Gastroenterology Flashcards
What is vomiting?
Physical act that results in gastric contents forcefully brought up to and out of the mouth aided by sustained contraction of the abdominal muscles and the diaphragm at a time when the cardia of the stomach is raised and the pylorus is contracted
What is regurgitation?
Effortless expulsion of gastric contents
What is rumination?
Frequent regurgitation of ingested food
What is possetting?
Small volume vomits during or between feeds in otherwise well child
What controls vomiting?
Vomiting centre
Chemoreceptor trigger zone
What neurotransmitters are involved in vomiting?
Histamine (H1), dopamine (D2), serotonin (5-HT3), acetylcholine (muscarinic), neurokinin (substance P)
What are the key precipitants of vomiting?
Toxic material in lumen of GI tract Visceral pathology Vestibular disturbance CNS stimulation Toxins in blood/CSF
What are the different types of antiemetics?
Antihistamines - H2 receptor antagonists, CI acute porphyrias, for motion sickness and PONV treatment
Dopamine D2 antagonist for medication related N&V
Serotonin 5-HT3 antagonists - CI in long QT syndrome, for treatment of PONV
Steroids
Neurokinin receptor antagonist
Name 2 antihistamines for anti sickness treatment and their dose
Cyclizine 50mg
Promethazine 20-25mg
Name 2 dopamine D2 antagonists for anti sickness treatment and their dose
Prochlorperazine 12.5mg
Metoclopramine 20mg over 3 mins, CI 3-4 days post intra-abdominal surgery, obstruction, haemorrhage, perforation, or obstruction and phaeochromocyomas
Droperidol 0.625-1.25mg, CI bradycardia, CNS depression, coma, hypokalaemia, hypomagnesaemia, phaeochromocytoma, long QT syndrome
Name 2 serotonin 5-HT3 antagonists used for anti-sickness treatment and their dose
Ondansetron 4mg
Granisetron 1mg diluted to 5ml given over 30s
Name a steroid used for anti-sickness treatment and their dose
Dexamethasone 3.3-6.6mg
For chemotherapy related N&V
Name a neurokinin receptor antagonist for anti-sickness treatment and its dose
Aprepitant 80mg
For chemotherapy related N&V
What questions are important to ask in a vomiting history?
Bilious/non-bilious (helps localise)
Bloody/non-bloody (inflammation/damage)
Projectile/non-projectile (specific diagnosis)
Age
Febrile/afebrile
Nausea, abdominal pain, distention, diarrhoea, constipation
Headache, changes in vision, polyuria, polydipsia, weight loss - rule out increased ICP or DKA
Hydration status
What are the red flags in a vomiting history?
Meningism
Costovertebral tenderness
Abdominal pain
Any evidence of raised ICP
What is the examinations you should do in a vomiting child?
General - hydration, temp, obs, weight loss, jaundice/pallor
Abdo - distension, scars, tenderness, rigidity, bowel sounds
Neuro - GCS, meningism, neurological deficit
Plot growth
Assessment of hydration status
Evidence of infection
Presence of dysmorphic features, ambiguous genitalia or unusual odours
What are the GI obstruction differentials for vomiting?
Pyloric stenosis Malrotation with intermittent volvulus Intestinal duplication Hirschsprung's disease Antral/duodenal web Foreign body Incarcerated hernia
What other GI problems are differentials for vomiting?
Achalasia Gastroparesis Gastroenteritis Peptic ulcer Eosinophilic oesophagitis/gastroenteritis Food allergy IBD Pancreatitis Appendicitis
What are some neurological differentials for vomiting?
Hydrocephalus SDH Intracranial haemorrhage Intracranial mass Infant migraine
What are some infectious differentials for vomiting?
Sepsis Meningitis UTI Pneumonia Otitis media Hepatitis
What are some metabolic/endocrine differentials for vomiting?
Galactosemia Hereditary fructose intolerance Urea cycle defects Amino and organic acidaemias Congenital adrenal hyperplasia
What are some renal differentials for vomiting?
