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Y4 paeds > Gastro > Flashcards

Gastro Flashcards

1
Q

What is the definition of colic?

A

Distress or crying in an infant which lasts for more than 3 hrs a day for more than 3 days a week for at least 3 weeks in an otherwise healthy infant.

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2
Q

How should you assess a child you suspect has colic?

A 
In history ask for:
- Feeding method
- Weight gain
- Bowel habit
- Vomiting/ reflux
- Time and duration of crying
Examine:
- general exam inc weight 
- abdo, hernial orifices and genitalia 
Investigations:
- usually none, unless they have failure to thrive
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3
Q

Give 5 differentials for an acutely distressed infant

A
  • Cold/ wet/ hungery
  • Severe nappy rash
  • Corneal abrasion (scratch themselves)
  • Intussusecption
  • Volvulus
  • Strangulated hernia
  • Testicular torsion
  • Non accidental injury
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4
Q

Give 3 differentials for a chronic colic history?

A
  • Reflux- commonest
  • Lactose intolerance
  • Constipation
  • Cows milk protein allergy
  • Parenting skills and post natal depression
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5
Q

What advice should be given to parents with a baby with colic?

A
  • Hypoallergic diet for mother may be helpful in some cases
  • Share childcare so avoid exhaustion
  • Simeticone (infacol) and dicyclomine hydrochloride are unlikely to be harmful but have little evidence in support
  • Will pass on its own by 3-4 months of age
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6
Q

Describe the clinical features of a constipated child

A
  • Infrequently passing stools (less than 3 a week)
  • Stools may be hard and small
  • Abdominal pain, distension, fullness and bloating
  • May present with overflow diarrhoea: unaware of passing stool or needing to, may be thick and sticky or dry and flakey
  • Large stools that block the loo
  • Reventive posturing (tiptoes, straight legged, arching of back)
  • Rabbit droppings
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7
Q

Give 5 red flags for constipation

A
  • from birth or in first few weeks of life
  • failure/ delay in passing meconium > 48hrs
  • ribbon stools
  • weakness in legs/ locomotor delay
  • abdo distension +/- vomiting
  • abnormal appearance of anus
  • abdnormal examination of spine
  • abnormal neuromuscular signs or reflexes
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8
Q

Most organic causes of constipation present within the first few weeks of life, give 4 organic causes of constipation in an infant

A
  • anorectal malformations
  • fissure
  • hirschprungs disease (delayed meconium + failure to thrive)
  • spinal cord/ neuroenteric problems (eg myelomeningocele)
  • hypocalcaemia
  • coeliac
  • cystic fibrosis
  • cows milk allergy
  • medications
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9
Q

give 4 functional causes of constipation?

A
  • poor diet
  • poor motility
  • low fluid intake
  • anxiety over pooing
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10
Q

How should functional/ idiopathic constipation be managed? (generally)

A
  • reassure and advise that treatment can take months
  • assess for faecal impaction and treat if found, then give maintainance therapy
  • give diet and lifestyle advise (fibre, fluids exercise are mainstay)
  • refer is no response in 3 months
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11
Q

How should a constipated child be disimpacted? (initially then further steps)

A

1st: movicol then increase dose
2nd: if no response in 2 weeks, add stimulant (picosulphate) +/- lactulose or ducosate if hard stool)
3rd: specialist disimpaction: manual evac under general, NG tube delivery of polyethylene glycol solution for whole gut lavage, antegrade colonic enema and psychological therapy

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12
Q

What maintainance therapy and behaviour modifications should be made to manage constipation after disimpaction?

A

Maintenance: regular laxatives (usually movicol, avoid stimulants)
Behaviour modifications: increase fibre and fluid intake, unhurried toileting, reward systems, relaxation techniques, regular toileting if soiling

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13
Q

What causes hypernaturaemia in dehydration and why is it important?

A
  • high Na+ occurs when fluid loss exceeds loss of electrolytes
  • leads to fluid loss rom cells so brain shrinkage and sheering of blood vessels - eventually leading to cerebral bleeding and thrombosis
  • at some point the brain cells create idiogenic osmoles to compensate and protect themselves, but this can lead to cerebral odema when fluid replacement is too rapid
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14
Q

How may hypernaturaemic dehydration be clinically different to iso/hyponaturaemic dehydration?

A
  • skin recoil is normal

- neuro signs such as irritability, high pitched inconsolable cry, hypertonia and hyperreflexia

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15
Q

How should dehydration be investigated?

