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Child Health > Gastroenterology > Flashcards

Gastroenterology Flashcards

1
Q

Non-organic/ functional abdominal pain

A

Very common in over 5

No disease process can be found to explain the pain

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2
Q

Medical causes of abdominal pain

A 
Constipation is very common 
UTI
Coeliac disease
IBD
IBS
Mesenteric adenitis
Abdominal migraine
Pyelonephritis 
Henoch-Schonlein purpura
Tonsilitis
DKA
Infantile colic
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3
Q

Causes of abdominal pain in adolescent girls

A 
Dysmenorrhea (period pain)
Mittelschmerz (ovulation pain)
Ectopic pregnancy 
PID
Ovarian torsion
Pregnancy
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4
Q

Surgical causes of abdominal pain

A

Appendicitis: central abdo pain-> RIF
Intussusception: red jelly stools, colicky non-specific pain
Bowel obstruction: pain, distension, absolute constipation, vomiting
Testicular torsion

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5
Q

Red flags for serious abdominal pain

A 
Persistent or bilious vomiting 
Severe chronic diarrhoea
Fever 
Rectal bleeding
Weight loss or faltering growth 
Dysphagia 
Nighttime pain 
Abdominal tenderness
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6
Q

Abdominal pain investigations

A 
Anaemia: IBD, coeliac disease
ESR/CRP: indicates IBD 
Raised anti-TTG or anti-EMA; coeliac disease
Raised faecal calprotectin: IBD
Positive urine dipstick: UTI
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7
Q

Recurrent abdominal pain

A

Repeated episodes of abdominal pain
No identifiable underlying cause
Non-organic/ functional pain

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8
Q

Effects of recurrent abdominal pain

A

Psychosocial problems
Missed days at school
Parental anxiety

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9
Q

Association of recurrent abdominal pain

A

Abdominal migraine
IBS
Functional abdominal pain

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10
Q

Causes of recurrent abdominal pain

A

Stressful life events
Loss of relative or bullying
Inappropriate pain signals from visceral nerve

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11
Q

Management of recurrent abdominal pain

A

Distract child
Encourage parents to not ask about the pain
Advice about sleep, regular meals, healthy balanced diet, staying hydrated, exercise and reduced stress
Probiotics with IBS
Avoid NSAIDs
Address triggers, psychosocial
Support from school counsellor and child psychologist

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12
Q

Abdominal migraine

A

Occur in young children before traditional migraines
Episodes of central abdominal pain
Lasting >1hr
Normal examination

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13
Q

Associated features of abdominal migraine

A 
N/V
Anorexia
Pallor
Headache
Photophobia
Aura
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14
Q

Management of acute abdominal migraine

A

Low stimulus environment (quiet, dark room)
Paracetamol
Ibuprofen
Sumatriptan

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15
Q

Medications to prevent abdominal migraine

A

Pizotifen, serotonin agonist
Propanolol
Cyproheptadine: antihistamine
Flunarazine: CCB

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16
Q

Pizotifen for abdominal migraine

A

Main preventative measure
Needs to be withdrawn slowly
Withdrawal symptoms; depression, anxiety, poor sleep and tremor

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17
Q

Secondary causes of constipation

A

Hirschsprung’s disease
CF
Hypothyroidism

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18
Q

Features in history and examination

Constipation

A 
<3 stools/week
Hard stools are difficult to pass 
Rabbit dropping stools 
Straining and passage of stools
Abdominal pain 
Retentive posturing 
Rectal bleeding
Overflow soiling from faecal impaction, incontinence of loose smelly stools 
Hard stools palpable in abdomen 
Loss of sensation of need to open the bowel
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19
Q

Encopresis

A

Faecal incontinence
Not pathological in <4
Chronic constipation-> rectum stretched and lose sensation
Loose stools bypass blockage of hard stools, soiling

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20
Q

Causes of encoparesis

A 
Chronic constipation 
Spina bifida
Hirschsprung’s disease
Cerebral palsy 
Learning disability
Psychosocial stress
Abuse
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21
Q

Lifestyle factors causing constipation

A 
Habitually not opening bowels
Low fibre diet
Poor fluid intake and dehydration
Sedentary lifestyle
Psychosocial problems: safeguarding
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22
Q