Obstructive uropathy
Renal insufficiency
What are some toxic differentials for vomiting?
Lead
Iron
Vit A and D
Medications - digoxin, theophylline
What are some cardiac differentials for vomiting?
Congestive HF
Vascular ring
What are some psychiatric differentials for vomiting?
Munchausen syndrome
Child neglect or abuse
Self induced
What are the most common causes of vomiting in children 0-2 days old?
Duodenal or other intestinal atresia
TEF (types A/C)
What are the most common causes of vomiting in children 3 days-1 month old?
Gastroenteritis Pyloric stenosis Malrotation +/- volvulus TEF (types B/D/H) Necrotising enterocolitis Milk protein intolerance CAH IEM
What are the most common causes of vomiting in children 1-36 months old?
Gastroenteritis UTI, pyelonephritis GOR/GORD Ingestion Intussusception Milk protein intolerance
What are the most common causes of vomiting in children 36 months-12 years old?
Gastroenteritis UTI DKA Increased ICP Eosinophilic oesophagitis Appendicitis Ingestion Post-tussive vomiting
What are the most common causes of vomiting in children 12 -18 years old?
Gastroenteritis Appendicitis DKA Increased ICP Eosinophilic oesophagitis Bulimia Pregnancy Post-tussive vomiting
How does malrotation/volvulus present and how is it managed?
Sudden bilious vomit, abdominal distension
As progresses - abdomen can feel peritonitic
Blood per rectum
Metabolic acidosis
Contrast study essential for diagnosis and USS
Urgent surgical referral - division of Ladd bands (Ladds procedure) - return SB to right and LB to left, caecum in LUQ
How does Hirschsprung’s disease/meconium ileus/intestinal atresia present and how is it managed?
Delayed passage of meconium, abdominal distension, bilious vomiting
Surgical referral
How does necrotising enterocolitis present and how is it managed?
Usually pre-term infant, abdominal distension, bilious vomiting
Antibiotics, enteral rest, surgical referral if severe
How does infection present and how is it managed?
May be non-specific or point to source of infection
Investigations to establish cause
May require fluid resuscitation and empirical antibiotic treatment
How does GORD present and how is it managed?
Vomiting associated with feeds
Poor feeds
Cough, wheeze
Step-wise approach
How does food intolerance present and how is it managed?
Vomiting, loose stools, constipation, eczema
Elimination diet
How does pyloric stenosis present and how is it managed?
Progressive projectile vomiting, hypokalaemia, hypochloraemic metabolic acidosis FTT Palpable olive shaped mass Dehydration Fluid and electrolyte replacement prior to surgery NG tube NBM Ramdtedt's pyloromyotomy
How does intussusception present and how is it managed?
Usually 3-36 months of age, colicky abdominal pain, bilious vomiting, red-currant jelly stools
Distended abdomen
Peritonitic
IVI
IVabx
Pneumatic air insufflation or barium enema for reduction
Surgery
How does strangulation hernia/adhesion obstruction present and how is it managed?
Bilious vomiting, abdominal pain
Surgical referral
How does raised ICP present and how is it managed?
Early morning vomiting, bulging fontanelle
CT/MRI
How does acute appendicitis present and how is it managed?
Anorexia, central abdominal pain migrating to RIF, vomiting, pyrexia
Appendectomy
How does pancreatitis present and how is it managed?
Vomiting, abdominal pain
Fluids, analgesia
How does cyclical vomiting syndrome present and how is it managed?
Recurrent episodes of vomiting, child well in between
Exclusion of other causes
How does DKA present and how is it managed?
Polydipsia, polyuria, hyperglycaemia, ketonuria, metabolic acidosis on blood gas
As per national and local guidance
How does medication/alcohol/illicit drug intoxication present and how is it managed?
History of ingestion, recently commenced on new medication
Remove offending substance, supportive care
How is post-operative/pain managed?
Analgesia
Anti-emetics
How do psychiatric causes of vomiting present and how is it managed?
