Gastro Flashcards
What can diahorrea be a sign of?
Can be early sign of septic illness
Watery stools in breastfed babies are normal
What are the main causes of diahorrea in children?
Secretory:
-Increased secretion or decreased absorption e.g. Cholera, C. diff, e. coli
Osmotic:
-increased osmotic load in gut lumen
Motility disorders:
-Increased - thyrotoxicosis, Irritable bowel syndrome
-Decreased - pseudo-obstruction, intusucception
Inflammatory:
-Salmonella, shigella, rotavirus, UC/Crohns
-Coeliac disease
-Haemolytic ureamic syndrome
What are the causes of gastroenteritis in children?
Most commonly rotavirus
Can be norovirus, astrovirus or adenovirus
How is gastroenteritis treated?
Correct any dehyrdation with either oral or IV fluids in more severe cases
Oral rehydration therapy such as dioralyte
Continue breastfeeding
If ORT refused offer other fluids or consider giving it by NG tube
Reintroduce milk after 4hr of ORT or sooner if recovers and is hungry
What are the complications of gastroenteritis?
Dehydration
Malnutrition
Post-enteritis enteropathy reolves around 7wks
What investigations can be done for gastroenteritis?
Stools - look for bacteria, ova, cysts and parasites
What is Kwashiorkor?
This is the combination of signs resulting from poor protein intake
It causes diahorrea, anorexia, apathy, oedema, skin and hair depigmentation and distended abdomen
Need to re-educate child, family and politicians to graducally increase proteins and vitamins in diet
What is Marasmus?
This is a lack of calories and a discrepancy between height and weight associated with HIV
May require paraenteral nutrition
Even following treatment often have longterm growth abnormalities
What are the surgical causes of abdominal pain in children?
Appendicitis
Intususception - colicky pain with redcurrent jelly stools
Bowel obstruction - vomiting and constipation
Testicular torsion - sudden onset unilateral testicular pain, vomiting and nausea
What is the management of recurrent functional abdominal pain?
Distracting the child with other activities or interests
Encourage parents not to ask about the pain
Advice about sleep and reducing stress
Aim to address psychosocial triggers and exacerbating factors
What are the features of abdominal migraine?
Generalised abdo pain for more than an hour with normal examination
May have symptoms of normal migraine in conjunction
How can abdominal migraine be managed acutely and preventatively?
Acutely - dark room, NSAIDs, Sumitriptan
Preventative - Pizotifen - needs to be stopped gradually to prevent withdrawl
What is encopresis?
This is faecal incontinence after the age of 4 that is caused by chronic constipation - loose stools overflow causing soiling
What are the lifestyle factors that affect constipation?
Habitually not opening the bowels Low fibre diet Poor fluid intake and dehydration Sedentary lifestyle Psychosocial problems such as a difficult home or school environment (always keep safeguarding in mind)
What are the red flags to look for in constipation?
Not passing meconium within 48 hours of birth (cystic fibrosis or Hirschsprung’s disease)
Neurological signs or symptoms, particularly in the lower limbs (cerebral palsy or spinal cord lesion)
Vomiting (intestinal obstruction or Hirschsprung’s disease)
Ribbon stool (anal stenosis)
Abnormal anus (anal stenosis, inflammatory bowel disease or sexual abuse)
Abnormal lower back or buttocks (spina bifida, spinal cord lesion or sacral agenesis)
Failure to thrive (coeliac disease, hypothyroidism or safeguarding)
Acute severe abdominal pain and bloating (obstruction or intussusception)
What is the management of constipation?
correct reversible causes, encourage high fibre and good hydration
Start laxatives (movicol 1st line)
Faecal impaction may require disimpation regime with high doses of laxitives at first
Encourage going to the toilet
What is normal in terms of reflux in babies?
Normal for babies to have reflux as long as they are growing normally
Due to immaturity of the lower gastro oesophageal junction
Most grow out of this by one year
What are some of the signs of problematic reflux in babies?
Chronic cough
Hoarse Cry
Reluctance to feed
Poor weight gain
What are some of the causes of vomiting in kids?
Overfeeding GORD Pyloric stenosis Gastroenteritis Appendicitis Infections e.g. tonsillitis Intestinal obstruction
What are the red flags for vomiting?
Not keeping down any feed Projectile vomiting Bile stained vomit (obstruction) Haematemesis of melena Abdo distension Signs of infection Rash
What is the management of GORD?
General: Small frequent meals Burping regularly Keeping baby upright after meals More severe: Gaviscon mixed feeds Thickened milk Omeprazole
What is sandifers syndrome?
Abnormal movements associated with GORD including torticollis and dystonia
How does pyloric stenosis present in babies? What does examination show?
Hungry baby that is thin, pale and failing to thrive
Have projectile vomiting
A firm round mass like a large olive in the upper abdomen, this is the hypertrophic pylorus
What kind of blood gas will pyloric stenosis show?
Shows a hypochloric metabolic alkalosis due to all of the hydrochloric acid being vomited up
What is the investigation and management of pyloric stenosis?
It is investigated with ultrasound and treated with a laproscopic pylomyotomy
This involves an incision into the smooth muscle to widen the canal
What age does coeliac present?
