Gastro/Liver Flashcards
GI CF management
Monitoring appetite, stools and GORD
Replace pancreatic enzymes (e.g. pancreatin, CREON)
+ PPI to improve alkaline environment for pancreatin to do its thing
Nutrition - increased caloric intake (150%) - consider overnight feed by gastrotomy
Vitamins ADEK
Ursodeoxycholic acid (improve bile flow)
Ranitidine/omeprazole to help with GORD symptoms
Four gastro causes of recurrent abdominal pain
IBD IBS Gastritis/dyspepsia Abdominal migraine (Recurrent abdominal pain (RAP))
IBS mx
Diet and lifestyle modification (avoiding triggers, stress coping strategies)
Antispasmodic (e.g. Buscopan)
If mainly diarrhoea: Antidiarrhoeals (e.g. loperamide)
If mainly constipation: Laxatives
TCA/SSRI
CBT/hypnotherapy
Conservative measures IBS
Diet and lifestyle modidication
CBT
Hypnotherapy
Which type of GI ulcers are more common in children?
Duodenal
How is H.pylori diagnosed?
C13 breath test, stool antigen
Gastric antral biopsy
Mx acute gastritis
Endoscopy +/- blood transfusion
Lansoprazole
Mx chronic gastritis. Next steps if failure to respond
If H.pylori - triple therapy:
- PPI
- Clari
- Amox
If fail to respond = upper GI endoscopy
Dyspepsia with normal biopsy
Functional dyspepsia
Where is the pain loated in abdominal migraines?
Central, midline
Presentation abdominal migraine
Central pain
Vomiting
Pallor
Associated with headache migraines
Personal/FHx migraines
What percentage of IBD patients prsent in childhood?
25%
What is recurrent abdominal pain defined as?
More than three months of abdominal pain sufficient to disrupt normal activities
Non gastro causes of recurrent abdo pain
Urinary (UTI)
Gynae (dysmenorrhoea, PID, cysts)
Psychosocial (RAP)
Hepatobiliary (hepatitis, stones, pancreatitis)
Commonly affected areas in Crohn’s
Distal ileum to proximal colon
Presentation of Crohn’s
Bloody diarrhoea
Abdo pain
Weight loss
Pallor
FTT
Clinical features of Crohn’s (+ SIGNS)
Bloody diarrhoea
Abdo pain
Weight loss
Pallor
FTT
Erythema nodosum Fissures Fistulae Tags Ulcers
Investigations for Crohn’s
Bloods (raised CRP/ESR, low Hb, low albumin)
Small bowel biopsy w/ histology (non-caseating epthelioid cell granulomata)
Management of Crohn’s
Conservative: stop smoking
Medical:
- Steroids - budenoside (induce and maintain remission)
- Immunosuppressants: azathioprine/methotrexate
- Biologics - infliximab (with abx)
Nutritional support. Enteral supportive feed if necessary.
Ca, VitD, B12, ferritin
Presentation of UC
- Bloodu, mucous diarrhoea
- Abdo pain (colicky)
Weight loss
Growth failure
Erythema nodosum
Clubbing
Ix for UC
Bloods
Colonic biopsy - crypt damage and abscesses in the mucosa
How is the severity of UC assessed?
Paediatric Ulcerative Colitis Activity Index
Higher score = increased severity
Mx of UC (mild/mod/severe/steroid dependent)
Mild - mesalazine (induce and maintain remission). Oral pred if relapse Mod - Oral pred for 2-4 weeks then taper Mesalazine Severe - MEDICAL EMERGENCY. IV methylprednisolone Parenteral nutrition Surgery
Steroid dependent - infliximab
Features of malabsorptive disease
FTT / poor growth
Abnormal stools
Specific nutrient deficiencies
Four examples conditions resulting in malabsorption
Coeliac
Biliary atresia
Pancreatic exocrine dysfx (e.g. CF)
Short bowel syndrome
Presentation of coeliac
Poor growth/FTT Buttock wasting Abnormal/offensive/fatty stools Abdominal distension General irritability Pallor
Rash - dermatitis herpetiformis
Age of presentation coeliac
8-24 months
Pathophysiology of coeliac
Non-IgE reaction against gliadin protein in gluten.
Immune response in the mucosa of the proximal small intestine
Which part of the bowel is most affected in coeliac?
Proximal small bowel (mucosa)
Which other conditions is coeliac associated with (and should children with coeliac be screened for)?