As part of eating disorder
Psychiatry referral
How does pregnancy present and how is it managed?
Weight gain
May not admit to being sexually active
Pregnancy test
How does infection present in older children and how is it managed?
Pyrexia, tachycardia, identifiable source of infection
Antibiotics
What investigations should you do in a child that is vomiting?
Depends on underlying cause, history, presentation, and age of patient
Acute - U&E, stool virology, abdo XR, surgical opinion, exclude systemic disease
Chronic - FBC, ESR/CRP, U&E, LFT, H pylori serology, urinalysis, upper GI endoscopy, abdo USS, small bowel enema, brain imaging, test feed
Cyclic - amylase, lipase, glucose, ammonia
What are the metabolic consequences of vomiting?
K+ deficiency
Alkalosis
Sodium depletion
What are the consequences of vomiting?
Metabolic
Nutritional
Mechanical injuries to oesophagus and stomach
Dental
Oesophageal stricture, Barrett’s, broncho-pulmonary aspiration, FTT, anaemia
What types of mechanical injury can you get to oesophagus and stomach due to vomiting?
Mallory-Weiss
Boerhaave’s syndrome
Tears of short gastric arteries resulting in shock and haemoperitoneum
What is the treatment for vomiting?
Supportive - IV fluids, analgesia, antiemetics
Treat cause - medical/surgical
Pharmacological
What signs may suggest disorders other than GORD?
Bilious vomiting GI bleeding Persistently forceful vomiting New onset of vomiting > 6 months Failure to thrive Diarrhoea Constipation Fever Lethargy Hepatosplenomegaly Bulging fontanelle Macro/microcephaly Seizures Abdominal tenderness or distension Suspected metabolic syndrome
When is reflux normal?
Reflux is normal physiological response in children, often resolves by a year in most children
What is GOR?
Passage of gastric contents into oesophagus, with or w/o regurgitation or vomiting
What is GORD?
Presence of troublesome symptoms and/or complications of persistent GOR
What complications can you get from GORD in children?
Faltering growth Oesophagitis +/- stricture Apnoea, ALTE, SIDS Aspiration, wheeze, hoarseness IDA Seizure-like events, torticolis
How does GORD present in children?
Heart burn
Epigastric pain
What investigations should you do for GORD?
pH Barium swallow and meal Endoscopy Nuclear scintigraphy, tests on ear, lung and oesophageal fluids, USG, combined multiple intraluminal impedance PPI test
What is the management of GORD?
Conservative - Optimise position - Parental education and support - Thicken eg carobel/change feeds - Avoid over feeding - Smaller, more frequent feeds - Weight monitoring - Gaviscon Drugs - antacid, H2 blocker, PPI Surgery - fundoplication
What is a food allergy?
Body’s immune system reacts adversely to specific foods, characterised by multisystem reaction - skin, GI, resp, cardio, immediate reaction
What is a food intolerance?
Food intolerance - unpleasant physical reaction to food due to difficulty digesting them, characterised by mainly GI symptoms, bloating, abdominal pain, diarrhoea, delayed reaction few hours after eating food
What are the different types of food allergy?
IgE mediated - acute, urticaria, oral allergy
Non-IgE mediated - food protein induced enteropathy
Mixed IgE and non-IgE mediated - gastroenteritis
Cell mediated - allergic contact dermatitis
What are the different types of food intolerance?
Metabolic (lactose intolerance)
Pharmacologic (caffeine)
Toxic (fish toxin)
Other idiopathic/undefined
What is the most common food allergy?
Cow’s milk protein alelrgy
What is CMPA associated with?
Atopy, IgA deficiency, and IgG subclass abnormalities
How common is CMPA?
Prevalence varies from 2% to 7.5%
How do you diagnose CMPA?
Elimination diet
Skin prick testing
RAST
Oral food challenge
How is CMPA managed?
