gastro Flashcards
What causes GORD
immaturity of oesophageal sphincter
Which pt is GORD most common in
Preterm
Cerebral palsy
hx of surgery
How do you diagnose GORD
Clinical picture
Also 24 hour pH monitoring
Mx of GORD
Reassure (begins early, can take a year to go away)
Review if:
Projectile vomiting, haematemesis, bile stained vom, FTT, persistent regurgitation beyond 1 year of life
If breast fed:
breast feeding assessment
alginate
If formula: check right vol. is given trial smaller more frequent feeds trial thickened formula alginate
Positional stuff:
keep baby upright
Medicine:
2-4 week trial of PPI or antihistamine in children who have 1 or more of :
unexplained feeding difficulty (choking), distressed behaviour, failure to thrive
Dx of pyloric stenosis
Symptoms:
vomiting which becomes worse –> projectile
hunger after vomiting (til they become so dehydrated that they don’t feed)
Mass in RUQ that feels like olive
What are people with pyloric stenosis at risk of
Hypochloraemic metabolic ALKALOSIS with low potassium and sodium
Mx pyloric stenosis
IV rehydration (with 5% dextrose +0.45% saline) at 1.5x maintenance rate Add potassium once output is up
Cure is Ramstedt pyloromyotomy
What is infant colic
excessive paroxysmal crying accompanied by drawing up of knees and passing excess flatus
common in first 4 months of life
if persistent –> CMP allergy
Mx for colic
Reassure that it often resolves around 6 months
If breastfeeding mum can benefit from hypoallergenic diet
If bottle fed check bottle size
Info: NHS choices
Strategies to soothe baby - white noise, holding
Signs + symptoms of appendicitis
Vomiting, anorexia, abdo pain
Pain aggravated by movement, fever, Guarding (may not get it if appendix is retrocaecal)
What is non-specific abdo pain
Pain that resolves within 24-48 hours
Often accompanied by cervical lymphadenopathy and URTI
These children can be diagnosed w/ mesenteric adenitis
Presentation of intussusception
PAROXYSMAL colicky abdo pain accompanied by pallor around the mouth
usually resolves but there may be some lethargy
child draws legs up
Redcurrant jelly stool
refusing feed
vomiting (bile stained)
What can cause intussusception
preceding viral illness (swollen peyer’s patches)
meckel’s diverticulum (most common place is ileum through ileo-caecal valve)
Complications of intussusception
Blocked venous flow, bleeding, inflammation, necrosis, perforation
Ix for intussusception
AXR - may show no air in large bowel
US - confirmatory test - target sign
Mx intussusception
ABCDE, IV fluids and NG aspiration may be needed
1.If no peritonitis - rectal air insufflation
- If clinically stable w/ no contraindications for contrast enema (peritonitis, perforation, hypovolaemia) + BSA clindamycin and gentamicin
- surgery
If recurrent Ix investigate for pathological lead point
How can Meckel’s diverticulum present
Rectal bleeding and low Hb Can also present more acutely: Meckel's diverticulitis (presents similarly to appendicitis) intussusception volvulus
Ix for Meckel’s
techentium scan
As meckel’s has gastric mucosa it takes technetium up
Mx for Meckel’s
Asymptomatic - nothing
Symptomatic - remove
2 presentations of malrotation
Obstruction - get bilious vomiting
Obstruction and vascular compromise
Mx of malrotation
vascular compromise - urgent laparotomy
Ladd procedure - divide Ladd bands and put bowel back in its place
Defintion of recurrent abdo pain
Pain that interrupts daily activities for up to 3 months
How does IBS present
(often precipitated by intra-abdominal infection)
non-specific abdo pain Complain of explosive stools Bloating constipation incomplete defecation
RULE OUT COELIAC’S
What is IBS associated with
FHx, anxiety, mental health issues
Mx of IBS
Lifestyle:
reduce stress
avoid caffeine
add fibre
Diarrhoea predominant:
lifestyly, antidiarrhoeals (give TCA +/- CBT if in pain)
Constipation predominant:
lifestyle, laxatives (give SSRI +/- CBT if in pain)
If both give combination of drugs
When to suspect duodenal ulcers
Rare in kids
if pain wakes them up at night, back pain, 1st deg relative w/ peptic ulcer
Mx of peptic ulcer
Trial PPI and do Ix
If suggestive of h.pylori - triple therapy (amox, clari, PPI)
If not do UGI endoscoopy - if this shows ulcer give PPI (or H2 antagonist 2nd line)
If this is negative then it’s functional dyspepsia
If bleeding: endoscopy +/- blood transfusion, PPI; then do surgery and embolisation
How does eosinophilic oesophagitis present
difficulty swallowing, vomiting
What is eosinophilic oesophagitis associated with
Atopic conditions
Dx of eosinophilic oesophagitis
Trachealisation of oesophagus - give corticosteroids
How does campylobacter gastroenteritis present
abdominal pain
Features of shigella and salmonella infetcion
Dysenteric infection
blood and pus in stool
tenesmus
pain
Features of cholera and enterotoxigenic e.coli
Profuse watery diarrhoea
Mx of gastroenteritis
Consider admission
rehydrate
Advice on preventing spread
Tx dehydration
None - <10kg - 60-120ml, >10kg 120-240ml of oral rehydration solution per episode of vomiting (this is baseline
Mild (<5%) - 50mL of ORS/kg OVER 4 HOURS + the baseline
Moderate (5-10%) - 100ml/kg ORS over 4 hours + baseline
Severe (>10%) Emergency, admit + IV resusc w/ saline 20ml/kg every hour
NB - ABx rarely given
maintenace fluid algorithm
0-10kg - 100ml/kg
10-20 - 50ml/kg
20+ - 20ml/kg
to be given over 24 hours
How do you get isonatraemic + hyponatremic dehydration
Kids w/ diarrhoea drink water, they don’t replace sodium so water goes into intraceullular space
Brain expands – > seizures
How do you get hypernatremic dehydration? What is the risk with correcting this?
