Gastro and Urinary Flashcards
What is enuresis defined as
Involuntary discharge of urine by day or night in a child over 5 in the absense of congenital or acquired defects of the NS or urinary tract
How is nocturnal enuresis categorised
Primary- never achieved continence
Secondary- child had been dry for at least 6 months
Management of enuresis
Rule out other causes
General adive- fluid intake, empty bladder before bed and during day
Reward system- eg star chart for going toilet before bed and not for a dry night
Then- Enuresis alarm
Then- desmopressin
When would use desmopressin for enuresis
Short term control needed- sleepoves
Enuresis alarm not effective or acceptable
Examination findings of testicular torsion
Swollen testicle
Absent cremasteric reflex
Elevation of testicle worsens pain
What causes threadworms
Enterobius vermicularis
Infestation occurs after swallowing eggs in the environment
How can threadworms be investigated
Could put piece of tape over anus and then do MCS
Management of threadworms
Under 6 months- hygiene measures for 6 weeks (same if pregnant or breastfeeding)
6 months- 2 years- piperazine single dose
Over 2 years- Single does of mebendazole with hygiene measures for 2 weeks if over 2 years
Consider treating whole family too
If infection persists over 2 weeks/6 weeks treat again
What is hirschprungs disease
Presence of aganglionic segement of bowel from developmental failure of parasympathetic Auerbach (myenteric) and meissner (submucosal) plexuses
Presentation of hirschprungs disease
Failure to pass meconium in first 24 hours
Bilious vomiting
Abdo distension
Constipation mixed with overflow diarrhoea
Complications of hirschprungs disease
Enterocolitis
Perofration
Meconium plug syndrome
Initial investigation for hirschprungs and diagnostic
AXR if obstruction
Full thickness rectal biopsy
Treatment for hirschprungs
Bowel irrigation initially- can be barium enema
Transanal endorectal pull through
Risk factors for hirshcprung disease
Trisomy 21
Male
MEN2A
Risk factors for GORD
Preterm delivery
Neuro disorders
Presentation of GORD
Vomiting of feeds
Develops before 8 weeks typically
Alongside
- arching of back
- irrittable
- crying
When should arrange same day referral for GORD
Haematemesis
Melaena
Dysphagia
When should arrange a specialist assessment by paediatrician GORD
Uncertain diagnosis
Growth issues
Unexplained distress in those with communication difficulty
Not responding to treatment
Avoiding food
Unexplained IDA
No improvement in GORD after a year
Sandifers syndrome suspected
Recurrent aspiration pneumonia
Upper airway erosion
Dental erosion in child with neurodisability
Recurrent otitis media (more than 3 episodes in 6 months)
Management of GORD in child breastfeeding
- Breastfeeding assessment and advice
- 1-2 week trial of alginate therapy- if symptoms improve after 2 weeks continue the therapy. Stop at regular intervals to see if symptoms have improved
If have not then medical treatment
Mangement of GORD in formula fed
- Reduce volume of milk if excessive (150ml a day per kg)
- Offer 1-2 weeks of smaller more frequent unless they already are small and frequent
- 1-2 weeks of feed thickeners
- Alginate therapy
- Medical management
Medical management of GORD
4 week suspension of omeprazole
If doesnt work refer for possible endoscopy and potential metoclopramide treatment
Complications of GORD
Distress
FTT
Aspiration
Frequent otitis media
Dental erosion in older children
When does pyloric stenosis typically present
2nd-4th week of life
What causes pyloric stenosis
Hypertrophy of smooth circular muscles of pylorus
Risk factors for pyloric stenosis
Male
Positive family history
First born child
Turners syndrome
Examination finding of pyloric stenosis
Palpable olive epigastric mass
Dehydration
Visible peristalsis
Blood gas finding of pyloric stenosis
Hypochloraemic, hypokalaemic alkalosis but can become dehydrated lactic acidosis
Presentation of pyloric stenosis
Projectile vomiting 30 mins after feed
Constipation and dehydration
How is pyloric stenosis diagnosed
Test feed where look for visible peristalsis
US- target lesion over 3mm
Hos is pyloric stenosis managed
Treat fluid and electrolyte loss
NG tube
Ramstedt pyloromyotomy
Chronic diarrhoea differentials in a child
Cows milk intolerance
Toddler diarrhoea
Coeliac disease
Lactose intolerance
How does lactose intolerance present
Abdo pain and bloating linked to dairy eating
Diarrhoea
How can an upper UTI be diagnosed in a child
2 ways
