Gastroenterology Flashcards
1
Q
What are the red flag clinical features of vomiting? (11)
A
- Bile-stained vomit
- Haematoemesis
- Projectile vomiting (in first few weeks of life)
- Vomiting at end f paroxysmal coughing
- Abdominal tenderness/pain on movement
- Abdominal distension
- Hepatosplenomegaly
- Blood in stool
- Severe dehydration, shock
- Bulging fontanelle/seizures
- Faltering growth
2
Q
What does bile-stained vomit in a vomiting child indicate?
A
Intestinal obstruction
3
Q
What does haematemesis in a vomiting child indicate?
A
Oesophagitis, peptic ulceration, oral/nasal bleeding, oesophageal variceal bleeding
4
Q
What does projectile vomiting in a vomiting child indicate?
A
Pyloric stenosis
5
Q
What does vomiting at end of paroxysmal coughing in a vomiting child indicate?
A
Whooping cough
6
Q
What does abdominal tenderness/pain on movement in a vomiting child indicate?
A
Surgical abdomen
7
Q
What does abdominal distension in a vomiting child indicate?
A
Intestinal obstruction including strangulated inguinal hernia
8
Q
What does hepatosplenomegaly in a vomiting child indicate?
A
Chronic liver disease, inborn error or metabolism
9
Q
What does blood in stool in a vomiting child indicate?
A
Infussusception, bacterial gastroenteritis
10
Q
What does severe dehydration and shock in a vomiting child indicate?
A
Severe gastroenteritis, systemic infection eg UTI, meningitis, diabetic ketoacidosis
11
Q
What does bulging fontanelle/seizures in a vomiting child indicate?
A
Raised intracranial pressures
12
Q
What does faltering growth in a vomiting child indicate?
A
GORD, coeliac disease, chronic GI conditions
13
Q
What are some causes of vomiting in infants? (9)
A
- GORD
- Feeding problems
- Infection (gastroenteritis, RTI, UTI, whooping cough)
- Food allergy/intolerance
- Eosinophilic oesophagitis
- Inborn errors of metabolism
- Intestinal obstruction (pyloric stenosis, atresia, malrotation, volvulus, intussusception, hirschsprung)
- Congenital adrenal hyperplasia
- Renal failure
14
Q
What are some causes of vomiting in preschool children? (9)
A
- Gastroenteritis
- Infection (RTI, UTI, whooping cough, meningitis)
- Appendicitis
- Intestinal obstruction (Intussusception, malrotation, volvulus, adhesions, foreign body (bezoar)
- Raised intracranial pressure
- Coeliac disease
- Renal failure
- Torsion of testes
- Inborn errors of metabolism
15
Q
What are some causes of vomiting in school age/adolescents? (14)
A
- Gastroenteritis
- Infections
- Peptic ulceration and H.Pylori
- Appendicitis
- Migraine
- Raised intracranial pressure
- Coeliac disease
- Renal failure
- Diabetic ketoacidosis
- Alcohol/drug ingestion
- Cyclical vomiting syndroe
- Bulimia/anorexia nervosa
- Pregnancy
- Torsion of tests
16
Q
What are some investigations performed for a vomiting child?
A
- Vomiting hx (colour, billious/non-billious, bloody?, regurgitation vs projectile), associated symptoms
- Physical examination
- Abdominal and chest x-ray
- Gastroscopy
17
Q
What is the management for a vomiting child?
A
- Manage dehydration
- Treat underlying cause
18
Q
What is gastro-oesophageal reflux disease?
A
Contents from the stomach reflux through the lower oesophageal sphincter into the oesophagus
19
Q
What is gastro-oesophageal reflux disease caused by?
A
Immaturity of lower oesophageal sphincter
20
Q
What is gastro-oesophageal reflux disease more common in?
A
- Children with cerebral palsy or other neurodevelopmental disorders
- Preterm infants, esp those with bronchopulomonary dysplasia
- Following surgery for oesophageal atresia/diaphragmatic hernia
21
Q
What is the most common cause of gastro-oesophageal reflux disease?
A
Vomiting in infants
22
Q
What are the clinical features of gastro-oesophageal reflux disease in children under 1yo? (6)
A
- Chronic cough
- Hoarse cry
- Distress, crying, unsettled after feeding
- Reluctance to feed
- Pneumonia
- Poor weight gain
23
Q
What are the clinical features of gastro-oesophageal reflux disease in children over 1yo? (5)
A
- Heartburn
- Acid regurgitation
- Retrosternal/epigastic pain
- Bloating
- Nocturnal cough
24
Q
When is further investigations of gastro-oesophageal reflux disease in children indicated?
