Gastro Flashcards
Define Constipation
Decrease in frequency of bowel movements characterised by passage of stools which may be large and associated with straining/pain
Termed chronic if lasting more than 8 weeks
What is the normal Bowel Frequency in children?
<4 weeks - QTS
1y - BD
4y - Adult frequency (3 per day to 3 per week)
Name some causes of Constipation in children
Inadequate fluid/fibres
Psychosocial issues
Impaired mobility (Cerebral Palsy)
Neurodevelopmental (Downs)
Diagnosis of Constipation requires Atleast two of:
<3 complete stools a week
Hard large stool
Rabbit droppings
Overflow soiling
What is Retentive Posturing?
Straight legged
Tip toes
Arched back
Name three red flags for Constipation in children
Symptoms occurring from birth (?Hirschsprungs)
Abdominal Distension (?Hirschsprungs)
Ribbon stool pattern (?Anal Stenosis)
What suspected diagnoses with constipation would require a non urgent referral?
Coeliac
Hypothyroidism
CMPA
How is Constipation disimpacted?
Macrogol using escalating dose regimen (increasing dose until soft stools form)
Describe maintenance therapy in constipation
Movicol in escalating dose (normally half the dose required for disimpaction)
Can add Senna if required
What general advice should you give parents whose child is constipated?
Scheduled toiletting Bowel diary Star chart Adequate fibre and fluids Don’t stop laxatives abruptly
Name four organic causes of Abdominal Pain
Constipation
Coeliac
Mesenteric Adenitis
Abdominal Migraine
Give three red flags in an Abdominal Pain presentation
Persistent vomit
Fever
Rectal bleeding
What initial investigations should be done in Abdominal Pain?
FBC, CRP, TTG, Urine Dipstick
Define Recurrent Abdominal Pain
Abdominal pain occurring Atleast four times a month, over Atleast two months which limits child’s activity and can’t be attributed to another cause
Believed to be due to dysregulation of visceral nerve pathways
How can recurrent abdominal pain be managed?
Encourage distraction and school
Peppermint Oil, Antispasmodics, Antidiarrhoeals
CBT
What are the different patterns of vomiting?
Acute (discrete episodes of moderate to high intensity)
Chronic (low grade daily pattern)
Cyclic (severe discrete episodes with pallor/lethargy/pain)
Give three causes of newborn vomiting
Pyloric Stenosis
Duodenal Atresia
Intestinal Malrotation
What diagnoses for vomiting would you consider after the newborn period?
GOR
Intussusception
Allergies
Give four Non GI causes of vomiting
Meningitis
Pyelonephritis
Migraines
Raised ICP
Give three causes of cyclical vomiting
Abdominal migraine
Cyclical vomiting syndrome
Intermittent obstruction
What features in a vomiting history could help differentiate the cause?
Bilious vs Non Bilious
Bloody vs Non Bloody
Projectile vs Non Projectile
Febrile vs Non Febrile
What investigations are required in acute vomiting?
Bloods
Stool Culture
AXR
Abdominal USS if projectile
What investigations are required in chronic vomiting?
H.Pylori testing
Coeliac AB screen
Urinalysis
?Imaging
What investigations are required in cyclical vomiting?
Serum Amylase
Serum Lipase
Serum Ammonia
Management of vomiting is supportive and treat underlying cause. What complications could occur?
Dehydration
Electrolyte Disturbance
Mallory Weiss
If no underlying organic cause for vomiting, what diagnosis should be considered?
Psychogenic
Define Diarrhoea
Change in consistency and frequency of stools, with enough loss of fluids and electrolytes to cause illness
Give 5 causes of Diarrhoea in children
Infective Gastroenteritis Food Hypersensitivity Drugs (Antibiotics) HSP Intussusception
How would you manage mild to moderate diarrhoea?
No tests necessary
Replace fluids and electrolytes with oral glucose and electrolytes
How would you manage severe diarrhoea?
IV Fluids and electrolytes
Full range of bloods, ABG, Stool Culture, USS
Anti motility not recommended
What is Chronic Diarrhoea?