A
  • Capillary blood gas ASAP for sodium assessment
  • urine dip- ketones for DKA
  • bloods: FBC (?sepsis), U&E (? AKI), glucose, CRP, more if cause not obvious
  • appropriate cultures if suspect infection eg stool for Gastroenteritis
  • ECG
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16
Q

What signs/ symptoms may be present which indicate dehydration is moderate (but not severe/ shocked)?

A
  • appears unwell
  • altered responsiveness
  • decreased urine output
  • sunken eyes
  • dry mucous membranes
  • tachycardia (red flag- indicated impending shock)
  • tachypnoea (also red flag)
  • reduced skin turgor (red flag)
  • skin colour normal
  • warm extremities
  • normal pulses
  • normal cap refill
  • normal BP
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17
Q

What signs/ symptoms suggest the dehydration is clinically severe and they child is in shock

A
  • decreased consciousness
  • pale or mottled skin
  • cold extremities
  • sunken eyes
  • dry membranes
  • tachycardia and tachypnoea
  • weak pulses
  • prolonged cap refill
  • reduced turgor
  • hypotension (decompensated shock)
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18
Q

How is mild dehydration managed?

A
  • fluids/ breast milk for oral rehydration

- if oral intake not sufficient then pass an NG tube

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19
Q

How is moderate and severe dehydration managed?

A 
Moderate= IV matintenance fluid + calculated losses over 24 hrs
Severe= IV maintenance fluid + losses+ resus bolus over 24 hrs
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20
Q

What fluid should be given if the pt is in shock?

A

20ml/kg bolus- twice then get senior review. Then add 100ml/kg onto maintenance requirement and monitor response

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21
Q

How is a pts fluid requirement calculated? (3 parts)

A

Calculate fluid deficit: weight (kg) x % dehydated x 10
+
ongoing losses (from drains, NG tubes, urine, resp, sweating)
+
maintenance requirement

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22
Q

How are maintenance requirements calculated?

A

100mls/ kg for first 10kg, then 50mls/kg for next 10kg and 20mls/ kg for any weight after 20kg.

23
Q

How is the management of iso/ hypotonic dehydration different to hypertonic dehydration?

A

Is iso/ hypotonic you give them their fluid requirement over 24 hrs
If hypertonic you give them it over 48 hrs (remember to times their calculated maintenance fluid requirement by 2 and the hourly ongoing losses by 48 instead of 24) and can give 0.45% NaCl if severe

24
Q

What type of fluid should be used to correct a child’s dehydration?

A

0.9% saline +/- 5% dextrose or 0.45% saline and 5% dextrose if hypernaturaemic

25
Q

What is normal urine output for a child age 0-1, 1-3, 3-12 and 12+?

A

0-1: 2 mls/ kg/ hr
1-3: 1.5 mls/kg/ hr
3-12: 1 mls/kg/ hr
12+: 0.5 mls/kg/ hr

26
Q

How should failure to thrive be assessed?

A

History:
- quantity, frequency and quality of feeding
- what is environment of feeding
- what is behaviour like at meal time
- any symptoms eg fever, pain, cry, dysphagia, N/V/D
- other paeds hx- labour and birth, development, allergies, social hx
- check growth plots
Examine: signs of acute or chronic illness, mother interactions with child, child behaviour and habitus
Investigations: if indicated by clinical assessment

27
Q

Give 5 causes of failure to thrive

A
  • Prenatal: prem, maternal malnutrition, IUGA, genetic abnormalities
  • Post natal feeding issues: inability to suck or swallow due to NMD, vomiting may have CNS, metabolic, obstructive or renal cause
  • GORD
  • physical problems: cleft palate, prader willi, hypotonia
  • poor absobtion/ metabolism: CF, coeliac, CKD, hypothyroid, diabetes, inbored errors of metabolism, infections
  • increased metabolic demand: hyperthyroid, heart disease, resp disease, renal disease, malignancy
  • functional causes: feeding difficulties, lack of prep for parenting, family dysfunction, difficult children, child neglect, emotional deprivation syndrome
28
Q

How should failure to thrive from birth to 1 month be managed if GP?

A
  • if weight loss is less than 10% in early days of life then reassure its normal, they should return to normal weight within 3 months
  • if >10% or not returned within 3 weeks of age: refer to paeds, ensure parents have sufficient feeding support from midwife/ health visitor
29
Q

What should failure to thrive be refered to paeds? (& what is significant changes on growth charts?)

