
Investigations for GORD
24hr pH monitoring of oesophagus.
24hr impedance monitoring
Endoscopy
Treatment for GORD
Education - more prone position with feed, thickening agents to feed.
Alginate therapy e.g. Gaviscon.
If occurring alone do not offer meds.
If sever/other symptoms - PPI e.g. omeprazole or H2 receptor antagonist e.g. ranitidine.
Cause of metabolic acidosis in children
Pyloric stenosis due to recurrent vomiting.
Surgical procedure for pyloric stenosis
pyloromyotomy
Surgical procedure for malrotation
Ladd procedure.
Differentials for abdo pain in neonates
Gastroenteritis
Mesenteric adenitis
Trauma/NAI
Intussusception
Differentials for abdo pain in infants
Gastroenteritis Constipation UTI Appendicitis Mesenteric adenitis Intussusception Trauma
Differentials for abdo pain in children
Gastroenteritis Constipation UTI IBD Appendicitis Trauma
Differentials for abdo pain in teens
Gastroenteritis UTI IBD Gynae problem Gallstones Trauma Mesenteric adenitis
Age of appendicitis
After 3yrs
Clinical features of acute appendicitis
Anorexia Vomiting Abdo pain initially at at umbilicus then radiating to right iliac fossa. Aggravated by movement. Low-grade fever Tachycardia
Pathognomic feature of NEC
Peumatosis intestinal - gas in gut wall
Local area for tenderness and guarding in appendicitis
MacBurney’s point in right iliac fossa.
Even though appendicitis is rare in infants why is it risky?
Higher rate of perforation, less developed omentum.
Management of appendicitis
Appendiectomy.
Investigations for abdo pain
URINE DIP FBC, CRP AXR Renal imaging USS Barium studies.
Intussusception pathogenesis
Small bowel telescopes and invaginates on itself. Gut tries to peristalsis itself, gets stuck, ischaemia and can lead to perforation. Mostly ileum passing into caecum at ileocaecal valve.
Epidemiology of Intussusception
More common males. Any age but mostly 5-12months.
Clinical features of intussusception
Episodic. Lethargy Pallor Inconsolable crying Vomiting Colic - leg drawing. PR blood and red current jelly stool. Palpable sausage mass.
Investigations for intussusception
USS - doughnut sign/target with a crescent sign.
ABX - absent gas in distal bowel, distended small bowel, sausage shaped mass in lower right quadrant.
Enlargement of Peyer’s patches.
Management of intussusception
Fluid resus
Air enema/air insufflation reduction
Surgical reduction
Pathogenesis of Merkel’s diverticulum
Diverticulum of ileum from remnant vitello-intestinal duct. Contains ectopic gastric mucosa and pancreatic tissue.
Rules of 2 with Merkel’s diverticulum
2% of population
2 inches long.
Clinical features of Merkel’s diverticulum
Asymptomatic
PR bleeding (not bright red nor brown 😒)
Obstruction - intussusception, volvulus.
Pain mimicking appendicitis.
Management of Merkel’s diverticulum
Surgical excision.
Breastfed babies and stools
Breastfed babies can have non-patholgical diarrhoea.
Kwashiorkor
Oedematous malnutrition.
Low protein and amino acids in diet
Common in children weaned late from breast milk onto a high-starch diet.
Clinical features = poor growth, diarrhoea, anorexia, depigmentation of hair and skin, distended abdo, oedema, angular stomatitis, abdo distension and hepatomegaly.
Bloods = Low glucose, low potassium, low magnesium, low haemoglobin, low albumin, low cholesterol.
Marasmus
Low calorie intake and large discrepancy between weight for height (more than 3 SD below median), is less than 70%weight for height.
Clinical features = distended abdo, diarrhoea, infection esp HIV, reduced mid-arm circumference, lethargy, apathy.
Common causative organism in developed countries for gastroenteritis
Rotavirus (now part of immunisation schedule)
Norovirus
Common causative organism in less developed countries for gastroenteritis
C.jejuni E.coli Shigella Salmonella Due to contaminated food and water
Clinical features of gastrenteritis
Diarrhoea - usually 3times in 24hrs. Nausea Sudden onset vomiting Blood or mucus in stool Fever Malaise Crampy abdo pain Dehydration (complication rather than symptom)
Investigations and management of gastroenteritis
Mostly clinical diagnosis with good history (e.g. contact with other sick people, foreign travel, exclusion of other diagnosis rash, bilious vomit, neck stiff)
Stool culture
Assess for shock or dehydration and rehydration with fluids and oral rehydration therapy via Dioralyte..
Children at increased risk of dehydration when ill
Less than 1yr old.
Low birth weight infants
Passage of more than 5 loose stools in 24hrs
Vomiting twice in 24hrs
Unable to tolerate/accept supplementary fluids.
Refusing to breastfeed babies.
Signs of malnutrition.
Clinical features in a dehydrated baby
Altered responsiveness - lethargy, irritable
Sunken eyes
Dry mucous membranes
TC
TP
Reduced skin turgor
Normal pulse, BP and cap refill. Unchanged skin colour. Warm peripheries
Clinical features of a child in shock
Hypotensive Prolonged cap refill Weak peripheral pulses TC TP Cold extremities Mottled, pale skin Decreased level of consciousness.