T1DM
Hypothyroid
Down’s
Ix for suspected coeliac
Bloods (anti-TTG Abs, Endomysial antibodies) - in some cases these are now sufficient for diagnosis
Small bowel (jejunum) biopsy - villous blunting, crypst hyperplasia
Removal of gluten = catch up growth
Mx of coeliac
MDT
Remove gluten from diet (with dietary advice from dietician)
Calcium, vitaminD, iron
Regular monitoring of height, weight, development
How can coeliac patients’ diets be checked?
Serology
Complications of coeliac disease
Malnutrition
EATL lymphoma
Osteoporosis
Causes of diarrhoea
Gastroenteritis Toddler's diarrhoea IBD Coeliac IBS Medications Food allergy/intolerance
Commonest cause persistent loose stoolin preschool children
Toddler’s diarrhoea
Presentation toddler’s diarrhoea
Persistent loose stool
Undigested veg
Varying consistency
Child is otherwise WELL AND THRIVING
Pathophysiology of toddler’s diarrhoea
Underlying delay in intestinal maturity
Complication of toddler’s diarrhoea
Achieving faecal continence may be delayed
Mx toddler’s diarrhoea
More fat and fibre in diet to slow gut transit
Causes of constipation in infants
Hirschsprung's Atresia Hypothyroid Hypocalcaemia Anorectal abnormalities
Causes of constipation in children
Dehydration
Poor diet
Toilet training issues
Stress
Hypothyroid
Hypocalcaemia
Constipation presentation
Infrequent passage hard, dry faeces
Accompanied by straining/pain
Palpable abdo mass
May have overflow diarrhoea
Red flag symptoms associated with constipation
Neuro signs - SCC/SOL
FTT
Gross distension
Anal sx - sexual abuse?
Constipation mx
Movicol (osmotic)
Diet
Increased fluid
Behavioural interventions - regular toileting, reward system, bowel habit diary
CBT
Family therapy
Four types of laxative
Osmotic - movicol
Stimulant - senna
Bulk-forming - fybogel
Stool softener - docusate sodium
Features of overflow diarrhoea
Faecal incontinence
Foul smelling diarrhoea
Mx anal fissure
Increase fibre
Increase fluids
Stool softeners (e.g. docusate sodium)
Topical GTN intra-anally
Analgesia
Anal hygiene
AVOID stool withhoding
If not healed after 2 weeks, come back
Causes vomiting in a neonate
Hirschsprung's Pyloric stenosis Allergy Atresia Sepsis CAH Overfeeding Meconium plug Intussusception Malrotation/volvulus GORD
Pathophysiology of Hirschsprung’s
Absence of myenteric plexus in rectum –> colon
Presentation of Hirschsprung’s
Failure to pass meconium in first 48 hours of life
Gross abdominal distension
Eventually bilious vomiting
Mx Hirschsprung’s
Bowel irrigation
Surgical - colostomy followed by anorectal pull through: anastamoses of normally innervated bowel to anus
Complications Hirschsprung’s
Acute enterocolitis (15%)
Is Hirschsprung’s more common in males or females?
Males (4:1)
Presentation of pyloric stenosis
Projectile vomiting
HUNGER (will keep attempting to feed until they are dehydration when they will no longer attempt)
Weight loss
- Peristalsis across abdomen
- Mass RUQ
Age of presentation pyloric stenosis
2-7 weeks
Which infants more commonly get pyloric stenosis
Males
(Particularly first born)
Maternal GDM
Pathophysiology of pyloric stenosis
Hypertrophy of pyloric muscle = gastric outlet obstruction
Ix for pyloric stenosis
Gas (often metabolic alkalosis)
- Hypochloraemic, Hyponatraemic, Hypokalaemic
USS
What acid-base disturbance occurs as a result of pyloric stenosis?
Metabolic alkalosis
Mx pyloric stenosis
IV fluid resuscitation (severe dehydration)
- 1.5x maintenance with dextrose and saline
- Add potassium once urine output is adequate
Surgery - Ramstedt pyloromyotomy - dividing hypertrophied muscle (not mucosa)
What must be done before surgery to correct pyloric stenosis?
IV fluid resuscitation and electrolye balancing
Presentation duodenal atresia
Persistent bile stained vomit
Meconium may be passed, but then with subsequent delay
Abdominal distension
Which genetic abnormality is duodenal atresia associated with?
Down’s syndrome
Do higher or lower lesions present earlier in duodenal atresia?