Desensitisation of rectum

A 
Develop habit of not opening bowels
Ignore sensation of full rectum 
Over time lose sensation of needing to open bowels 
Open bowels even less frequently 
Retain faeces in rectum 
Faecal impaction
Rectum stretches
Leads to more desensitisation 
Need to treat constipation
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23
Q

Secondary causes of constipation

A 
Hirschsprung’s disease
CF (meconium ileus)
Hypothyroidism
Spinal cord lesions
Sexual abuse
Intestinal obstruction 
Anal stenosis 
Cow’s milk intolerance
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24
Q

Constipation red flags

A

Delayed passing of meconium (>48hrs): CF/ Hirschsprung’s
Neurological signs or symptoms: cerbral palsy, spinal cord lesion
Vomiting; intestinal obstruction, Hirschsprung’s disease
Ribbon stool: anal stenosis
Abnormal anus: anal stenosis, IBD, sexual abuse
Abnormal lower back or buttocks: spina bifida, spinal cord lesion, sacral agenesis
Failure to thrive: coeliac disease, hypothyroidism, safeguarding
Acute severe abdominal pain and bloating; obstruction or intussusception

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25
Q

Complications of constipation

A 
Pain
Reduced sensation
Anal fissures
Haemorrhoids
Overflow and soiling
Psychosocial morbidity
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26
Q

Management of constipation

A

Correct any reversible contributing factors
High fibre and good hydration
Movicol
Disimpaction regimen for faecal impaction With high laxative dose
Encourage and praise visiting toiletry
Scheduling visits, bowel diary, start charts
Long-term laxative and slowly weaned off

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27
Q

GORD

A

Contents from stomach reflux through lower oesophageal sphincter into oesophagus, throat and mouth

Babies have an immature LOS, normal to reflux contents
Should be better by 1 year

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28
Q

Regurgitation

A

Reflux of stomach contents beyond the oesophagus

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29
Q

Epidemiology of GORD

A

Regurgitation and GORD usually appear in the first 2 weeks of life

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30
Q

Why is tone of LOS too low in infants in GORD

Anatomical and physiological features

A

Short, narrow oesophagus
Delayed gastric emptying
Shorter, lower oesophageal sphincter that is slightly above the diaphragm
Liquid diet and high calorie requirement, distending the stomach and increasing pressure gradient between stomach and oesophagus
Larger ratio of gastric volume to oesophageal volume
Spending significant periods recumbent

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31
Q

Risk factors for GORD

A

Prematurity
Parental history of heartburn or acid regurgitation
Obesity
Hiatus hernia
Hx of congenital diaphragmatic hernia (repaired)
Hx of congenital oesophageal atresia
Neurodisability (cerebral palsy)

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32
Q

History of GORD

A

Distressed behaviour: excessive crying, unusual neck posture, back arching
Unexplained feeding difficulties: refusing feeds, gagging, choking
Hoarseness and/or chronic cough in children
Single episode of pneumonia
Faltering growth
Retrosternal/ epigastric pain
Feeding history

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33
Q

Feeding history GORD

A

Position, attachment, technique, duration, frequency, type of milk
Calculate volume of milk being given: can be over-fed and have gastric over-distension
Frequency and volume of vomits
Relationship of symptoms to feeds

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34
Q

Examination of GORD

A

Hydration status
Signs of malnutrition
Abnormalities indicating DD
Assess growth charts

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35
Q

GORD dd

A 
Pyloric stenosis
Intestinal obstruction 
Any acute surgical abdominal issue
Upper GI bleed: haematemesis
Sepsis
RICP
Bacterial gastroenteritis, cows milk protein allergy
Chronic diarrhoea
UTI
If onset >6 months of age or if symptoms persist beyond 1 year then reflux is unlikely
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36
Q

Investigations GORD

A

Not needed to diagnosis
Barium swallow
Ph study
Endoscopy

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37
Q

Causes of vomiting

A 
Over feeding
GORD
Pyloric stenosis
Gastritis or gastroenteritis 
Appendicitis
Infections such as UTI, tonsilitis or meningitis
Intestinal obstruction
Bulimia
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38
Q

Management of GORD if breast fed with frequent regurgitation causing marked distress

A

Self-resolve by 1 year of age

  1. Use alginate (Gaviscon) mixed with water immediately after feeds for 2 week trial
  2. Start PPI or histamine antagonist (e.g. omeprazole or ranitidine)
  3. If symptoms persist refer to paediatrics and reconsider differential diagnosis
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39
Q