A
  • height or weight below 0.4th centile or sustained fall through 2 centiles, can consider if either is below the 2nd centile
  • safeguarding concern
  • signs/ symptoms indicating underlying disorder
  • rapid weight loss or severe malnutrition
  • slow linear growth or unexplained short stature
30
Q

If a childs failure to thrive doesn’t warrant referral (ie not severe or functional), what general measures can be taken to ensure better growth?

A
  • Three meals and 2 snacks a day
  • Increase number and variety of food
  • Calorie dense foods- add cream and cheese to everything
  • Limit milk intake to 500ml per day
  • Avoid excessive juice and squash
  • Regular meal times with family
  • Make meal times last 20- 30 mins
  • Praise when food is eaten
31
Q

What are the most common causes of gastroenteritis in children?

A
  • rotavirus: most will get it before 5 yrs
  • norovirus: commonest across all age groups
  • adenovirus: usually causes resp infections but can get gastroenteritis also, esp if age >2 yrs
  • camplyobacter: commonest bacterial causes
  • E.coli: important as some strains have life threatening complications such as haemorrhagic colitis or haemolytic uraemic syndrome
32
Q

Give 4 complications of gastroenteritis?

A
  • Haemolytic uraemic syndrome: can cause acute renal failure and haemolytic anaemia
  • Reactive arthritis, carditis, urticaria, erythema nodosum, conjunctivitis
  • Toxic megacolon: rare but can occur due to rotavirus infection
  • Aquired/ secondary lactose intolerance: due to lining of intestine being damaged, resolved when gut lining heals
33
Q

Why do infants get reflux?

A
  • Short and narrow oesophagus
  • Delayed gastric emptying
  • Liquid and high calorie diet
  • Larger gastric: oesophageal volume ratio
  • Lots of time spend lying down
34
Q

Give 4 risk factors for GORD in an infant?

A
  • Prematurity
  • Parents get heartburn
  • Obesity
  • Hiatus hernia
  • Neurodiability eg cerebral palsy
35
Q

Give 4 clinical features of GORD

A
  • Distressed behaviour: excessive crying, unusual neck postures, back arching
  • Unexplained feeding difficulties (refusing feeds, gagging, choking)
  • Pneumonia
  • Faltering growth
  • If onset is >6 months or persist beyond 1 yr then GORD is unlikely
  • reflux and posseting are common in infants, it only becomes GORD when they have some of the above features/ symptoms
36
Q

Describe the stepwise management to GORD

A
  1. give alginate (gaviscon) with water after feeds if breast fed (then skip to step 6)
    if not breastfed:
  2. ensure not over fed (no more than 150 ml/kg/ day)
  3. decrease feeding volume by increasin frequency to 2-3 hrly
  4. use feed thickener
  5. stop thickener and add alginate to formula
  6. if no improvement with alginate after 2 weeks, then start PPI or H2R antagonist
37
Q

give 3 complications of GORD

A
  • reflux oesphagitis
  • aspiration pneumonia
  • otitis media
  • dental erosion
38
Q

What is gilberts syndrome? how does it present

A
  • unconjugated hyperbilirubinaemia due to a genetic defect in enzyme which conjugates bilirubin
  • usually presents around puberty with jaundice that is precipitated by something such as illness, stress, fasting, dehydration, exertion, lack of sleep, alcohol, surgery etc
  • no treatment is needed and life expectancy is normal but there are a few drugs to avoid
39
Q

What is wilsons disease and how does it present and what is needed for diagnosis?

A
  • genetic disorder causing copper deposits in the liver
  • presents with liver abnormalities and/ or movement disorders in children and adolescents
  • hepatic features: hepatomegaly, elevated AST/ALT, acute or chronic liver failure, cirrhosis
  • neuro features: tremour and parkinsonism
  • kayser fleischer rings and low serum caeruloplasmin are needed for diagnosis
40
Q

How is wilsons disease managed?

A
  • avoid alcohol and hepatotoxic drugs
  • copper chelating agents
  • medications to block copper absorption from GI tract
41
Q

How does autoimmune hepatitis tend to present?

A
  • peak onset age 10-20
  • fatigue, nausea, upper abdo pain, anorexia, rashes, odema, hepatomegaly and jaundice (50%), splenomegaly, ascites, encephalopathy
42
Q

How is autoimmune hepatitis diagnosed?