- fever over 38 and bacteriuria
- fever under 38, bacteriurua and loin pain/tenderness
What to do if upper UTI suggested in child
Depending on severity send urine for MCS and if severe consider referral
What do if UTI suspected in under 3 months
Refer to paediatrics with parenteral abx
What do if UTI suspected in child over 3 months
Perform dipstick
What do if in child leukocyte and nitrite positive
Start treatment
Send a culture if recurrent UTIs, suspect upper UTI, no response in 48 hours to treatment
What to do in child if leukocyte pos and nitrite negative
Under 3 start abx and send for culture- reassess after
Over 3 only start abx if really suspect UTI
What to do in child if leukocyte neg and nitrite pos
Start abx and send for culture
Which 2 abx are available for upper UTI
Co-amoxiclav or cefalexin depending on sensitivity
Referral depends on severity
Children older than 3 months with UTI treatment
1st line- trimethoprim (if there is low risk of resistance), or nitrofurantoin (if eGFR ≥ 45ml/minute)
2nd line- nitrofurantoin (if eGFR ≥ 45ml/minute) if it has not been used as a first-line option, amoxicillin (only if culture results available and susceptible), or cefalexin.
Potentially do an US if indicated
When prescribing nitrodurantoin to over 3 months what is important criteria
eGFR over 45
When is an US indicated in UTI DURING the infection
In all children
- poor urinary flow
- abdo or bladder mass
- sepsis
- raised creatinine
- does not respond within 48 hours
- non-ecoli
If under 6 months with recurrent UTI
When is an US indicated in UTI 6 weeks after the infection
Children aged 6 months or older with recurrent UTI
Children under 6 months with first time UTI that responds to treatment
When is DMSA and MCUG scan indicated 6 months after UTI
If under 3 years and atypical or recurrent UTI
If over 3 years and recurrent UTI
What defines recurrent UTI
2 upper UTI episodes
1 upper and 1 lower UTI episode
3 lower episodes
What is done if somone has recurrent UTIs
Prophylactic abx which depends on local resistance
First line- trimethoprin and nitro
Second line- cefalexin and amoxicillin
If under 6 months do US during the infection
If over 6 months do in 6 weeks
Do a DMSA scan within 6 months
Presentation of wilms tumour
Abdo mass
Painless haematuria
Flank pain
Anorexia and fever
Where does wilm tumour most commonly metastasise
The lung
What do with unexplained enlarged abdo mass in achild
Refer for paediatric review in 48 hours
How are nephroblastomas imaged
USS intitally then CT NOT Biospy
Management of wilms tumour
Nephrectomy and chemo
Radiotherapy if advanced
Associations of Wilms tumour
Beckwith-Wiedemann syndrome
WAGR
Loss of function mutation in the WT1 gene chromosome 11
What is included in WAGR syndrome
Wilms tumour, Aniridia, Genitourinary malformations, mental Retardation
Management of undescended testes
Unilateral
- Patient should be referred from around 3 months seeing a urological surgeon by 6 months of age
- if bilateral reveiwed within 24 hours as needs urgent genetic or endocrine investigation
What is hypospadias
Congenital abnormality of the urethral opening- appears with ventral urethral meatus
How can hypospadias be identified
Newborn check
Abnormal urine flow noticed by parent
Examination findings of hypospadias
Ventral urethral meatus
Hooded prepuce (where foreskin wide open)
Ventral curvature of the penis
Management of hypospadias
Refer to specialists
Operation at 12 months
Can’t be circumcised
If very distal may not need operation
Associated conditions of hypospadias
Inguinal hernia
Cryptochordism
How does meckels diverticulum present
Rectal bleeidng
Abdo pain like appendicitisi
What determines the initial investigation for meckels diverticulum
If haem stable technietium99
If not and needed transfusion- arteriography
Managment of meckels diverticulum
Surgical- wedge excision or resection
What are differences between gastrochisis and ampholacele
Gastrochisis is lateral to umbilicus whereas ampholacele is through umbilicus
Ampholacele has a thin sac whereas gastrochisis is just the organs
Gastrochisis is vaginal delivery versus C section in ampholacele to preserve the sac
Gastrochisis requires surgery within 4 hours but ampholacele surgery done in stages
Gastrochisis associated with smoking and low scoioeconomic status whereas ampholacele associated with downs, kidney and cardiac abnormalities
Features indicative of idiopathic constipation
Meconium passed within 48 hours of birth (in a full-term baby).