Diarrhoea persisting for more than 14 days
Can be due to reduced absorption (coeliac), osmotic (lactase deficiency), inflammatory (UC), or secretory (VIP secreting tumour)
What is Toddler’s Diarrhoea?
Occurring from 6 months to 5 years
Colicky intestinal pain, distension and undigested food
Managed with increased fibre and occasional loperamide
What stool tests could you do in chronic diarrhoea?
Microscopy Leukocytes Fat Culture pH Elastase Calprotectin
Other than Stool, Blood and Radiological investigations, what else can be done in Chronic Diarrhoea?
H2 breath (Lactose Intolerance)
Biopsy (Coeliac/IBD)
Sweat (CF)
Coeliac is an autoimmune response to gluten. Describe the pathophysiology
Combination of immunological responses to an an environmental factor (gliadin) and genetic factors (HLA DQ2/DQ8)
Epithelial destruction and follows atrophy via antitissue transglutaminase and anti endomysial
Describe the classical presentation of Coeliac
Presenting at 9-24 months with features of malabsorption, failure to thrive, weight loss, loose stools
Describe the atypical presentation of Coeliac
Osteoporosis Peripheral Neuropathy Anaemia Dermatitis Herpetiformis Dental Enamel Hypoplasia
Positive serology only
What would the classic histology show in Coeliac?
Crypt Hyperplasia
Villous Atrophy
Describe the latent presentation of Coeliac
Predisposing genes
Normal mucosa
Possible positive serology
Describe the silent presentation of Coeliac
Damaged small intestine
Positive Serology
No symptoms
How is suspected Coeliac investigated?
Patient has to be eating gluten at time and for Atleast 6 months before
Total IgA then tTG IgA
Duodenal biopsy if positive serology
Describe the staging of Coeliac biopsy
0 - normal
1 - Increased intraepithelial lymphocytes
2 - Increased inflammatory cells and crypt hyperplasia
3 - all of the above plus mild to complete villous atrophy
State four complications of Coeliac
Anaemia
Osteopenia
Osteoporosis
Malignancy
Define GORD
Gastro-Oesophageal reflux is the passage of gastric contents into the oesophagus
Becomes known as GORD when it is symptomatic
What is Posseting?
Reflux of contents beyond oesophagus, and can be normal in infants
Eg after feeding
Why are children predisposed for reflux?
Reduced LOS tone
Short Oesophagus
Liquid diet
Significant periods recumbent
Give three risk factors for GORD
Prematurity
Obesity
Hiatus Hernia
How does GORD present?
Excess crying
Back arch
Chronic cough
Faltering growth
What should you establish in a GORD history in relation to feeding?
Position and technique
Volume given (?over distension)
Frequency/Volume of vomits
Relationship to feeds
GORD is a clinical diagnosis. Give three differentials
Pyloric Stenosis (Projectile)
Malrotation (Bile Stained)
CMPA (Blood in stool)
How should you manage breast fed infants with GORD?
Alignate with water immediately post feed
How should you manage formula fed infants with GORD?
1) Ensure not overfed (150ml/kg/d total)
2) Decrease feed volume and increase frequency
3) Use feed thickener
4) Stop thickener and add alignate
If GORD doesn’t improve with alignates, what can be used?
PPI
H2 Antagonist
The features of Crohns can be remembered by the mnemonic NESTS, describe this
No blood or mucous Entire GI tract Skip Lesions Terminal Ileum/Transmural Smoking is a risk factor
The features of UC can be remembered by the mnemonic CLOSE UP, describe this
Continuous inflammation Limited to colon/rectum Only superficial mucosa Smoking is protective Excrete blood and mucous
Use Aminosalicyclates
PSC association
Give four extraintestinal features of IBD
Clubbing
Erythema Nodosum
Pyoderma Gangrenosum
Iritis
How is IBD investigated in children?
Faecal Calprotectin
OGD and colonoscopy with biopsy
AXR/Small Bowel MRI/CT for complications
How is remission induced in Crohns?
First line - Oral Prednisolone/IV Hydrocortisone
Second Line - Azathioprine, Infliximab
What is the maintenance treatment in Crohns?