Higher
Mx duodenal atresia
NBM D&S (NGT) IV fluid resuscitation Surgery \+/- abx
Intrauterine trachy-oesophageal fistulae
Polyhydramnios
Presentation of trachy-oesophageal fistulae
Persistent drooling
Vomiting
Aspiration
Which multi-system syndrome are trache-oesophageal fistulae associated with?
VACTERL
Vertebrae Anal atresia Cardiac Trache-oEsophageal fistula Renal Limb
Risk factors for GORD (young infants)
Short oesophagus
Horizontal posture
Fluid diet
Complications of GORD
FTT
Recurrent aspiration
Oesophagitis – IDA
Sandiser syndrome - dystonic neck posture
When do most GORDs resolve spontaneously by?
1 year
Ix GORD
24hr pH monitoring
Endoscopy
(USS to rule out pyloric stenosis, atresia)
Mx GORD
REASSURE
Consider (breast feeding) assessment
1) Mechanical/conservative - vertical position when feeding, winding. Feeds little and often. Thicken feeds.
2) Baby gaviscon / alginate therapy
3) PPI trial
4) Enteral feeding / Nissen fundoplication if FTT
Pathophysiology of intussusception
Invagination of proximal bowel into distal bowel causes obstruction
Where does intussusception often take place
Ileo-caecal valve
Age of presentation of intusussception
3mos - 2 years
What is the commonest cause of GI obstruction after the neonatal period?
Intussusception
Complications of intussusception?
Engorgement
Bleeding
Ischaemic bowel – enterocolitis
Presentation of intussusception
Paroxysmal, severe colicky pain Pallor, increasingly lethargic Bile stained vomit Refusal of feeds Sausage-shaped palpable mass on abdomen REDCURRANT JELLY STOOL
What diagnosis is redcurrant jelly stool indicative of?
Intussusception
Ix intussusception
USS: target lesion
AXR: distended small bowel loops. Absence of gas in distal colon
Bloods: shock
Mx intussusception
ABCDE
(IVI and NG tube aspiration)
AIR INSUFFLATION
Broad spec abx - clindamycin + gentamicin
Surgery if insufflation fails
When is air insufflation not appropriate in treating intussusception?
If there are signs of peritonitis, perforation, hypovolaemic shock
Percentage of children with Meckel’s diverticulum
2%
Presentation of Meckel’s diverticulum
Severe PR bleed - not bright red nor malaena
intussusception/malrotation
Mx Meckel’s diverticulum
Surgical excision
Adhesion lysis
+/- bowel resection
What is a Meckel’s diverticulum?
Ileal remnant of vitello-intestinal duct
Presentation of malrotation
Intestinal obstruction with reduced blood supply - bile stained vomit, distended abdomen
Age of presentation malrotation
Usually first 1-3 days of life
Ix malrotation
Upper GI contrast study
Mx malrotation if evidence of vascular compromise
Emergency laparotomy
Mx malrotation
Surgery: Ladd procedure - detort bowel, divide, Ladd bands
Normally also remove appendix to avoid future confusion
Abx: cefalozin
Appendicitis presentation
Abdo pain (starting umbilical, localise to RIF)
Anorexia
Vomiting
Oral fetor
Low grade fever
McBurney’s/Rovsing’s signs
Ix appendicitis
Bloods (raised WCC, CRP)
BC
USS - inflammed, thickened. Increased blood flow on dopplers.
Mx appendicitis
SURGERY
NBM
IVI fluid resuscitation
Abx: cefalozin
Mx mesenteric adenitis
Self resolving
Presentation mesenteric adenitis
Non specific abdo pain
Often accompanied by URTI and cervical lymphadenopathy
Commonest viral cause of gastroenteritis
Rotavirus
Ix gastroenteritis
Bloods
BC
Stool sample
Monitor weight loss
Ix post gastroenteritis syndrome
Positive clinitest
Post gastroenteritis syndrome
Temporary lactose intolerance
Mx gastroenteritis
Fluid replacement
Presentation of hepA
Mild illness - lethargy, some nausea, malaise
Management of hepA
Notify HPU
Supportive (for pain, nausea, itch)
Close contacts should be vaccinated within 2 weeks of illness starting
How is hepB transmitted?
Vertical from mother Horizontal from families Blood products Needlestick injuries Renal dialysis (Sexual transmission in adults)
Mx of acute hepatitis B
Notify HPU
Supportive
Anti-virals e.g. tenofovir disoproxil
Mx of chronic hep B
Notify HPU
Supportive
Anti-virals - interferon, tenofovir disoproxil
What % of asymptomatic carriers develop chronic HBV infection?