Hydrolysed or AA feeds - broken down into smaller peptides
What are the symptoms of IgE mediated allergy? GI
Angioedema of lips, tongue, palate Oral pruritis Nausea Colicky abdominal pain Vomiting Diarrhoea
What are the symptoms of non-IgE mediated immunity? GI
GORD Loose or frequent stools Blood and/or mucus in stools Abdominal pain Infantile colic Food refusal or aversion Constipation Perianal redness Pallor and tiredness Faltering growth in conjunction with at least one or more GI symptom (with or without significant atopic eczema)
What skin symptoms do you get with IgE mediated allergy?
Pruritus
Erythema
Acute urticaria - localised/generalised
Acute angioedema - most commonly around lips, face, and eyes
What skin symptoms do you get with non-IgE mediated allergy?
Pruritus
Erythema
Atopic eczema
What respiratory symptoms do you get with IgE mediated allergy?
Upper - nasal itching, sneezing, rhinorrhoea, congestion
Lower - wheezing/SOB
What respiratory symptoms do you get with non-IgE mediated allergy?
Cough, chest tightness
What are the different types of lactose intolerance?
Primary - rare
Late onset - common
What are the symptoms of lactose intolerance?
Explosive watery stools, abdominal distension, flatulence, audible bowel sounds
How do you diagnose lactose intolerance?
Stool chromatography, lactose hydrogen breath test, small bowel biopsy and elimination diet
How do you treat lactose intolerance?
Lactose free formula/milk-free diet with calcium and vitamin D supplements
What is constipation?
Infrequent passage of stool associated with pain and difficulty, or delay in defecation
What is encopresis?
Involuntary faecal soiling or incontinence secondary to chronic constipation
What is the ROME IV criteria for constipation?
2/fewer defecations per week for at least one month
At least 1 episode of faecal incontinence per week
Retentive posturing or stool retention
Painful or hard bowel movements
Presence of large faecal mass in rectum
Large diameter stools that may obstruct the toilet
After appropriate evaluation, the patient symptoms must not be fully explained by another medical condition
What is the pathogenesis of constipation?
Cycle of painful defecation, voluntary withholding, prolonged fecal stasis, re-absorption of fluids and increase in size and consistency, more pain
What should you ask about in the history of a child with constipation?
Frequency and consistency of stools (Bristol Stool chart)
Pain with passing stool or straining, rectal bleeding, ever clog the toilet, changes in appetite, abdominal pain, medications (opioids)
What examination should you do in a child with constipation?
General physical examination, palpable faecal mass on abdominal examination
Visual inspection of anorectal area completed for all patients to identify possible organic aetiologies
Rectal examination - often not required
What are the red flags in a constipation history?
Delayed passage of meconium Fever, vomiting, bloody diarrhoea Failure to thrive Tight, empty rectum with presence of palpable abdominal faecal mass Abnormal neurological exam
What are possible differentials for constipation?
Hirschsprung's disease Anorectal malformations Neuronal intestinal dysplasia Spina bifida Neuromuscular disease Hypothyroidism Hypercalcaemia Coeliac disease Food allergy/intolerance CF Perianal group A streptococcal infection Anal fissure Pelvis/spinal tumours Child sexual abuse Drugs
What are the short term complications of constipation?
No sequelae
What are the long term complications of constipation?
Acquired megacolon, anal fissures, overflow incontinence, behavioural problems
What investigations can you do for constipation?
Usually not necessary
Only if organic cause suspected, remain constipated despite medical treatment
T4/TSH, serum Ca, coeliac panel, sweat test, AXR, anal manometry, rectal biopsy, spinal imaging
What is the management of constipation?
Explanation of normal bowel function Diet/fluids and exercise Behavioural advice Toilet training advice Simple reward schemes Medications - Softener - lactulose, liquid parafin - Bulking agent - fybogel - Movicol - Senna, dulcolax - stimulants - Enema - Anal fissure - anaesthetic cream +/- vasodilator If treatment for constipation is unsuccessful or organic cause of constipation suspected refer to paediatric gastro
What is diarrhoea?