A
  • liver biopsy
43
Q

How is autoimmune hepatitis managed and monitored?

A
  • immunosurpression w/ pred + azathioprine commonly
  • liver transplants can be done if terminal but may reoccur after
  • need regular LFTs, glucose and FBC monitoring + DEXA scans and cateracts screens if on steds
44
Q

What is the aetiology of cows milk protein allergy?

A
  • can be IgE, non IgE or mixed

- the allergy can be to casein and/ or whey in the milk

45
Q

Describe the clinical features of IgE and non IgE mediated cows milk protein allergy?

A

IgE mediated:
- Rapid onset (within 2 hrs)
- Pruritis, erythema, urticarial, angio- odema
- Nausea, colicky abdo pain, vomiting, diarrhoea
- Cough, chest tightness, wheeze, SOB
- Sneezing, rhinorrhoea or nasal congestion
Non IgE mediated:
- Onset generally delayed (up to 2-7 days after)
- Pruritis, erythema and atopic eczema
- GORD, lose/ frequent stools, blood/ mucus in stool, abdo pain, colic, food refusal, constipation, perianal redness, pallor and tiredness, faltering growth
- Cough, tightness, wheeze, SOB

46
Q

Describe the management of cows milk protein allergy

A
  • Avoid cows milk in all forms while mum is breast feeding
  • Eliminate it from the diet for 6 months or until 9-12 months old, then re- evaluate every 6-12 months for tolerance
  • Extensively hydrolysed formula or amino acid formula (more expensive but used if still symptomatic to hydrolysed formula) for infants who are formula fed
  • Soya based formulas not recommended if <6 months
  • Anaphylaxis is rare and most are tolerant by early childhood
47
Q

Describe the clinical features of coeliac disease

A 
Classical presents age 1-2 w/ 
- persistent diarrhoea
- faltering growth
- distension
- constipation 
- anaemia/ iron deficiency resistant to oral iron 
- abdo pain
- miserable child
Atypical: 
- later w/ extra intestinal manifestations (anaemia, fatigue, pruritis, epilepsy, ataxia, neuropathy, arthritis, short, delayed puberty, isteoporisis etc), fewer- no intestinal symptoms
Also silent and latent forms
48
Q

Describe the process of diagnosing coeliac (ie what tests todo and when)

A
  • initial screening with total IgA and IgA anti tTG antibodies
  • if Anti tTG x10 upper limit normal-> can do anti EMA and HLA DQ2/8 typing OR dueodenal biopsy to confirm diagnosis
  • if <10x upper limit normal but raised then do biopsies (4 from D2 or lower and 1-2 from duodenal cap)
  • if tTG negative and IgA normal then coeliac is unlikely
49
Q

Other than overflow diarrhoea, what could cause encopresis (soiling)?

A
  • failure to obtain initial bowel screening
  • toileting phobia
  • soiling to manipulate environment
  • irritable bowel syndrome
  • 90% of soiling is due to overflow diarrhoea
50
Q

Define functional abdominal pain

A

Abdominal pain which occurs at least four times a month over a period of two months or more, which is severe enough to limit a child’s activities and which, after appropriate evaluation, cannot be attributed to another medical condition.

51
Q

How should functional abdominal pain be managed?

A
  • be careful not to over investigate but coelaic screen, fbc, crp, endomysial antibodies, stoop sample and urine culture are appropriate
  • ease pain with distraction techniques and try carry on as normal- dont miss school
  • acknowledge pain is real but no organic cause so should pass
  • peppermint oil and anti spasmodics can have some benefit
  • CBT, hypnotherapy, yoga and acupuncture can be tried and are successful for many
52
Q

How is crohns disease managed? (acutely and 3 steps of maintenance)

A
  • for acute attacks: pred 1-2mg/kg/day up to 40mg for 2-4 weeks
  • you can also manage acute attacks without steroids by putting them on an exclusively liquid diet for 6 weeks
  • then maintain with aza or 6mp then try methotrex then inflix or surgery
  • growth, nutrition and bone support + pain management throughout
53
Q

How is ulcerative colitis managed? (acute and maintainance)

A
  • sulphasalazine for mild flares and corticosteroids for mod- severe flares
  • aminosalicylates then aza or 6mp
  • surgery if resistance or toxic megacolon develops
  • oral aminosalicylates +/- topical treatment eg enemas of amisalicylate or steroid if left sided/ distal colitis

Y4 paeds (14 decks)

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