Management of GORD in formula-fed with frequent regurgitation causing marked distress

A
  1. Ensure infant isn’t over-Fed (<150ml/kg/day)
  2. Decrease feed volume be increasing frequency (2-3hourly)
  3. Use feed-thickened (or pre-thickened formula)
  4. Stop thickener and start alginate added to formula
  5. Start PPI or histamine antagonist (e.g. omeprazole or ranitidine)
  6. If symptoms persist refer to paediatrics and reconsider differential diagnosis
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40
Q

Red flags for GOR

A

Not keeping down any food: pyloric stenosis or intestinal obstruction
Projectile or forceful vomiting: pyloric stenosis or intestinal obstruction
Bile stained vomit: intestinal obstruction
Haematemesis or malaena: peptic ulcer, oesophagitis or varices
Abdominal distension: intestinal obstruction
Reduced consciousness, building fontanelle, neurological sign: meningitis or RICP
Respiratory symptoms: aspiration and infection
Blood in stools: gastroenteritis or Cows milk protein allergy
Signs of infection: pneumonia, UTI, tonsilitis, otitis, meningitis
Rash, angioedema, signs of allergy: cows milk protein allergy
Apnoea

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41
Q

Simple cases of GORD mx

A

Small, frequent meals
Burping regularly to help milk settle
Not over-feeding
Keep baby upright after feeding

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42
Q

Complex cases of GORD mx

A

Gaviscon mixed with feeds
Thickened milk or formula
Ranitidine
Omeprazole with ranitidine is inadequate

Barium meal
Endoscopy
Fundoplication

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43
Q

Complications of GORD

A

90% will resolve in first year: older, more solid diet, more upright
Reflux oesophagitis
Recurrent aspiration pneumonia
Recurrent acute otitis media (>3 episodes in 6 months)
Dental erosion (children with neuro disability)

Apnoea
Apparent life-threatening events: apnoea, colour change, change in muscle tone, choking and gagging

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44
Q

Sandifers syndrome

A

Brief episodes of abnormal movements
Associated with GORD in infants
Infants usually neurologically normal

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45
Q

Key features of sandifers syndrome

A

Torticolis: forceful contraction of neck muscles causes twisting of neck
Dystonia: abnormal muscle movements causing twisting movements, arching of back or unusual postures

Self-resolves
DD: infantile spasms and seizures

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46
Q

Epidemiology of gastroenteritis

A

Common isolates: Rotavirus and Campylobacter

Adenovirus, respiratory infections

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47
Q

Acute gastroenteritis

A

Inflammation of stomach and intestines

Main concern is dehydration

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48
Q

Viral causes of gastroenteritis

A

Rotavirus
Norovirus
Adenovirus (less common), more subacute diarrhoea

Highly contagious

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49
Q

When to consider Differential diagnosis of gastroenteritis

A 
Temperature >38 if <3months 
Temperature >39 of >3 months
Breathlessness or tachypnoea
Altered GCS
Blood/ mucous in stool
Bilious vomit
Severe/ localised abdominal pain
Abdominal distension or guarding
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50
Q

Differential diagnosis of diarrhoea

A 
Infection
IBD
Lactose intolerance
Coeliac disease
CF
Toddlers diarrhoea
IBS
Medications
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51
Q

Rotavirus gastroenteritis

A

Most common cause
<5 years
Uncommon in adults, vaccine given at 8 and 12 weeks
Faecal oral route or by environmental contamination
Incidence peaks over winter months

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52
Q

Norovirus gastroenteritis

A

Single stranded RNA viruses
Commonest cause of gastroenteritis in all age groups
Faecal oral contamination and environmental contamination

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53
Q

Adenovirus gastroenteritis

A

Infections of respiratory system

<2 years

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54
Q

E.coli for gastroenteritis

A

Most strains are harmless
VTEC E.coli 0157:H7 can cause haemorrhagic colitis and haemolytic uraemic syndrome
Spread through contaminated food, person-to-person contact, contact with infected animals

E.coli 0157 produces the Shiga toxin

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55
Q

Shiga toxin

A 
Produced by Ecoli 0157
Abdominal cramps 
Bloody diarrhoea
Vomiting
Shiga toxin: destroys blood cells and leads to HUS, ax increases this risk
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56
Q

Campylobacter jejuni

A

Travellers diarrhoea
Most common cause of bacterial gastroenteritis in the UK
Gram negative bacteria: curved or spiral shape