Change in consistency of stools and/or increase in frequency of evacuations with or without fever or vomiting which lasts less than 7 days and not longer than 14 days
What questions should you ask in a diarrhoea history?
When did it start?
What’s its progression been?
How many times per day?
Watery? Blood? Mucus?
ssociated symptoms - fever, vomiting, urine output, abdominal pain, lethargic, weight loss
Context - immune status, recent hospitalisation, antibiotic use, any recent medications, recent travel, vaccination
What are the causes of infection causing acute diarrhoea?
Viruses
Bacteria
Parasites
What viruses can cause acute diarrhoea?
Rotavirus
Calicivirus
Astrovirus
Enteric-type adenovirus
What bacteria can cause acute diarrhoea?
Campylobacter jejuni Salmonella E coli Shigella Yerninia enterocolitica Aeromonas hydrophilia C difficile
What parasites can cause acute diarrhoea?
Giardia lamblia
Cryptosporidium
What other things can cause acute diarrhoea?
Other infections - otitis media, tonsilitis, pneumonia, septicaemia, UTI, meningitis
Allergy/food hypersensitivity reactions
Drugs
Haemolytic uraemic syndrome
Surgical causes - pyloric stenosis, intestinal obstruction, appendicitis, intussusception
How common is diarrhoea?
24 of 1000 consultations with GPs in children under 5 for gastroenteritis
Annual hospital admission rate about 7 per 1000
How does diarrhoea present?
Diarrhoea +/- blood stools (dysentry)
Fever +/- vomiting
Dehydration and reduced consciousness
What investigations should you consider for a child with diarrhoea?
Perform stool microscopy if
- Suspect septicaemia
- Blood or mucus in stool
- Child immunocompromised
Consider performing stool microscopy if
- Recently travelled abroad
- Diarrhoea has not improved by day 7
- Uncertain about diagnosis of gastroenteritis
Bloods not necessary in simple gastroenteritis but measure serum electrolytes including glucose if
- Severe dehydration
- IV fluid therapy required
- Symptoms and/or signs suggesting hypernatraemia
- Altered conscious state
- Co-morbidity of renal disease or on diuretics
Ileostomy
What examination should you do in children with diarrhoea?
Assess for dehydration
Best clinical indicators > 5% dehydration are prolonged CRT, abnormal skin turgor and absent tears
How do you treat diarrhoea?
Most cases self resolving
Antibiotics - bacterial GE complicated by septicaemia or systemic infections or immunocompromised and malnourished patients
Probiotics
No antiemetics/anti-motility drugs
What is hypernatraemic dehydration?
Unusual and serious
Irritable with doughy skin
Water shifts from intracellular to extracellular
Rehydration should be slow
What is chronic diarrhoea?
> 2 weeks
What can cause chronic diarrhoea?
Continued infection with first pathogen Infection with second pathogen Post enteritis syndrome Spurious - constipation Chronic non-specific diarrhoea Food intolerance Malabsorption
How common is IBD in children?
Prepubertal males > females
Ileo-colonic or colonic UC
Inflammatory phenotype, non-structuring, non-penetrative
More have surgery than adults 40% in 10 years from diagnosis vs 20%
Similar presentation depending on location
Extrintestinal manifestations
Same treatment
What is the most significant difference between adult and paediatric IBD?
Growth - Poor growth - Delayed puberty - Reduced final adult height - Catch up growth Persistent poor growth - only sign of disease activity
How is IBD diagnosed?
- Nuclear medicine
- Clinical evaluation
- Biochemical - faecal calprotectin in stool
- Endoscopic
- Radiological
- Histological - biopsy
What treatment might you give for Crohn’s?
Exclusive enteral nutrition Corticosteroids (prednisolone/budesonide) - problems with bone health Aminosalicylates (topical and oral) Antibiotics Immunomodulators (6-mercaptopurine, azathioprine, methotrexate) Biologics (infliximab, adalimumab) Surgery Parenteral nutrition
What treatment might you give for UC?