A
Usually unnecessary, diagnosed clinically
- Atypical history
- Complications are present
- Failure to respond to treatment
25
What is included in investigations of gastro-oesophageal reflux disease in children?
- 24hr oesophageal pH monitoring --> quantify degree of acid reflux
- 24hr imedance monitoring
- Endoscopy with oesophageal biopsy --> identify oesophagitis and exclude other causes of vomiting
26
How is gastro-oesophageal reflux disease in children managed?
- Small, infrequent meals
- Burping regularly --> to help milk settle
- Not over-feeding
- Keep baby upright after feeding
- Gaviscon mixed into feeds --> for more problematic cases
- Medications eg hydrogen receptor antagonists (Ranitidine), proton pump inhibitors (Omeprazole)
- Surgery --> surgiclal fundoplication if very severe
27
What are 5 complications of gastro-oesophageal reflux disease in children?
- Faltering growth - from severe vomiting
- Oesophagitis
- Recurrent pulomonary aspiration
- Sandifer syndrome
- Apparent life-threatening events
28
What does oesophagitis in gastro-oesophageal reflux disease in children indicate?
Haematemesis, discomfort on feeding, heartburn, iron-deficiency anaemia
29
What does recurrent pulmonary aspiration in gastro-oesophageal reflux disease in children indicate?
Recurrent pneumonia, cough and wheeze, apnoea (in preterm infants)
30
What does sandifer syndrome gastro-oesophageal reflux disease in children indicate?
Torticolis - forceful contractio of neck muscles causing twisting of neck
Dystonia - abnormal muscle contractions causing twisting movements (Arching of back)
31
What are 12 medical causes of abdominal pain in children?
- Constipation
- Urinary tract infection
- Coeliac disease
- Inflammatory bowel disease
- Irritable bowel syndrome
- Mesenteric adenitis
- Abdominal migraine
- Pyelonephritis
- Henock-schonlein purpura
- Tonsilitis
- Diabetic ketoacidosis
- Infantile colic
32
What are 6 medical causes of abdominal pain specific to female children?
- Dysmenorrhoea
- Mittelschmerz
- Ectopic pregnancy
- Pelvic inflammatory disease
- Ovarian torsion
- Pregnancy
33
What are 4 surgical causes of abdominal pain in children?
- Appendicitis
- Intussusception
- Bowel obstruction
- Testicular torsion
34
How would appendicitis be presented in children with abdominal pain?
Central abdominal pain radiating to right iliac fossa
35
How would intussusception be presented in children with abdominal pain?
Colicky non-specific pain with redcurrant jelly stools
36
How would bowel obstruction be presented in children with abdominal pain?
Pain, distension, absolute, constipation, vomiting
37
How would testicular torsion be presented in children with abdominal pain?
Sudden onset, unilateral testicular pain, nausea, vomiting
38
What are 8 red flag symptoms of abdominal pain in children?
- Persistent/billous vomiting
- Severe chronic diarrhoea
- Fever
- Rectal bleeding
- Weight loss/faltering growth
- Dysphagia
- Night-time pain
- Abdominal tenderness
39
What are 4 investigations to do in children with abdominal pain? And what do they indicate?
- Bloods
- -> Anaemia: IBD, coeliac disease
- -> Raised inflammatory markers: IBD
- Increased anti-ITG, increased anti-EMA: coeliac disease
- Increased faecal calprotein: IBD
- Positive urine dipstick: UTI
40
How is abdominal pain in children managed?
Treat underlying cause
41
What is the definition of recurrent abdominal pain?
More than 2 discrete episodes in a 3-month period interfering with school and/or usual activities
42
What are 8 gastrointestinal causes of recurrent abdominal pain in children?
- Irritable bowel syndrome
- Constipation
- Non-ulcer dyspepsia
- Abdominal migraine
- Gastritis and peptic ulceration
- Eosinophilic oesophagitis
- Inflammatory bowel disease
- Malrotation
43
What are 3 gynaecological causes of recurrent abdominal pain in children?
- Dysmenorrhoea
- Ovarian cysts
- Pelvic inflammatory disease
44
What are some psychosocial causes of recurrent abdominal pain in children?
Bullying, abuse, stress etc so often corresponds to stressful life events
45
What are 3 hepatobility/pancreatic causes of recurrent abdominal pain in children?
- Hepatitis
- Gall stones
- Pancreatitis
46
What are 2 urinary tract causes of recurrent abdominal pain in children?