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57
Q

Campylobacter transmission

A

Raw or improperly cooked poultry
Untreated water
Unpasteurised milk

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58
Q

Campylobacter incubation

A

2-5 days

Symptoms resolve after 3-6days

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59
Q

Campylobacter symptoms

A

Abdominal cramps
Diarrhoea, often with blood
Vomiting
Fever

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60
Q

Campylobacter management

A

Severe symptoms
Other risk factors: HIV, heart failure
Azithromycin, ciprofloxacin

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61
Q

Clinical features of gastroenteritis

A

Sudden onset of loose/ watery stool with/without vomiting
Abdominal pain/crams
Mild fever
Recent contact with someone with diarrhoea or vomiting

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62
Q

Which diarrhoea children are more at risk of dehydration

A

Young children <6 months
Children who have passed >5 diarrhoea stools in last 24hrs
Children who have vomited >2x in last 24 hrs
Children who have stopped breast feeding during illness

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63
Q

Symptoms of dehydration

A 
Appears to be unwell or deteriorating
Altered responsiveness 
Decreased urine output
Skin colour unchanged
Warm extremities
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64
Q

Symptom of shock

A 
Decreased level of consciousness
Pale or mottled skin
Cold extremities
Decreased urine output
Appears to be unwell or deteriorating
65
Q

Signs of clinical dehydration

A 
Altered responsiveness 
Skin colour unchanged
Warm extremities 
Sunken eyes
Dry mucous membranes 
Tachycardia
Tachypnoea
Normal, peripheral pulses
Normal CRT
Reduced skin turgor
Normal blood pressure
66
Q

Signs of clinical shock

A 
Decreased level of consciousness
Pale or mottled skin
Cold extremities 
Sunken eyes
Dry mucous membranes
Tachycardia
Tachypnoea
Weak peripheral pulses
Prolonged CRT
Reduced skin Turgor
Hypotension
67
Q

Investigations for gastroenteritis

A

Stool sample if:
Septicaemia suspected
Blood and/or mucus in stool
Immunocompromised child

Measure Na, K, Cr, Ur and glucose if:
IV fluids are going to be used
Symptoms/signs of hypernatraemia (jittery, increased muscle tone, hyperreflexia, convulsions, drowsiness or coma)

Measure acid-base status
Chloride concentration
Shock

68
Q

Management of gastroenteritis

Immediate if not clinically dehydrated

A

Continue breast feeding/ other milk feeds
Encourage fluid intake
Discourage fruit juices and carbonated drinks
Oral rehydration salt solution as supplemental fluid to those at risk of dehydration

69
Q

Management of gastroenteritis

Immediate if dehydrated

A

Use IV therapy if shock is suspected, red flags, evidence of dehydration, vomiting persistently

Oral therapy:
ORS solution: 50mL/kg over 4 hours
Plus maintenance fluid
If child is refusing oral fluid, consider NG tube

70
Q 
Maintenance fluid calculation
Childs weight
0-10kg
10-20kg
>20kg
A

0-10kg: 100ml/kg/day
10-20kg: requirement for first 10kg + 50mL/kg/day
>20kg: requirement for first 20kg (1500ml) + 20ml/kg/day

71
Q

Following rehydration after gastroenteritis

A

Advise parents to give full strength milk straight away
Slowly re-introduce the child’s solid food
Suggest that fruit juices and carbonated drinks are avoided until the diarrhoea has resolved
Advice on hand washing and avoiding towel sharing
Wait 48hours since last D/V before school
Child shouldn’t swim for 2 weeks after last episode

72
Q

Complications of gastroenteritis

A

Haemolytic uraemic syndrome
Reactive complications with bacterial gastroenteritis
Toxic mega colon
Acquired/ secondary lactose intolerance

Diarrhoea lasts 5-7 days
Vomiting lasts 1-2 days

73
Q

Haemolytic uraemic syndrome (HUS)

A

Rare but serious complication of acute infectious gastroenteritis that occurs mostly in young children and the elderly.
This can be a life-threatening complication causing:
acute renal failure,
haemolytic anaemia

74
Q

Reactive complications of bacterial gastroenteritis

A

Including arthritis, carditis, urticaria, erythema nodosum and conjunctivitis.
REMEMBER: Reiter’s syndrome (the combination of urethritis, arthritis, and uveitis).