Azathioprine/Mercaptopurine first line
Surgery for complications
How is remission induced in UC?
Mild to Moderate - Aminosalicyclate first line, Prednisolone second line
Severe - IV Hydrocortisone or IV Ciclosporin
What is the maintenance treatment for UC?
Aminosalicyclate or Azathioprine
Panprotocolectomy is curative (either Ileostomy or J Pouch)
Describe the different types of viral hepatitis
A- Faecal Oral B - Blood Products, IVDU, Sex, Vertical C - Same as above, mostly chronic D - Coinfection for Hep B E - Faecal Oeal G - IV
(+ EBV,HIV, CMV)
What are the non viral causes of Hepatitis?
Metabolic Disease (Wilson’s)
Autoimmune
Reye Syndrome
What is Reye’s Syndrome?
Acute Encephalopathy associated with aspirin therapy and fatty liver infiltration
Nausea and vomiting, Hypoglycaemia, Abdo Pain
Hepatitis can present in various ways in children. Describe some
Asymptomatic
Fulminant (Encephalopathy, Coagulopathy)
Fever, fatigue, anorexia, RUQ pain, jaundice
Give five investigations for Hepatitis
LFTs Blood Glucose Viral Serology Serum Immunoglobulins Serum Copper
Hepatitis is normally managed supportively with the avoidance of alcohol. How is Fulminant Hepatitis managed?
PICU
Liver Transplant
Hepatitis is normally managed supportively with the avoidance of alcohol. How is Reyes Syndrome managed?
Maintain glucose >4mmol/l
Prevent sepsis
Give four causes of CHRONIC hepatitis in Children
Chronic Hepatitis
NAFLD
A1 Antitrypsin
Biliary Atresia
Biliary Atresia results in conjugated jaundice. How is it managed?
Kasai Portoenterostomy (attaching small intestine to liver opening)
How could Chronic Hepatitis present in Children?
Jaundice
Pruritus
Anaemia
Developmental Delay
What investigations could you do for Chronic Hepatitis that are different to those from Acute?
Sweat Test
A1 Antitrypsin Level
Serum/Urinary Copper
Liver Biopsy
How is Autoimmune Hepatitis treated?
Prednisolone and Azathioprine
How is Chronic Viral Hepatitis treated?
Interferon Alpha and Ribavirin
How is Hepatitis due to Wilson’s disease treated?
Penicillamine
Peptic Ulcers present similarly in children as adults. How could it be investigated?
Breath Test for H.Pylori
How are Peptic Ulcers managed?
Omeprazole
If H.Pylori add Amoxicillin and Metronidazole
Give five causes of Gastritis in Children
H.Pylori Irrational introduction of adult foods Unbalanced food composition Poor chewing Too Cold/Very Hot food
Describe the pathophysiology of Gastritis
Some foods may cause formation of oedema cells and enhance acid synthesis
Inflammation and blood circulation to wall increases, altering nervous regulation (alters contractions)
How would you investigate Gastritis in Children?
Full range of bloods
Faecal Culture and Analysis
H.Pylori
How would you manage Gastritis in children?
Diet - mashed/puréed food without spices or additives, exclude roughage and carbonated drinks
PPIs
Antispasmodics
What is the normal milk requirement in an infant?
150ml/kg/d
Name four different types of formula milk
Cows Milk - early weeks are whey based, later weeks are casein based
Soya milk - now not recommended due to photo-oestrogens
Hydrolysed Cows Milk (CMPA)
Elemental Formula (Severe CMPA)
When should solids be introduced to a child’s diet? What should the be?
Not recommended until 6 months
Baby rice, fruit and vegetables
No low fat products
Supplementary Vit ACD
When should breast formula feeding be continued until?
1y
Why should children avoid excess juices/fizzy drinks?
Cause of Toddler’s Diarrhoea
How is Parenteral Nutrition given?
Via central or peripheral lines
What are the two components of Parenteral Nutrition?
Lipid component (fat and fat soluble vitamins over 20h)
Aqueous component (Carbohydrate, protein, electrolytes, minerals over 24h)