Onset of constipation at least a few weeks after birth.
Presence of precipitating factors:
- Dietary factors (for example changes to infant formula or weaning, poor diet, or insufficient fluid intake).
- Acute illness, such as infection.
- Anal fissure.
- Use of drug treatments such as sedating antihistamines or opiates.
- Timing of potty or toilet training.
- Psychosocial factors such as difficulty accessing a toilet, moving house, starting nursery or school, other major change in family circumstances, and fears and phobias
What to do if amber and red signs in constipation history
Red- refer immediately to specialist and do not treat immediately
Amber- refer for specialist help (2 weeks) and can treat in meantime
Red flag features for constipation
Symptoms of constipation appearing from birth or during the first few weeks of life — may indicate Hirschsprung’s disease
Delay in passing meconium for more than 48 hours after birth, in a full-term baby
Abdominal distention with vomiting
Family history of Hirschsprung’s disease
Ribbon stool pattern
Leg weakness or motor delay
Examination may reveal unexplained lower limb deformity or abnormal neuromuscular signs, including abnormal reflexes.
Abnormal appearance of the anus
Abnormalities in the lumbosacral and gluteal regions
Amber features for constipation
Evidence of faltering growth, developmental delay, or concerns about wellbeing, which may indicate a systemic condition - coeliac disease, hypothyroidism, cystic fibrosis, and electrolyte disturbance
Constipation triggered by the introduction of cows’ milk
Concern of possible child maltreatment — follow local child safeguarding procedures.
What does ribbon stools suggest
Anal stenosis- typically in infants
Umbilical hernias in children
Very normal and will often resolve by 3 years
Management is obervation
Features which suggest sexual abuse in a child
pregnancy
sexually transmitted infections, recurrent UTIs
sexually precocious behaviour
anal fissure, bruising
reflex anal dilatation
enuresis and encopresis
behavioural problems, self-harm
recurrent symptoms e.g. headaches, abdominal pain
Who is most likely person to sexually abuse a child
Father
Unrelated man
Older brother
What is position of appendix if obturator sign present
Pelvic
Most common position of appendix
Retrocaecal
How does oesophageal atresia present
Drooling
Gags and chokes when feeding
Cough
Cyanotic
Investigations for oesophageal atresia/TOF
NG tube aspiration with CXR
Gastrogaffin swallow is gold standard
Complications of oesophageal atresia and TOF
Aspiration of food
Acid in the lungs causing CLD
What is faecal impaction and how does it present
When there is a large faecal mass in the rectum
Presents with
- severe constipation symptoms
- overflow sx like soiling
- large mass on palpation
Management of faecal disimpaction
Macrogol and review after 1 week
If after 2 weeks does not work use stimulant laxative like Senna
If does not work refer to specialist
If not tolerant of macrogol use senna and if the stools are hard add lactulose or docusate
Management of constipation
Macrogol (drug depends on age) If over 12 Mavicol, if under mavicol paediatric
If not tolerated use senna and add lactulose if not tolerated
If does not improve use Senna however if get diarrhoea reduce dose
When to refer gastroenteritis
Bilious vomiting/difficult to control vomiting
Blood in stool
Severe dehydration/shock
HUS
How is giardia treated
Tinidazole
When can go back to school with HUS
2 consecutive negative samples 24 hours apaprt
How are viral gastroenteritises diagnosed
Stool electron microscopy
Managment of primary enuresis with daytime symptoms
Refer all children with daytime symptoms to enuresis clinic
Management of secondary bedwetting
Urinalysis and constipation checks
If no cause found refer
How can volvulus present
Bilious vomiting and severe pain/irritability
Blood in stool is late stage of ischaemia
How does autosomal recessive PCKD present