75
Q

Toxic mega colon

A

Rare but significant complication of rotavirus gastroenteritis

76
Q

Acquired /secondary lactose intolerance

A

Occurs due to the lining of the intestine being damaged.
Leads to symptoms of bloating, abdominal pain, wind and watery stools after drinking milk.
Improves when infection resolves and gut lining heals (5).
Gastroenteritis complication

77
Q

Shigella gastroenteritis

A

Spread by faces contaminated drinking water, swimming pools and food
Incubation: 1-2days
Symptoms resolve within 1 weeks without treatment
Causes bloody diarrhoea, abdominal cramps and fever
Shiga toxin: HUS
Mx: azithromycin or ciprofloxacin

78
Q

Salmonella gastroenteritis

A

Transmission: raw eggs, poultry, faeco-oral
Incubation: 12hrs-3days, symptoms resolve at 1week
Watery diarrhoea associated with mucus or blood, abdominal pain and vomiting
Ax: stool culture and sensitivities

79
Q

Bacillus cereus gastroenteritis

A 
Gram positive rod
Spread through inadequately cooked food 
Fried rice left out at room temperature
Produces toxin:: cereulide
Vomiting within 5 hours, diarrhoea within 8 hours, resolution within 24hours
80
Q

Cereulide

A

Produced by bacillus cereus
Within 5 hours of ingestion: Causes abdominal cramping and vomiting
8 hours after ingestion: Produces toxins in intestine, watery diarrhoea
Usually all symptoms resolve within 24hours

81
Q

Yersinia enterocolitis

A

Gram negative bacillus
Pigs, raw or uncooked pork can cause infection
Also spread through contamination with urine or faeces of other mammals, such as rats and rabbits

82
Q

Yersinia clinical presentation

A

Most frequently affects children
Watery or blood diarrhoea, abdominal pain, fever and lymphadenopathy
Incubation 4-7days, illness can last longer that other causes of enteritis
Symptoms lasting 3 week or more
Older children: can present with fever and right sided abdominal pain due to Mesenteric lymphadenitis
Impression of appendicitis

83
Q

Staphylococcus aureus toxin

A

S.aureus produces enterotoxin when growing on eggs, dairy and meat
Small intestine inflammation
Symptoms: diarrhoea, perfuse vomiting, abdominal cramps and fever
Symptoms start within hours of ingestion
Settle within 12-24hours
Enterotoxin causes enteritis

84
Q

Giardiasis

A 
Giardia lambia
Parasite
Small intestines of mammals 
Releases cysts, Falcon oral 
Diagnosis with stool microscopy
Metronidazole
85
Q

Principles of gastroenteritis management

A

Good hygiene
Isolate patients
Barrier nursing and rigorous infection control
No school for 48hrs after symptoms have resolved
Faecal sample: microscopy, culture and sensitivities
Attempt fluid challenged
Diorylate rehdration fluid

86
Q

Complications post-gastroenteritis

A

Lactose intolerance
IBS
Reactive arthritis
Guillian-Barre syndrome

87
Q

Coeliac disease

A

Autoimmune condition
Gluten causes an immune response
And inflammation in small intestine
Usually develops in childhood

88
Q

Pathophysiology of coeliac disease

A

Immunological response (antibodies) to gliadin in gluten
Antibodies: anti-TTG, anti-EMA
Genetic factors (HLA-DQ2/DQ8)
Antibodies target epithelial cells, damage villi of small intestine
Lead to inflammation and Malabsorption
Epithelial cell destruction and villous atrophy

T-cell mediated immune disorder
Development of inflammatory anti-gluten CD4 T-cell response, anti-gluten ab, autoantibodies against tissue transglutaminase, endomysium, activation of intraepithelial lymhphocytes

89
Q

Risk factors coeliac disease

A 
Wheat, barley, rye
Bread, beer, squash, biscuits, cereal, cake, pasta, pies
TY1 diabetes
Down syndrome
Turner syndrome
Thyroid disease, RA, Addison’s disease 
HLA-DQ2 gene
90
Q

Classic coeliac presentation

A 
9-24months presentation
Malabsorption 
Failur yo thrive
Diarrhoea 
Steatorrhea
Anorexia
Abdominal pain
Abdominal distension
Muscle waste
Crypt hyperplasia and villous atrophy on histology 
Mouth ulcers
Anaemia
91
Q