30-50%
How cna hepB be prevented?
Antenatal screening
Antiviral therapy for HBsAg positive mothers
HepB vaccine for infants born to HBsAg positive mothers
+ immunoglobulin if mother is HBeAg positive
Commonest hepatitis C infection
Chronic carrier
% of chronic hepC carriers who go onto have HCC/cirrhosis
20-25%
Treatment chronic hepC
Notify HPU
S/c peg interferon and ribavarin
Commonest causes of acute liver failure, including three most common
- PARACETAMOL OD
- NON-A TO G HEPATITIS
- METABOLIC
- Hep ABC
- AI hep
- Other poisons
Pathophysiology of acute liver failure
Massive hepatic necrosis = reduced liver function +/- encephalopathy
Presentation of acute liver failure
Jaundice
Bleeding
Hypoglycaemia
Electrolyte disturbances
Encephalopathy
- Irritability/confusion/drowsiness
- Aggressive/difficult behaviour
Complications of acute liver failure
Hepatic encephalopathy Cerebral oedema Bleeding Sepsis Pancreatitis
Mx of acute liver failure (think of liver fx)
Hypoglycaemia - IV dextrose Haemorrhage - IV vit K, cryo, FFP Oedema - fluid restriction/mannitol diuresis Sepsis risk - broad spec abx Gastritis - PPI/H2 antagonist Transplant
Which features are suggestive of a poor prognosis in acute liver failure?
Shrinking liver
Rising BR with falling transaminases
Worsening coagulopathy
Coma
Causes of chronic liver disease
Chronic hepatitis (B,C, AI, PSC, drugs) Wilson's alpha1-antitrypsin CF Neonatal liver disease Bile duct lesions
Which drugs particularly can predispose to chronic liver failure?
Nitrofurantoin
NSAIDs
Commonest causes of chronic liver disease
Hep B C
AI hep
Presentation of chronic liver failure
Lethargy
Malnutrition
Insidious hepatosplenomegaly
Age of presentation AI hepatitis
7-10 years
Is AI hepatitis more common in boys or girls?
Girls
Presentation of AI hepatitis
Lethargy, malnutrition
Liver signs
+ other AI signs - rash, arthralgia, haemolytic anaemic, nephritis
Investigations for AI hepatitis
Bloods: hypergammaglobulinaemia (IgG>20)
+ve autoantibodies
Reduced serum C4
Histology
Mx of AI hepatitis
Prednisolone
Azathioprine
If PSC: ursodeoxycholic acid
Mx of PSC
Ursodeoxycholic acid
Wilson’s mode of inheritance
AR
Pathophysiology of Wilson’s
Reduced copper excretion in bile, reduced caeruloplasmin = copper deposits in liver, brain, kidney, cornea
Ix Wilson’s disease
Urinary copper excretion (particularly raised after chelation)
Mx Wilson’s disease
Zinc - reduces copper absoprtion in intestine
Trientine - increases copper excretion in urine
Pyridoxine - vitB6 prevents peripheral neuropathy
Mx of NAFLD
Weight loss - diet, exercise, bariatric surgery
Treat underlying insulin resistance
Vitamin E
Mx of cirrhosis/portal HTN (think ascites)
Na/fluid restriction
Diuretics
HAS/clotting factors
Paracentesis
NUTRITIONAL SUPPORT
What nutritional support to patients with cirrhosis need?
Vits ADEK
Increased calories
Management for encephalopathy
Supportive
Aim to reduce nitrogenous load – protein restricted diet,
lactulose
Why might intussusception occur after a febrile illness?
Enlarged Peyer’s patches acting as the lead point for intussusception
What may be the cause of recurrent intussusception ?
Pathological lead point, e.g. Meckel’s diverticulum
Should CF children have increased or reduced caloric intake?
Increased (150%)
HLA associated with coeliac?
HLA DQ8
What happens if you remove the gluten from the diet of a child with FTT caused by coeliac?
Catch up growth
Why is increased fat diet recommended in toddler’s diarrhoea?
Slow gut transit
What should be monitored in a child with gastroenteritis?
Weight loss (dehydration)
Features of post- gastroenteritis syndrome?
Temporary lactose intolerance
+ve clinitest
Normal hepB immunisation schedule
8/12/16 weeks
HepB immunisation schedule if infected mother (HBsAg +ve)
4/12/16 weeks
AND
Birth, 4 weeks, 1 year