Mild to moderate induction - aminosalicylate
Moderate to severe induction - corticosteroids
Mild to moderate remission - aminosalicylate
Moderate to severe remission - 6 MP/azathioprine
Surgical resection
What is chronic abdominal pain?
Long lasting, intermittent or constant that is functional or organic disease, 3 attacks over at least 3 months duration
What is functional abdominal pain?
Abdominal pain w/o evidence of disease/pathologic process - functional dyspepsia, IBS, abdominal migraine, functional abdominal pain syndrome
What is recurrent abdominal pain?
One of most common recurrent pain syndromes in children
Classic definition based on 4 criteria
- Hx of at least 3 episodes of pain
- Pain that is severe enough to affect activities
- Episodes that occur over 3 months
- No known organic cause
What are the organic causes of abdominal pain?
GORD PUD H pylori infection Food intolerance Coeliac disease IBD Constipation UTI Dysmenorrhoea Pancreatitis Hepato-biliary disease
What functional disorders can cause abdominal pain?
Functional dyspepsia IBS Functional abdominal pain Abdominal migraine Aerophagia
What is the pathogenesis of functional disorders?
Abnormal bowel reactivity to
- Physiological stimuli (meal, gut distension, hormonal)
- Noxious stressful stimuli (inflammatory process)
- Psychological stressful stimuli (parental separation, anxiety)
Leading to development of visceral hyperalgesia
What questions should you ask in an abdominal pain history?
Onset, duration Location and radiation How long does it last? Character Aggravating/relieving factors Intermittent/constant Associated symptoms
What in the history suggests functional disorder?
Concurrent stressful event in life Peri-umbilical or epigastric Prolonged duration with no clear signs Vague, gradual onset, variable severity Reinforcement from parents No relationship to interventions Constant Signs of anxiety FHx of IBS Migraines
What in the history suggests organic cause?
Trauma/travel
Well localised away from umbilicus
Variable duration
Isolated sudden onset pain
Sometimes medications or position change help
Intermittent
Associated with fever, rash, weight loss, growth faltering, FHx of ulcers or IBD
What are red flags in an abdominal pain history?
Weight loss or poor growth
Pain that is not periumbilical
Change in bowel habits, nocturnal or diarrhoea/constipation
Disturbed sleep due to pain
Repeated vomiting, especially bilious
Any constitutional symptoms such as fever, lethargy, reduced appetite
What are red flags in an abdominal examination?
Weight loss or decreased growth velocity suggest serious underlying cause
Any organomegaly
Abdominal tenderness that is localised, especially if not periumbilical
Perianal abnormalities like fissures, skin tags, ulcerations
Swollen, warm or hot joints
Ventral hernias of the abdominal wall
What alarm S&S warrant diagnostic testing in children with abdominal pain?
Involuntary weight loss Deceleration of linear growth GI blood loss (visible or occult) Significant vomiting (including bilious, protracted, cyclical) Chronic severe diarrhoea Persistent R upper/lower quadrant pain Unexplained fever Family Hx IBD Abnormal or unexplained physical findings
What are the primary aims of treatment for abdominal pain?
Return to normal function
Avoidance of reinforcement of pain behaviours
Distraction, providing attention, rest, identifying triggers for pain
Reassurance
Education for family
Emphasize that no serious life-threatening process/condition
What are the secondary goals of treatment for abdominal pain?
Relief of symptoms Pharmacologic Cognitive therapy Relaxation Massage/PT/OT/exercise
What is acute abdominal pain?
Less than 7 days duration, sudden onset and severe
What are the 2 most common cause of acute abdominal pain in children?
Non-specific abdominal pain and appendicitis in children presenting to hospital
What is guarding?
Contraction of abdominal wall musculature, classically in response to underlying peritoneal inflammation
How can you tell the difference between voluntary and involuntary guarding and why is this important?
Voluntary - contraction of the abdominal wall muscles in anticipation of painful stimulus
Involuntary - true guarding, conducted at reflex arc level, when patient distracted or relaxed, voluntary guarding disappears
Causes of involuntary guarding often need surgery
How does your examination of the abdomen differ in a child compared to an adult?