Usually in early childhood but can present at any age
What are the autoantibodies that develop in coeliac?
Anti ttg and anti endomysial (anti-EMA)
They target epithelial cells leading to inflammation
They rise and fall with disease activity
What are the presenting features of coeliac?
Can be asymptomatic Failure to thrive Diarrhoea Fatigue Weight loss Anaemia Dermatitis herpetiformis - itchy blistering rash on abdomen
What are all patients with type 1 DM tested for?
Coeliac as commonly linked
What are the features of crohns?
Crows NESTS No mucus in stool Entire GI tract Skip lesions Transmural Smoking is a risk factor
What are the features of ulcerative colitis?
U C CLOSEUP Continous inflammation Limited to colon and rectum Only superficial mucosa Smoking is protective Excrete blood and mucus Use aminosalicylates Primary sclerosing cholangitis
What are the extraintestinal manifestations of inflammatory bowel disease?
Clubbing Erythema nodosum Pyoderma gangrenosum Episcleritis and iritis Inflammatory arthritis Primary sclerosing cholangitis
What investigations should be done for inflmmatory bowel disease?
Bloods for anaemia, infection, thyroid, CRP for active inflammation, kidney and liver function
Faecal calprotectin 90% sensitive and specific in adults
Endoscopy with biopsy gold standard
Imaging with ultrasound, CT and MRI for complications
What is the management of Crohns?
Inducing remission:
-1st line steroids - oral pred or IV hydrocortisone
-Can add immunosupression e.g. azathioprine or methotrexate
Maintaining remission:
-1st line - azathioprine or mercaptopurine
-Alternatives - Methotrexate or infliximab
Surgical resection
What is the management of UC?
Inducing remission:
Mild - aminosalicylates e.g. mesalazine oral or rectal
-2nd line pred
Severe - IV hydrocort or IV ciclosporin
Maintaining remission:
-Aminosalicylates or azathioprine
Surgery - removing colon and rectum (panprotocolectomy)
What is biliary atresia?
It is a conginital narrowing or absence of the bile duct
This leads to cholestasis and prevention of excretion of conjugated bilirubin
How does biliary atresia present in children?
It presents with persistent jaundice in a newborn.
It should be investigated after 2 weeks in term babies and 3 weeks in preterm babies
What is the initial investigation for biliary atresia?
Look at conjugated and unconjugated bilirubin levels
There will be a high proportion of conjugated bilirubin as it is being conjugated but can’t be excreted
What is the management of biliary atresia?
It is managed with a kosai procedure in which the biliary tree is attached directly to the GI tract
Most patients will require liver transplantation to fully resolve the problem
What are the presenting features of intestinal obstruction?
Bilious vomiting with bright green bile and absolute constipation - no passage of wind or stools
high pitched bowel sounds can be heard then absent
What are the causes of intestinal obstruction?
Meconium ileus Hirschsprungs disease Oesophageal atresia Duodenal atresia Intussuception Imperforate anus Volvulus stangulated hernia
How is bowel obstruction diagnosed?
With an abdo xray showing dilated bowel loops and absence of air in the rectum
What is the management of obstruction?
Keep them nil by mouth
Insert an NG tube to drain stomach and prevent further vomiting
Provide IV fluids to correct dehydration and electrolyte imbalances
What is hirschsprungs disease?
Congenital absence of ganglion cells in the distal colon and rectum
This means the bowel does not relax and causes obstruction
What conditions are associated with hirschsprungs?
Downs syndrome and neurofibromatosis
How does hirschsprungs present?
Severity and age varies in individuals Delay in passing muconium >24hrs Chronic constipation Abdo pain and distension Vomiting Poor weight gain and failure to thrive
What is hirschsprungs associated enterocolitis?
Inflammation and obstruction that occurs in 20% of hirschsprungs patients
Presents at 2-4weeks
Have fever, diarrhoea, distension and can have sepsis
Can lead to toxic megacolon and perforation
Requires urgent antibiotics and decompression
How is hirschsprungs diagnosed?
Abdo x ray to show obstruction
Rectal biopsy shows absence of ganglionic cells
What is the definitive management of hirschsprungs?
Surgical resection of aganglionic bowel section
What is intususseption?
This is when the bowel telescopes into itself causing obstruction
What age does intususseption tend to present?
In 6 months to 2 years
More common in boys
What conditions is intususseption associated with?
Concurrent viral illness
Henloch scholein purpura
Cystic fibrosis
Meckel diverticulum
What is the presentation of intususseption?
Present with obstruction
RUQ Sausage shaped mass in abdo
Redcurrent jelly stool
Vomiting
What is the management of intususseption?
Therapeutic ememas with water or air to force bowel back into normal shape
Surgical reduction may be required if this does not work
What is the peak age for appendicitis?
10-20 years
What are the examination findings of appendicitis?
There is generalised tenderness that moves to the RIF
Tenderness at McBurney’s point, one third of the distance from ASIS to umbilicus
How does cow’s milk protein allergy present?
Usually in the first few months
Diarrhoea after being fed with formula for a few months
Reflux