Presents perinatally and most of time will be dead by 12 months
Renal cysts with subsequent renal and hepatic fibrosis
Renal failure too
Complications of autosomal recessive PCKD
Oligohydramnios leading to pulmonary hypoplasia
Treatment for hyperconjugated hyperbilirubinaemia
Ursodeoxycolic acid
Causes of hyperconjugated bilirubinaemia
Biliary atresia
Choledochal cysts
Risks of gastrochisis
Dehydration and shock from fluid loss
Malrotation
Management of gastrochisis
Place cling film over bowels
Surgery within a few hours except for if signs of impaired bowel perfusion
Presentation of enterocolitis in hirschprungs
Abdo pain
Blood in stool
Fever
First line for intussusception
Air insufflation then surgical intervention
Complications of minimal change disease
Recurrent infections
Increased thrombosis risk
Hypercholesterolaemia
What causes bloating and diarrhoea post gastroenteritis
Is normal to get a post infectious IBS when normal diet reintroduced
Infections that can precede mesenteric adenitis
URTI
Gastroenteritis most commonly Yersinia
What can cause recurrent intussusception
Meckels diverticulum
What is most common cause of acute scrotum in children
Hydatid torsion
What is hydatid torsion
Twisting of testicular appendage which is a remnant of the muellerian tube
Presentation of hydatid torsion
Pain over a few days (not acute)
Swelling
Cremasteric reflex present
Blue dot sign
Tender at top of testicle not whole testicle
Presentation of epididymitis
Dysuria or discharge
Pain and swelling of the testicle
Prehns and cremasteric positive
How to investigate an acute scrotum
Doppler is best way to assess testicular blood flow
Surgical exploration is necessary if cant exclude torsion
Complications of undescended testicles
Testicular torsion
Infertility
Testicular cancer
What are the types of TOF
Type A- no connection between proximal and distal oesophagus
Type B- fistula between proximal oesophagus to trachea
Type C- fistula between distal oesophagus to trachea
Type D- fistula between proximal and distal oesophagus to trachea
Type E- normal oesophagus connection but fistula to trachea too
First line and definitive management of oesophageal atresia and TOF
Repogle tube to drain the saliva
Surgical management
What is blue dot sign
Blue dot on testicle caused by hydatid torsion typically
Triad for nephrotic syndrome
Oedema- normally periorbital or sacral
Hypoalbuminaemia- >25g/L
Proteinuria- 3g/24 hour or PCR over 15/mg/mmol
Complications of nephrotic syndrome
Hyperlipidaemia
Thrombosis
Pneumooccocal risk
Hypovolaemia
Treatment of hypovolaemia in nephrotic syndrome
IV albumin
Most common cause of nephrotic syndrome in a child
Minimal change disease
Treatment of minimal change disease
Oral pred and then reduce the dose over time
Causes of nephrotic syndrome in children
Minimal change disease
Focal segemental glomerulosclerosis
Mesangiocapillary glomerulonephritis
Membranous nephropathy
Steroid resistant causes of nephrotic syndrome
Focal segmental glomerulosclerosis- most common
Mesangiocapillary glomerulonephritis
Membranous nephropathy
Low complement levels
Haematuria
Renal function declining over many years
Older children
Mesangiocapillary glomerluonpehritis
What do if fail to cure minimal change disease
Biopsy
Biopsy finding of minimal change disease
Diffuse loss of podocytes
Causes of membranous nephropathy
Hep B
Benign causes of proteinuria
Transient- febrile illness or after exercise
Orthostatic- common if upright all of the day
Triad for nephritic syndrome
Hypertension
Haematuria
Oedema
(with oligouria)
Difference between red and brown coloured urine
Red- lower tract bleed
Brown- glomerular pathology as broken down into casts
Problems of glomerulonephritis
Loss of barrier function- blood or protein lost
Loss of filtering capacity- accumulation of toxins
Causes of glomerulonephritis
IgA nephropathy- most common
HSP
Anti-glomerular basement membrane (Goodpastures)
Post streptococcal
