gastro

Question 1

What causes GORD

Answer 1

immaturity of oesophageal sphincter

Question 2

Which pt is GORD most common in

Answer 2

Preterm
Cerebral palsy
hx of surgery

Question 3

How do you diagnose GORD

Answer 3

Clinical picture

Also 24 hour pH monitoring

Question 4

Mx of GORD

Answer 4

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

Question 5

Dx of pyloric stenosis

Answer 5

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

Question 6

What are people with pyloric stenosis at risk of

Answer 6

Hypochloraemic metabolic ALKALOSIS with low potassium and sodium

Question 7

Mx pyloric stenosis

Answer 7

IV rehydration (with 5% dextrose +0.45% saline) at 1.5x maintenance rate
Add potassium once output is up

Cure is Ramstedt pyloromyotomy

Question 8

What is infant colic

Answer 8

excessive paroxysmal crying accompanied by drawing up of knees and passing excess flatus
common in first 4 months of life
if persistent –> CMP allergy

Question 9

Mx for colic

Answer 9

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

Question 10

Signs + symptoms of appendicitis

Answer 10

Vomiting, anorexia, abdo pain

Pain aggravated by movement, fever, Guarding (may not get it if appendix is retrocaecal)

Question 11

What is non-specific abdo pain

Answer 11

Pain that resolves within 24-48 hours
Often accompanied by cervical lymphadenopathy and URTI

These children can be diagnosed w/ mesenteric adenitis

Question 12

Presentation of intussusception

Answer 12

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)

Question 13

What can cause intussusception

Answer 13

preceding viral illness (swollen peyer’s patches)

meckel’s diverticulum (most common place is ileum through ileo-caecal valve)

Question 14

Complications of intussusception

Answer 14

Blocked venous flow, bleeding, inflammation, necrosis, perforation

Question 15

Ix for intussusception

Answer 15

AXR - may show no air in large bowel

US - confirmatory test - target sign

Question 16

Mx intussusception

Answer 16

ABCDE, IV fluids and NG aspiration may be needed
1.If no peritonitis - rectal air insufflation

2. If clinically stable w/ no contraindications for contrast enema (peritonitis, perforation, hypovolaemia) + BSA clindamycin and gentamicin
3. surgery

If recurrent Ix investigate for pathological lead point

Question 17

How can Meckel’s diverticulum present

Answer 17

Rectal bleeding and low Hb 
Can also present more acutely:
Meckel's diverticulitis (presents similarly to appendicitis)
intussusception
volvulus

Question 18

Ix for Meckel’s

Answer 18

techentium scan

As meckel’s has gastric mucosa it takes technetium up

Question 19

Mx for Meckel’s

Answer 19

Asymptomatic - nothing

Symptomatic - remove

Question 20

2 presentations of malrotation

Answer 20

Obstruction - get bilious vomiting

Obstruction and vascular compromise

Question 21

Mx of malrotation

Answer 21

vascular compromise - urgent laparotomy

Ladd procedure - divide Ladd bands and put bowel back in its place

Question 22

Defintion of recurrent abdo pain

Answer 22

Pain that interrupts daily activities for up to 3 months

Question 23

How does IBS present

Answer 23

(often precipitated by intra-abdominal infection)

non-specific abdo pain 
Complain of explosive stools
Bloating
constipation 
incomplete defecation 

RULE OUT COELIAC’S

Question 24

What is IBS associated with

Answer 24

FHx, anxiety, mental health issues

Question 25

Mx of IBS

Answer 25

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

Question 26

When to suspect duodenal ulcers

Answer 26

Rare in kids | if pain wakes them up at night, back pain, 1st deg relative w/ peptic ulcer

Question 27

Mx of peptic ulcer

Answer 27

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

Question 28

How does eosinophilic oesophagitis present

Answer 28

difficulty swallowing, vomiting

Question 29

What is eosinophilic oesophagitis associated with

Answer 29

Atopic conditions

Question 30

Dx of eosinophilic oesophagitis

Answer 30

Trachealisation of oesophagus - give corticosteroids

Question 31

How does campylobacter gastroenteritis present

Answer 31

abdominal pain

Question 32

Features of shigella and salmonella infetcion

Answer 32

Dysenteric infection blood and pus in stool tenesmus pain

Question 33

Features of cholera and enterotoxigenic e.coli

Answer 33

Profuse watery diarrhoea

Question 34

Mx of gastroenteritis

Answer 34

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

Question 35

maintenace fluid algorithm

Answer 35

0-10kg - 100ml/kg 10-20 - 50ml/kg 20+ - 20ml/kg to be given over 24 hours

Question 36

How do you get isonatraemic + hyponatremic dehydration

Answer 36

Kids w/ diarrhoea drink water, they don't replace sodium so water goes into intraceullular space Brain expands -- > seizures

Question 37

How do you get hypernatremic dehydration? What is the risk with correcting this?

Answer 37

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

Question 38

Which part of bowel does coeliac affect

Answer 38

PROXIMAL SMALL INTESTINE

Question 39

Presentation of coeliac

Answer 39

``` FTT weight loss anaemia bloating BUTTOCK WASTING abdo distension dermatitis herpetiformis ```

Question 40

Ix for coeliac

Answer 40

anti-tTG Ab endomysial Ab duodenal biopsy: CONFIRM DIAGNOSIS Catch up of growth upon removing gluten also required to confirm dx

Question 41

Coeliac management

Answer 41

Remove gluten dietician referral calcium, iron vit d supplements (you get micronutrient def --> osteopenia) annual review to check height weight and bloods

Question 42

Causes of nutrient malabsorption

Answer 42

cholestatic liver disease short bowel syndrome Crohn's (loss of terminal ileum) exocrine pancreatic dysfunction

Question 43

How does crohn's present

Answer 43

Fatigue lethargy bloody stool can mimic anorexia

Question 44

Diagnostic features of Crohn's

Answer 44

useful features: Raised inf markers low albumin IDA Diagnosis done by UGI See narrowing, strictures, fistulae hallmark - non-caseating epithelioid cell granuloma Transmural inflammation

Question 45

What does crohn's affect

Answer 45

Terminal ileum

Question 46

Mx of crohn's

Answer 46

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

Question 47

presentation of UC

Answer 47

rectal bleeding colicky pain diarrhoea

Question 48

Extraintestinal manifestations of UC

Answer 48

erythema nodosum | enteric arthritis

Question 49

Diagnosis of UC

Answer 49

Mucosal INF Crypt destruction ulceration

Question 50

Mx of UC

Answer 50

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

Question 51

what can predispose to constipation

Answer 51

dehydration anxiety anal fissures

Question 52

Primary causes of constipation

Answer 52

``` Hirschprung Hypothyroidism rectal atresia hypercalcaemia coeliac's ```

Question 53

Red flags for constipation

Answer 53

``` FTT gross abdo distension Failure to pass meconium neuro problems of lower limbs sacral dimple (spina bifida) ```

Question 54

Mx of constipation

Answer 54

``` 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

Question 55

How does hirschprung's disease present

Answer 55

No meconium obstruction (with all these symptoms) can also get hirschprung enterocolitis in later life presents w/ constipation

Question 56

Diagnosis of hirschprung

Answer 56

absence of ganglion cells and acetylcolinesterase positive nerve trunks on full thickness suction biopsy

Question 57

Mx of hirschprung

Answer 57

Surgery (anorectal pullthrough)