- UTI
| - PUJ obstruction
47
What are 6 symptoms and signs that suggest organic disease causing recurrent abdominal pain in children?
- Epigastric pain at night, haematemesis (duodenal ulcer)
- Diarrhoea, weight loss, growth failure, blood in stools (inflammatory bowel disease)
- Vomiting (pancreatitis)
- Jaundice (liver disease)
- Dysuria, secondary enuresis (UTI)
- Bilious vomiting and abdominal distention (malrotation)
48
What are 8 ways to manage recurrent abdominal pain in children?
- Careful explanation and reassurance
- Distracting the child from pain with other activities or interests
- Encourage parents not to ask about or focus on pain
- Advice about sleep, regular meals, healthy balanced diet, staying hydrated, exercise and reducing stress
- Probiotic sypplements (may help with IBS)
- AVOID NSAIDS
- Address psychologicla triggers and exacerbating factors
- Support from school counsellor or child psychologist
49
How is abdominal migraine presented in children?
Epsiodes of central abdominal pain that lasts more than 1 hour
50
What is associated with abdominal migraine in children?
- Nausea and vomiting
- Anorexia
- Pallor
- Headache
- Photophobia
- Aura
51
How is acute attack of abdominal migraine treated in children?
Treat acute attack
- Low stimulus environment
- Paracetamol/Ibuprofen
- Sumatriptanm
52
How is abdominal migraine in children prevented?
- Pizotifen - serotonin agonist
- Propranolol - B-blocker
- cyproheptadine - antihistamine
- Flunarazine - Ca2+ channel blockers
53
What are 4 advantages of breastfeeding for infants?
- Provides the ideal nutrition for infants during first 4-6 months
- Life-saving in developing countries
- Enhances mother-child relationship
- Reduces risk of diseases and infections
54
What type of risks does breastfeeding reduce for infants? (7)
- Gastrointestinal infection
- Respiratory infection
- Otitis media
- Necrotising enterocolitis
Later in life
- Insulin-dependent diabetes
- Hypertension
- Obesity
55
What are 3 advantages of breastfeeding for the motnher?
- Promotes close attachment between mother and baby
- Increase time interval between children --> decrease birth rate in developing countries
- Reduces risk of breast cancer, ovarian cancer, type 2 diabetes
56
What is the physiology of breastfeeding? (5)
1. Baby uses rooting, sucking and swallowing reflexes to locate nipple and feed
2. Tactile receptors in nipple activated
3. Hypothalamus sends efferent impulses to anterior and posterior pituitary
4. Prolactin secretion stimulate milk secretion by cuboidal cells in acini of breast
5. Oxytocin secretion results in contraction of myoepithelial cells in the alveoli, forcing milk into larger ducts --> "let down" reflex
57
What are 9 potential complications of breastfeeding?
- Unknown intake
- Transmission of infection
- Breast milk jaundice
- Transmission of drugs
- Nutrient inadequacies
- Vitamin K deficiency
- Potential transmission of environmental contaminants
- Less flexible
- Emotional upset
58
What does the complication of unknown intake as a potential complication of breastfeeding indicate?
Volume of milk intake unknown so monitor weight gain
59
What are 3 examples of infections that can transmit as a potential complication of breastfeeding?
Maternal CMV, Hep B, HIV
60
What does breast milk jaundice as a potential complication of breastfeeding indicate?
Mild, self-limiting, unconjugated hyperbilirubinaemia
61
What drugs is contraindicated that can be a potential complication of breastfeeding?
Antimetabolites and other drugs
62
What does nutrient inadequacies mean as a potential complication of breastfeeding?
If breastfeeding beyond 6 months without timely introduction of solids, it can result in poor weight gain and rickets
63
What does vitamin K deficiency as a potential complication of breastfeeding indicate?
Insufficient Vit K in breast milk can cause haemorrhagic disease of newborns
64
What environmental contaminants are potentially transmitted in breastfeeding?
Nicotine, alcohol, caffeine
65
What does less flexible mean as a potential complication of breastfeeding?
Other family members cannot help and more difficult in public places
66
What are the 2 categories of anti-infective properties of breastmilk?
Humoral and cellular
67
What are 5 humoral properties of breastmilk and what are their purposes?
- Secretory IgA --> provides mucosal protection
- Bifidus factor --> promotes growth fo lactobacillus bifidus --> metabolises lactose to lactic and acetic acid
- Lysosome --> bacteriolytic enzyme
- Lactoferrin --> iron-binding protein --> inhibits growth of e.coli
- Interferon --> antiviral agent
68
What are 2 cellular properties of breastmilk and what are their purposes?