Difference between IgA nephropathy, HSP and post streptococcal
IgA and HSP within a few days
Post streptococcal within a month
HSP is in essence a systemic version of IgA nephropathy
What can precede intussusception
Coryzal illness
Tummy bug
What are associated with malrotation
Congenital diaphragmatic hernia
Exomphalos
Investigation for anti GBM
IgG type IV lung and kidney
Haemoptysis and haematuria cause of AKI
Anti-GBM
Hearing and vision loss with haematuria
Alports syndrome
How does rhabdomyolysis present
Dark urine
Muscle pain
Signs of hyperkalaemia
Blood findings of rhabdomyolysis
Hyperkalaemia
Increased CK
What is complication of a renal scar
HTN- may need monitoring regularly
How is severeity of UC classified
Either true love and witts or paediatric ulcerative colitis activity index
Categorised into mild, moderate and severe
Management of active UC
Mild to moderate
- topical aminosalicylates for 4 weeks
- if dont work use oral
- can use steroids too if ineffective (topical or oral)
Moderate to severe
- infliximab, adalimumab
How to maintain remission in UC
Oral aminosalicylate
Consider oral azathioprine or oral mercatopurine
What is monitored in children with UC and crohns
Vitamins and anaemia
Growth
Bone density
Sigmoidoscopy to screen for adenocarcinoma in UC
Managment of active crohns
Induction of remission
- oral glucocorticoid
If more than 1 exacerbation a year or can increase glucorticoid dose, add azathioprine or mercatopurine
If these are contraindicated add methotrexate
Maintaing remission in crohns
Azathioprine or mercatopurine
If fails/contraindicated then use methotrexate
Complications of UC
Toxic megacolon
Erythema nodosum
PSC
Haemorrhage
Cancer
Differences between UC and crohns
Crohns affects all layers, UC mucosa and submucosa
Crohns affects mouth to anus, UC distal to proximal spread
When refer with bedwetting
If have daytime symptoms then refer
If secondary bedwetting after have ruled out UTI, DM and anxiety
Primary if 2 rounds of treatment have not worked
What could cause secondary bedwetting
UTI
DM
Electrolyte abnormalities- hypokalaemia, hypercalcaemia
Anxiety
What is management of inguinal hernias in children
Refer to paeds surgery ASAP
How does intussuception present
Bilious vomiting
Screaming and crying
Bringing knees up
Red stool a late presentation
Guidelines for phimosis
If present under 2 is physiological- only refer when older than 2 years
Do not forcibly retract as can cause scarring
Management of ballooning of foreskin during micurition in under 2
Can leave alone until 2 years old then avoid
Where is most common palpated site of intussuception
RUQ
MOst common site of intussusception
Ileo-caecal
investigation for intussusception
USS- showing mass
Can also reveal free fluid and show ischaemia with colour doppler
When is air insufflation contraindicated and surgery recommended in intussusception
Peritonitis
Perforation
HSP- known complication
In post streptococcal glomerulonephritis what measure
C3, C4 and CH50
C3 very low and C4 normal
What conditions cause psot strep glomerulonephritis
Pharyngitis
Impetigo
What is whirlpool on USS of childs abdomen suggestive of
Malrotation
Perianal fistula suggests what disease
Crohns
Conditions associated with intussusception
Lymphoma
Gastroenteritis
HSP
AXR findings of intussusception
paucity (less) of air in RUQ
thickened wall (oedema)
poorly defined liver edge
dilated small bowel loops
Examination findings of intussusception
Sausage shaped mass
Dances sign- emptiness on palpation in RLQ
What is a scaphoid abdomen and what seen in
Concave chest shape
Seen in malrotation
Associations of malrotation
Congenital diaphragmatic hernia
Omphalocele
Difference in cause of gastroenteritis- young child vs older
Young- viral (rotavirus)
Older- bacterial (e coli)
Advice for toddlers diarrhoea
Encourage fibre intake
Management of lactose intolerance
Refer to dietician
Encourage vit d and calcium intake
How do inguinal hernias present