Hop/jump test - get child out of bed to jump up and down, positive if provokes pain
In/out tummy test - blow abdominal wall in/out
Stethoscope test - pretend listening to abdomen while gently pressing with stethoscope, useful if considering non-organic pain
Percussion test - looks for peritonism and rebound tenderness
What are the 6 most useful clinical indicators of acute appendicitis?
Migration of pain to RIF Anorexia Guarding Nausea Elevated temperature Tenderness in RIF
What colour vomit is associated with malrotation?
Green
What colour vomit is associated with intussusception?
Milky the green
What colour vomit is associated with pyloric stenosis?
Milky
What are the 4 most common causes of vomiting in young babies?
Overfeeding
GORD
Sepsis
Pyloric stenosis
Why does an intussusception happen?
A lead point in bowel wall causes peristalsis to drag the bowel forward into itself
Name 3 causes of acute vomiting
GI infection Non-GI infection eg UTI GI obstruction - congenital/acquired Adverse food reaction Poisoning Raised ICP Endocrine/metabolic disease eg DKA
Name 3 causes of chronic vomiting
PUD GI obstruction eg pyloric stenosis GORD Chronic infection Gastritis Gastroparesis Food allergy Psychogenic Bulimia Pregnancy
Name 3 causes of cyclic vomiting
Idiopathic CNS disease Abdominal migraine Endocrine eg Addison's Metabolic eg acute intermittent porphyria Intermittent GI obstruction Fabricated illness
How is pyloric stenosis diagnosed?
USS but don’t need if can feel olive shaped mass
What is malrotation?
Midgut volvulus
Failure of gut to rotate 90 of the 270 anticlockwise before returning to the abdominal cavity
Normally DJ flexure is to left of midline and terminal ileum is in RIF - broad mesentery
In malrotation
- DJ to right
- SMV to left of SMA
- Narrow base of mesentery
- Caecum displaced to epigastrium or right hypochondrium
- Ladd bands
What happens in volvulus?
Ladd bands can cause duodenal obstruction
SM vessels can twist and cause ischaemia
Name 2 differentials for duodenal obstruction
Duodenal web
Annular pancreas
What can cause intussuception?
Most cases idiopathic
10% - Meckel’s diverticulum, Peutz Jaghers polyps, SB lymphoma
What are the different types of intussuception?
SB into SB
SB into LB
LB into LB
LB into rectum
Name 5 causes of acute diarrhoea in children
Infective gastroenteritis - tends to be viral Non-enteric infections eg resp tract Food poisoning Colitis Food intolerance/hypersensitivity reactions NEC Drugs eg antibiotics HSP Intussusception Haemolytic-uraemic syndrome Pseudomembranous enterocolitis
Name 5 causes of chronic diarrhoea in children aged 0-24 months
Malabsorption eg post-enteritis syndrome due to lactose intolerance, CF, coeliac disease Food hypersensitivity Toddler's diarrhoea Excessive fluid intake Protracted infectious gastroenteritis Immunodeficiencies eg HIV Hirschsprung's disease Congenital mucosal transport defects Autoimmune encephalopathy Tumours (secretory diarrhoea) Fabricated illness
Name 5 causes of chronic diarrhoea in older children
IBD Constipation Malabsorption IBS Laxative abuse Infections including bacterial overgrowth and pseudomembranous colitis Excessive fluid intake Fabricated illness
Name 2 other causes of diarrhoea in children
Loss of sphincter control
Spina bifida
What is the treatment for chronic diarrhoea?
Oral disimpaction
What is the treatment for oral regimen for disimpaction?
Movicol
Stimulant laxative +/- osmotic laxative
What is the treatment for maintenance therapy for constipation?
Movicol
Name an osmotic laxative
Movicol
Lactulose
Name a stimulant laxative
Sodium picosulfate
Bisacodyl
Senna
Name a stool softener
Docusate