Causes of malnutrition
Inadequate intake - cleft palate, anorexia, neglect.
Inadequate retention or excessive calorie loss - vomiting.
Mal-absorption - Coeliac, CF, intolerance.
Failure to utilise nutrition - Hypothyroid, Turner’s.
Increase nutritional requirements - thyrotoxicosis, malignancy.
Coeliac disease associated illness
Type 1 DM
Hypothyroid
(other autoimmune diseases)
Pathology of coeliac disease
Autoimmune enteropathy. Gluten activates an abnormal mucosal response at the proximal small intestine.
Villious atrophy and chronic inflammation.
Clinical features of coeliac disease
Persistent symptoms. Diarrhoea - offensive smell Abdo bloating Faltering growth/short stature Failure to thrive Weight loss Anaemia and fatigue (low folate and ferritin) Wasting of buttocks Irritability
Investigations and results for coeliac disease
Serology = IgA tTGA or IgA EMA
Small bowel biopsy = commonly duodenum, villous atrophy, crypt hyperplasia, lymphocytic cell infiltration in intra-epithelia and lamina propria inflammation.
Management of coeliac disease
Gluten free diet
IgA tTGA
IgA tissue transglutaminase antibody.
EMA
Endomysial antibodies.
2 types of inflammatory bowel disease
Crohn’s
Ulcerative colitis
Pathogenesis of Crohn’s
Relapsing and remitting inflammation of the GI tract. Affects anywhere from mouth to anus but most commonly terminal ileum.
Areas affected = Skip lesions
Full thickness of mucosal wall is inflamed.
Clinical features of IBD
Diarrhoea UC = blood and mucus in stool, faecal urgency, Abdo pain and tenderness Failure to thrive - esp in Crohn's Weight loss fatigue Malaise Anorexia Fever Systemic symptoms = oral lesions, arthralgia, erythema nodosum, conjunctivitis, uveitis, clubbing, ankylosing spondylitis.
Pathogenesis of Ulcerative colitis
Relapsing and remitting inflammation of the mucosa in the rectum and colon (children mostly pancolitis).
inflammation formed from pseudo-polyps and hyperaemic mucosa.
Punctate ulcers can develop.
Investigations for UC
Biopsy = crypt damage/loss, mucosal inflammation, ulceration.
Management of UC
Mild = Aminosalicylates e.g. Mesalazine, topical steroids e.g. hydrocortisone.
Moderate = oral prednisone with tapering dose
Severe = IV hydration and electrolyte replacement, IV hydrocortisone, rectal steroids, exclude infection.
Relapse = Azathioprine
Surgical colectomy plus ileostomy.
Management of Crohn’s
Replace diet with whole-protein modular diet.
Oral steroids tapering dose.
Relapse = azathioprine, infliximab.
Complications of IBD
Bowel obstruction, toxic dilation = perforation, abscess formation, fistulae, colon cancer.
Features of Toddler’s Diarrhoea
Able to see undigested food.
Thriving child
varying consistency of stools
Differentials for diarrhoea in a child
Gastroenteritis
Coeliac disease (persistent, on solid foods, short growth)
CF (steatorrhoea, pulmonary symptoms)
Chronic constipation leading to overflow diarrhoea
Food intolerance
IBD
Differentials for constipation in a child
Hirschsprung (no faeces in 24hrs of life) Hypothyroidism Dehydration Anal stenosis Spina bifida Sexual abuse.
Loose stools after viral gastroenteritis
Transient post-infective lactose intolerance. Stools are green and frothy.
Abdo mass, painless haematuria, flank pain, anorexia.
Wilm’s nephroblastoma.
Common metastases for Wilm’s nephroblastaoma
Lung
Pathophys of cow’s milk protein allergy
IgE or non IgE mediated allergy. Associated with other atopic diseases.
Clinical features of cow’s milk protein allergy
Colic pain GORD Vomiting Blood and mucus stools Faltering growth Diarrhoea if IgE mediated. Constipation if non-IgE mediated. Oedema of lips
Components of cow’s milk which may initiate immune response
casein and whey fractions
Management of cow’s milk protein allergy
IX =skin prick and/or specific IgE antibody blood test.
If breastfed = maternal exclusion of cow’s milk in diet.
Formula fed = use hypoallergenic infant formulas.
Giardiasis
Diarrhoea. Cysts in stool and motile forms in jejunal juice.
Villus atrophy with IgA deficiency.
Metronidazole Rx
Human interleukin antigens linked to coeliac
HLA DQ2 and DQ8
Gluten sensitive rash
Dermatitis herpetiformis.
Granulomas in UC and Crohns
UC = uncommon non-caseating granulomas Crohn's = common non-caseating granulomas
Histology of Crohns
Deep mucosal inflammation Crypt abscess Skip lesions of no inflammation Non-caseating granulomas Fistulas and sinus tracts Lymphocytic infiltration May have thickened wall
Histology of UC
Rectum and colon only Superficial inflammation of mucosa Rarely granulomas Rarely lymphocytic infiltration No bowel wall thickening Continuous inflammation 'Cobblestoning' Shortening of crypts
Extra-GI symptoms of IBD
Arthritis (Pauci-articular) esp CROHN'S. Erythema nodosum Aphthous ulcers Episcleritis Metabolic bone disease e.g. osteopenia