Lump in testicle, maybe on crying/laughing
On examination- can not get above it
How to treat umbilical granuloma
Salt
If have bilaterally undescended testes, what is ruled out
CAH
Disorders of sexual differentiation
If on formula feeds, what is risk factor for gastroenteritis
Not sterilising water used to make up formula by boiling then cooling
Mass in groin area with severe vomiting and tense abdomen
Incarcerated hernia
Management of hepatitis A
Notify health protection agency
Encourage fluid intake
Most common cause of delayed meconium passage
Meconium plug syndrome
Causes of HTN in a child
Renal
- nephroblastoma
- CKD
- renal artery stenosis
Cardiac
- coarctation of aorta
Metabolic
- conns
- phaeo
- CAH
What is preferred BP measurement in a child
Manual
Management of 1 HTN reading in a child
Repeat
Flank mass causing HTN in a child
Neuroblastoma of adrenal medulla
Measure urine catecholamine
Anuria and enlarged bladder in a child
Posterior urethral valve causes backflow of urine entering urethra
Other than renal problems what does AR PCKD do
Pulmonary hypoplasia
Hepatic fibrosis
When is autosomal dominant PCKD picked up
Teenagers
What is operation for testicular torsion
Bilateral orchidopexy
Management of hydrocele in a child
Under 3 is fine- after if need to refer
What are these 3 signs for appendicitis
- rosvings
- cough
- obturator
Rosvings- pain in RIF on left sided palpation
Cough- pain on voluntary cough
Obturator- pain on internal rotation when flex right thigh
How long are upper vs lower UTIs treated for in kids
Lower- 3 days
Upper- 7 days
What is operation done for very severe GORD
Nissen fundoplication
How diagnose post strep glomerulonephritis
Anti-streptolysin titre
C3 and C4 levels as C3 low
Imaging for wilms tumour
Initially do an USS
Then a CT to stage
Best imaging for malrotation
Upper GI contrast
How do abdominal migraines present
Severe umbilical pain which can intterfere with daily life
Associated with
- headache
- vomiting
- photophobia
- nausea
- anorexia
- pallor
What is difference between regurgitation, GOR and GORD
Regurgitation involves bringing it up after feed
GOR= passage of stomach contents into oesophagus
GORD= GOR with symptoms of irritation
What is a hydrocele
Collection of fluid within the tunica vaginalis
What is management of hydatid torsion
Exploratory surgery as need to rule out torsion
Management of undescended testicles
Bilateral
- urgent endo review
Unilateral
- recheck at 6 wk baby check, then 4-5 months and if not refer to surgeons
Management of severe pyelonephritis
IV cefuroxime and gentamicin
If have TOF or oesophageal atresia what is another malformation these are associated with
Anal atresia
What do if measure childs bilirubin and is below phototherapy line but close
If unwell or 1 risk factor for neonatal jaundice keep in hospital and repeat in 18 hours
If none and seems well then come back in 24 hours
Investigation for malrotation
Barium swallow
What skin changes can be seen in neuroblastoma
Blueberry papules
What investigation should be done on any child presenting with swelling or pain in testicle
USS to screen for cancer
How can a urine culture be done on an infant
Urine collection pads
Difference between neuroblastoma and nephroblastoma mass and presentation
In neuroblastoma will cross the midline
Neuroblastoma with present with fever, weight loss, diarrhoea and vomiting- generally very unwell
How other than recurrent UTIs can VUR present
Enuresis
Incontinence
How does mesenteric adenitis present
Post URTI
- can be acute abdo pain
- lymphadenopathy
How is mesenteric adenitis investigated
Abdo USS showing mesenteric thickening
What can precipitate transient proteinuria
Seizures
Infections
Pregnancy
Exercise
What is risk of hydrocele
Inguinal hernias
What counts as daytime symptoms in a child
Wetting themselves
Passing urine over 7x a day
Most sensitive investigation for intussusception
Contrast enema
Management of VUR
Refer to paediatric surgeons