Coeliac disease neurological symptoms

A

Rare
Peripheral neuropathy
Cerebellar ataxia
Epilepsy

92
Q

Extra-intestinal symptoms coeliac

A 
Dermatitis herpetiformis
Dental enamel Hypoplasia
Osteoporosis
Short stature
Iron-deficient anaemia- resistant to oral Fe
Liver and biliary tract disease
Arthritis
Peripheral neuropathy, epilepsy, ataxia
93
Q

DD coeliac

A 
Tropical spruce
CF
IBD
Post-gastroenteritis
Autoimmune encephalopathy
Eosinophilic enteritis
94
Q

Genetic associations coeliac

A

HLA-DQ2

HLA-DQ8

95
Q

Coeliac autoantibodies

A

Anti-TTG: tissue transglutaminase antibodies
EMAs: endomysial antibodies
Anti-DGPs: deaminated gliadin peptides antibodies

Also check IgA deficiency

96
Q

Diagnosis coeliac

A

Need patient having gluten in diet, 6 weeks before testing
IgA TOTAL
IgA TTG
IgA EMA
Avoid HLA DQ2/8 testing
Endoscopic intestinal biopsy if serology positive
Duodenal biopsy

97
Q

Duodenal biopsy coeliac disease

A

Crypt hypertrophy

Villous atrophy

98
Q

Management of coeliac

A

Lifelong diet free of gluten
Iron supplements
Annual follow up: compliance, development, growth and long-term complications

99
Q

Complications coeliac

A 
Vitamin deficiency
Anaemia
Osteoporosis
Refractory coeliac, need steroid treatment
Malignancy: Non-Hodkin lymphoma 
Ulcerative jejunitis
Fertility problems
Depression/ anxiety
Enteropathic-associated T-cell lymphoma of the intestine
Small bowel adenocarcinoma
100
Q

Crohn’s disease

A 
Crows NESTS
No blood or mucus
Entire GI tract
Skip lesions on endoscopy
Terminal ileum most affected and transmural inflammaiton
Smoking is a risk factor

Also weight loss, strictures, fistula

101
Q

Ulcerative colitis

A 
U-C-CLOSEUP
Continuous inflammation
Limited to colon and rectum
Only superficial mucosa affected
Smoking is protective
Excrete blood and mucus
Use aminosalicylates
Primary sclerosing cholangitis
102
Q

Presentation of IBD

A 
Diarrhoea
Abdominal pain
Bleeding
Weight loss
Anemia 
Systemically unwell during flares, fever, malaise, dehydration
103
Q

Extra-intestinal manifestations IBD

A 
Finger clubbing
Erythema nodosum
Pyoderma gangrenosum
Episcleritis and iritis
Inflammatory arthritis
Primary sclerosing cholangitis (UC)
104
Q

IBD testing

A

Blood tests for: anaemia, infection, thyroid, kidney, liver function
Raised CRP: indicates active inflammation
Faecal calprotectin: released by intestines when inflamed
Endoscopy (OGD and colonoscopy) with biopsy is Gold-standard
Imaging with US, CT, MRI: look for fistula, abscesses, strictures

105
Q

General management IBD

A

MDT
Monitor growth and pubertal development, especially for exacerbations or when treated with steroids
Inducing remission during flares
Maintaining remission

106
Q

Inducing remission Crohn’s

A

Steroids: oral prednisolone,v IV hydrocortisone
Enteral nutrition to improve gut microbiome
Azathioprine
Mercaptopurine
Methotrexate
Infliximab
Adalimumab

107
Q

Maintaining remission Crohn’s

A

First line: azathioprine, mercaptopurine

Alternatives: methotrexate, infliximab, adalimumab

108
Q

Surgery for Crohn’s

A

Surgically resect distal ileum

Surgery to treat strictures and fistula

109
Q

Inducing remission in ulcerative colitis

Mild/moderate disease

A

First line: aminosalicylate (e.g. mesalazine oral or rectal)

Second line: corticosteroids (e.g. prednisolone)

110
Q

Inducing remission in ulcerative colitis

Severe disease

A

First line: IV corticosteroids (e.g. hydrocortisone)

Second line: IV cyclosporin

111
Q

UC maintaining remission

A

Aminosalicylate (e.g. mesalazine)
Azathioprine
Mercaptopurine

112
Q

Surgery UC

A

Remove colon and rectum (panproctocolectomy)
Patient left with permanent ileostomy or ileo-anal anastomosis (J-pouch)
J-pouch collects stools prior to patient passing motions

113
Q

Cows milk protein allergy

A

Immune-mediated allergic response to naturally-occurring milk proteins casein and whey.