- Macrophages: phagolytic - synthesise lysozyme, lactoferin, C3, C4
- Lymphocytes: T cells may transfer delayed hypersensitivity responses to infant
69
What are 7 nutritional properties of breastmilk?
- Protein quality
- Lipid quality
- Fat metabolism
- Calcium to phosphorus ratio 2:1
- Renal solute load (low)
- Iron content
- Long-chain polyunsaturated fatty acids
70
What are the nutritional properties of breastmilk in terms of protein quality?
More easily digested curd (whey-to-casein ratio 60:40)
71
What are the nutritional properties of breastmilk in terms of lipid quality?
Rich in oleic acid --> improved digestibility and fat absorption
72
What are the nutritional properties of breastmilk in terms of fat metabolism?
Enhanced lipolysis (from breast milk lipase)
73
What are the nutritional properties of breastmilk in terms of calicum to phosphorus ratio 2:1?
Reduces hypocalcaeic tetany and promotes calcium absorption
74
What are the nutritional properties of breastmilk in terms of iron content?
Bioavailable --> 40-50% absorption
75
What are the nutritional properties of breastmilk in terms of long chain polyunsaturated fatty acids?
Structural lipids - important in retinal detachment
76
What are the 9 causes of constipation in children?
- Functional/Idiopathic constipation
- Hirschspung's disease
- Cystic fibrosis
- Hypothyroidism
- Spinal cord lesions
- Sexual abuse
- Intestinal obstruction
- Anal stenosis
- Cow's milk intolerance
77
What are 10 presentations of constipation in children?
- Less than 3 stools/week
- Hard stools
- Rabbit dropping stools
- Straining and painful passage of stools
- Abdominal pain
- Abdominal posture --> retentive posturing
- Rectal bleeding associated with hard stools
- Faecal impaction causing overflow soiling with incontinence of particularly loose smelly stools
- Palpable hard stools in abdomen
- Loss of sensation of the need to open bowels
78
What are 8 red flag symptoms and signs of constipation in children?
- Failure to pass meconium within 24hrs of life
- Faltering growth
- Gross abdominal distention
- Abnormal lower limb neurology/deformity eg Talipes or secondary urinary incontinence
- Sacral dimple above natal cleft, over the spine (naevus, hairy patch, central pit, discoloured skin)
- Abnormal appearance/position/patency of anus
- Perianal bruising or multiple fissures
- Perianal fistulae, abscesses, fissures
79
What would you be concerned about if a child fails to pass meconium within 24hrs of life?
Hirschprung disease and cystic fibrosis
80
What would you be concerned about if a child presents with faltering growth?
Hypothyroidism, coeliac disease, safeguarding
81
What would you be concerned about if a child presents with gross abdominal distention?
Hirschsprung disease and other GI dysmotility
82
What would you be concerned about if a child presents with abnormal lower limb neurology/deformity eg talipes or secondary urinary incontinence?
Lumbosacral pathology
83
What would you be concerned about if a child presents with a sacral dimple above natal cleft, over the spine?
Spinal bifida occulta
84
What would you be concerned about if a child presents with abnormal appearance/position/patency of anus?
Abnormal anorectal anatomy
85
What would you be concerned about if a child presents with perianal bruising or multiple fissures?
sexual abuse
86
What would you be concerned about if a child presents with perianaul fistulae, abscesses, fissures?
Perianal crohn's disease
87
What are 6 complications of constipation in children?
- Pain
- Reduced sensation
- Anal fissures
- Haemorrhoids
- Overflow and soiling
- Psychosocial morbidity
88
What are 4 ways to manage constipation in children?
- Correct any reversible contributing factors --> recommend high fibre diet and good hydration
- Start laxatives (Movicol 1st Line)
- Disimpaction regimen w/ high dose laxatives
- Encourage and praise visiting toilet
89
What is Gastroenteritis?
Inflammation of stomach and intestines
90
How does Gastroenteritis present?
- Nausea
- Vomiting
- Diarrhoea
- Features of Dehydration
91
What are the features of dehydration in a child?
- Decreased level of consciousness
- Sunken fontanelles
- Dry mucous membranes
- Sunken eyes and tearless
- Tachypnoea
- Prolonged Capillary Refill time
- Tachycardia
- Weak peripheral pulses
- Reduced tissue turgor
- Pale or mottled skin
- Hypotension
- Reduced Urine output
- Cold extremities