Hot weather, low sodium diarrhoea
Water goes to intravscular so they look less dehydrated than they are
dangerous
Don’t corrct this too quickly as you can get too much water flowing into brain –> cerebral oedema
Which part of bowel does coeliac affect
PROXIMAL SMALL INTESTINE
Presentation of coeliac
FTT weight loss anaemia bloating BUTTOCK WASTING abdo distension dermatitis herpetiformis
Ix for coeliac
anti-tTG Ab
endomysial Ab
duodenal biopsy: CONFIRM DIAGNOSIS
Catch up of growth upon removing gluten also required to confirm dx
Coeliac management
Remove gluten
dietician referral
calcium, iron vit d supplements (you get micronutrient def –> osteopenia)
annual review to check height weight and bloods
Causes of nutrient malabsorption
cholestatic liver disease
short bowel syndrome Crohn’s (loss of terminal ileum)
exocrine pancreatic dysfunction
How does crohn’s present
Fatigue
lethargy
bloody stool
can mimic anorexia
Diagnostic features of Crohn’s
useful features:
Raised inf markers
low albumin
IDA
Diagnosis done by UGI
See narrowing, strictures, fistulae
hallmark - non-caseating epithelioid cell granuloma
Transmural inflammation
What does crohn’s affect
Terminal ileum
Mx of crohn’s
Polymeric diet (whole protein feeds) can send it into remission but it usually comes back
stop smoking
assess risk of osteoporosis
DO NOT RECEIVE LIVE VACCINES
Educate on recognisisng flare ups (weight loss)
for ileocaecal disease:
Mild - observation or budesonide or 5-ASA
moderate -
1. budesonide +/- 5-asa OR oral steroids
2. immunomodulator (azathioprine/methotrexate) + oral corticosteroid
3. biological therapy (infliximab) +/ oral steroid + azathioprine
Severe:
1.hospitalise + oral/IV corticosteroid
immunomodulator
2. biological therapy
presentation of UC
rectal bleeding
colicky pain
diarrhoea
Extraintestinal manifestations of UC
erythema nodosum
enteric arthritis
Diagnosis of UC
Mucosal INF
Crypt destruction
ulceration
Mx of UC
assess severity using paediatric ulcertaive colitis activity index
Mild - oral 5-ASA (can add steroids)
Moderate - oral pred, if good response give 5-ASA and taper, if not it’s steroid dependent disease
steroid dependent disease - infliximab, if inadequate think about surgery
Severe UC: medical emergency
High dose IV methylprednisolone
stop oral 5-ASA
Abx if bacteria
NB - 5-ASA used for maintaining remission (if this doesn’t work can add top 5-ASA or oral beclomethasone
what can predispose to constipation
dehydration
anxiety
anal fissures
Primary causes of constipation
Hirschprung Hypothyroidism rectal atresia hypercalcaemia coeliac's
Red flags for constipation
FTT gross abdo distension Failure to pass meconium neuro problems of lower limbs sacral dimple (spina bifida)
Mx of constipation
Check for faecal impaction, if impacted: disimpaction regime (osmotic laxative + lifestyle modification, may also need to add stimulant)
Start maintenance laxatives
dietary mod and osmotic laxative
behavioural interventions (scheduled toileting, bowel habit diary)
diet + lifestyl advice
secondary behaviour problems are common
How does hirschprung’s disease present
No meconium
obstruction (with all these symptoms)
can also get hirschprung enterocolitis
in later life presents w/ constipation
Diagnosis of hirschprung
absence of ganglion cells and acetylcolinesterase positive nerve trunks on full thickness suction biopsy
Mx of hirschprung
Surgery (anorectal pullthrough)