114
Q

Pathophysiology of Cow’s milk protein allergy

A

IgE mediated: TY1 hypersensitivity reactions, histamine and cytokines released from mast cells and basophils

Non-IgE-mediated: involves T cell activation against cows milk protein

115
Q

Risk factors CMPA

A

Personal history of atopy (eg. asthma, eczema, allergic rhinitis, other food allergies)

Family history of atopy (only allergic predisposition is inherited, not specific allergies)

116
Q

IgE mediated cows milk protein allergy

A 
Acute and frequently rapid onset
Pruritis
Erythema
Acute urticaria
Angio-oedema 
Oral pruritis
Nausea
Colicky abdominal pain
V/D
LRT symptoms: cough, chest tightness, wheezing, SoB
URT symptoms: nasal itching, sneezing, rhinorrhea, congestion
117
Q

Non-IgE mediated CMPA

A 
Non-acute and generally delayed onset
Pruritis
Erythema
Atopic eczema
GORD
Loos or frequent stools
Blood/mucus in stools
Abdominal pain
Infantile colic
Food refusal or aversion
Constipation
Perianal redness
Pallor/tiredness 
Faltering growth
LRI symptoms: cough, chest tightness, wheezing, SoB
118
Q

CMPA history

A 
Personal and family history of atopy
Diet and feeding history of infant
Mother’s diet if breastfed
Any previous management used for symptoms
Which milk/foods
Age of onset
Speed of onset following exposure
Duration
Severity and frequency of occurrence
Setting of reaction
Reproducibility of symptoms
119
Q

CMPA examination

A

General physical examination of patient with a focused gastrointestinal examination, specifically signs of malnutrition.

Review growth charts

Signs of atopic comorbidities such as asthma, eczema, allergic rhinitis.

120
Q

DD CMPA

A

Food intolerance (eg. lactose) may present as abdominal pain and diarrhoea following exposure to certain foodstuffs
Allergic reaction to other food or non-food allergens
Anatomical abnormalities such as Meckel’s diverticulum
Chronic gastrointestinal disease (e.g. gastro-oesophageal reflux disease, coeliac disease, inflammatory bowel disease, constipation, gastroenteritis)
Pancreatic insufficiency (eg. as a complication of cystic fibrosis)
Urinary tract infections

121
Q

Investigations CMPA

A

RAST-radioallegosorbent test: looks for IgE antibodies

Non-IgE CMPA is clinically diagnosis diagnosed

Check for iron deficiency anaemia

122
Q

Mx CMPA

A 
Avoidance of Cow’s milk for 6 months until infant is 9-12months
MAP guidance milk ladder
Nutritional counselling
Extensively hydrolysed formula 
Amino acid formula
123
Q

Complications of CMPA

A

Malabsorption

Reduced intake

124
Q

When to suspect spontaneous bacterial peritonitis

A

Undiagnosed fever
Abdominal pain
Tenderness
Unexplained deterioration in hepatic/renal function

125
Q

How to diagnose bacterial peritonitis

A

Diagnostic paracentesis

Send fluid for WCC, differential and culture

126
Q

How to treat bacterial peritonitis

A

Broad spectrum antibiotics

127
Q

Clinical feature of viral hepatitis

A 
Nausea
Vomiting
Abdominal pain
Lethargy
Jaundice
Hepatomegaly 
Splenomegaly 
ALT/AST elevated
Coagulation normal
128
Q

Hepatitis A

A

RNAvirus
Faeco-oral transmission
Vaccination for travellers to endemic areas

129
Q

Clinical features of HepA

A 
May be asymptomatic 
Majority have mild illness, 2-4weeks
Prolonged cholestatic hepatitis (self-limiting)
Fulminant hepatitis 
No chronic liver disease
130
Q

HepA diagnosis

A

Detect IgM antibody to virus

131
Q

HepA Mx

A

No treatment
Vaccinate close contacts within 2 weeks of illness onset
At risk (CLD), giving human normal immunoglobulin

132
Q

HepB

A

DNA virus

Sub-Saharan Africa and Far East

133
Q

HepB transmission

A

Sexually
Blood
Perinatal, horizontal spread: infants become chronic carriers

134
Q

Clinical features HepB

A

Infants who contract perinatally are asymptomatic chronic carriers
Classic features of hepatitis or asymptomatic
Small chance of developing hepatic failure

135
Q

HepB diagnosis

A

Detect HBV antigens and antibodies
IgM antibodies (anti-HBc) are positive in acute infection
Hepatitis B surface Antigen (HBsAg) denotes ongoing infectivity

136
Q

HepB mx

A

No treatment for acute HBV infection

137
Q

Chronic HepB

A

Asymptomatic carrier children-> chronic HBV liver disease
Progress to cirrhosis
Risk of hepatocellular carcinoma

138
Q

Management of chronic HepB

A

Interferon
Pegylated interferon
>2s: entecacir, tenofovir

139
Q

Prevention of chronic HepB

A

Immunisation
Screen pregnant women for HBsAg: if +ve give infant additional vaccine doses at birth
HBeAg+ve: give infant HepB Ig after birth

140
Q

Hepatitis C

A

RNA virus
Post-transfusion hepatitis
IVDU

141
Q

HepC transmission

A

Vertical transmission
Transmission more common if HIV+ve
Majority becom,e chronic carriers

142
Q

HepC clinical features

A

Chronic carriers

Can progress to cirrhosis or hepatocelllar carcinoma

143
Q

HepC Mx

A

Sofosbuvir
Ledipasvir
Treatment not indicated ~<3years, may resolve spontaneously

144
Q

HepD

A

RNA virus
Depends on HepB for replication
Superinfection
Cirrhosis occurs in chronic HDV infection

145
Q

HepE virus

A

RNA virus

Low-income countries

146
Q

HepE transmission

A

Enterally, contaminated water
Mild self-limiting illness
Blood transfusion
Infected pork

147
Q

HepE presentation

A

Fulminant hepatic failure in pregnant wo en

High mortality rate

148
Q

Acute liver failure (fulminant hepatitis)

A

Development of massive hepatic necrosis
Loss of liver function
With/without hepatic encephalopathy
High mortality

149
Q

Presentation acute liver failure (fulminant hepatitis)

A

Preceding infection/ metabolic condition
Hours/weeks later with jaundice, encephalopathy, coagulopathy, hypoglycaemia, electrolyte disturbance
Early signs of encephalopathy: irritability/ confusion with drowsiness
Older children may be aggressive and difficult

150
Q

Complications of acute liver failre

A 
Cerebral oedema
Haemorrhage from gastritis
Coagulopathy
Sepsis
Pancreatitis
151
Q

Causes of acute liver failure in <2

A 
Infection (herpes simplex)
Metabolic disease
Sero negative hepatitis 
Drug-induced
Gestational alloimmune liver disease
152
Q

Children >2years causes of acute liver failure

A 
Sero-negative hepatitis
Paracetamol overdose
Mitochondrial disease
Wilson disease
Autoimmune disease
153
Q

Diagnosis of acute liver failure

A 
Elevated transaminases
Alkaline phosphatase is increased
Coagulation is very abnormal 
Plasma ammonium is elevated 
Monitor acid-base balance
Blood glucose
Coagulation times
EEG: acute hepatic encephalopathy 
CT: cerebral oedema
154
Q

Management of acute liver failure

A

Refer to national paediatric liver centre
Maintain blood glucose >4mmol/L
Prevent sepsis: Ax, antifungal
Prevent haemorrhage with IV vitK, and PPI, H2 antagonists
Prevent cerebral oedema with fluid restriction and mannitol diuresis if oedema develo[s

155
Q

Features suggestive of poor prognosis in acute liver failure

A 
Shrinking liver
Rising bilirubin
Failing transaminases
Worsening coagulopathy
Progression to coma
Liver transplantation needed
156
Q

Peptic ulcer diseae

A

Duodenal ulcers uncommon in children

157
Q

When to consider peptic ulcers

A

Epigastric pain
Wakes them at night
Pain radiating to back
FH of peptic ulceration

158
Q

Diagnosis of peptic ulcer disease

A

Gastric biopsy on endoscopy for H.pylori
Carbon 13 breath test, detects urea s produced
Stool antigen tests for H.pylori

159
Q

Management of peptic ulcer disease in children

A

PPI: omeprazole

Antibiotics if H.pylori

Child Health (20 decks)

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