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Yr4: Child Health > Gastroenterology > Flashcards

Gastroenterology Flashcards

1
Q

Abdominal pain can be split into medical causes, surgical causes and non-organic/functional causes; state some medical causes

A
  • Constipation
  • Coeliac disease
  • IBD
  • IBS
  • Mesenteric adenitis
  • Abdominal migraine
  • UTI
  • Pyelonephritis
  • DKA
  • Henoch-Schonlein purpura
  • Infantile colic
  • Tonsillitis

Additional causes in adolescent girls….

  • Dysmenorrhea
  • Mittelschmerz (ovulation pain)
  • Ectopic pregnancy
  • PID
  • Ovarian torsion
  • Pregnancy
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2
Q

Abdominal pain can be split into medical causes, surgical causes and non-organic/functional causes; state some surgical causes

A
  • Appendicitis
  • Intussusception (colicky, non-specific, redcurrant jelly stools)
  • Bowel obstruction (pain, distension, absolute constipation, vomiting)
  • Testicular torsion (sudden onset, unilateral testicular pain, N&V)
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3
Q

Abdominal pain can be split into medical causes, surgical causes and non-organic/functional causes. What is non-organic/functional abdominal pain?

A
  • No disease process/underlying pathology can be found to explain abdominal pain
  • Common children >5yrs
  • Often corresponds to stressful life events
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4
Q

State some red flags for abdominal pain in children

A
  • Persistent or bilious vomiting
  • Severe chronic diarrhoea
  • Rectal bleeding
  • Weight loss or faltering growth
  • Dysphagia
  • Nighttime pain
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5
Q

State some initial investigations you may do for a child with abdominal pain

A
  • Urine dipstick (for UTI)
  • Faecal calprotectin (for IBD)
  • FBC (anaemia in IBD or coeliac)
  • CRP/ESR (for IBD)
  • Anti-TTG or anti-EMA (for coeliac)
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6
Q

For recurrent abdominal pain, discuss:

  • What it is
  • Triggers/associations
  • Management
A
  • Repeated episodes of abdominal pain with no identifiable cause (pain is non-organic/functional). Thought that is is due to increased sensitivity & inappropriate signals from visceral nerves in gut
  • Often associated with stressful life events e.g. bullying, bereavement
  • Management:
    • Education & reassurance
    • Encourage parents not to ask about or focus on pain
    • Distract child from pain
    • Advice about sleep, healthy eating, hydration, exercise, reducing stress
    • Address any psychosocial triggers/factors
    • Support from school counsellor or child psychologist
    • Avoid NSAIDs
    • Probiotic supplements for IBS symptoms
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7
Q

What are abdominal migraines/how do they present?

A

Episodes of central abdo pain lasting >1hr, may have similar triggers to head migraines, which may be associated with:

  • Nausea & vomiting
  • Headache
  • Photophobia
  • Aura
  • Pallor
  • Anorexia
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8
Q

How often should children open their bowels?

A

Normal stool frequency in children ranges from an average of four per day in the first week of life to two per day at 1 year of age. Passing between three stools per day and three per week is usually attained by 4 years of age.

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9
Q

Discuss the management of abdominal migraines, consider:

  • Management of an acute attack
  • Preventative management
A

Acute attack

  • Low stimulus environment
  • Paracetamol
  • Ibuprofen
  • Sumatriptan (NASAL, PO not licensed in children)

Preventative medications must be started by specialist

  • Pizotifen (serotonin agonist)
  • Propanolol
  • Cyproheptadine (antihistamine)
  • Flunarazine (calcium channel blocker)

*Pizotifen= main preventative medication. Must be withdrawn slowly due to withdrawal symptoms (depression, anxiety, poor sleep, tremor)

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10
Q

Most cases of paediatric constipation are idiopathic/functional (no underlying cause found other than simple lifestyle factors); however, sometimes it may be secondary to another condition. State some secondary causes of constipation (not including lifestyle factors)

A
  • Hirschsprung’s disease
  • Hypothyroidism
  • Cystic fibrosis
  • Hypercalcaemia
  • Learning disabilites
  • Anal fissure
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11
Q

State some typical features in history & examination that suggest constipation

A
  • <3 stools a week
  • Hard stools
  • Stools difficult to pass- straining, painful
  • ‘Rabbit droppings’
  • Abdominal pain
  • Retentive posturing (posture to avoid passing stool- typically straight legs, on tip toes with arched back)
  • Rectal bleeding associated with hard stools
  • Overflow soiling (encopresis= faecal incontinence)
  • Hard stools palpable in abdomen
  • Loss of sensation of need to open bowels
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12
Q

What 3 symptoms/signs indicate faecal impaction?

A
  • Symptoms of severe constipation
  • Overflow soiling
  • Faecal mass palpable in abdomen (only specialists should do DRE)
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13
Q

Describe how desensitisation of rectum and encoperesis develop

A
  • Develop habit of not opening their bowels when need to or ignore sensation of full rectum
  • Stretches rectum
  • Lose sensation
  • Open bowels less frequently
  • Retain faeces in rectum
  • Faecal impaction
  • … vicious cycle
  • Only lose stools are able to bypass blockage and leak out leading to encopresis
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14
Q

State some red flags in a constipation history

A

If red flags present must refer urgently to specialist:

  • Not passed meconium
  • Neurological signs or symptoms- particularly lower limbs (may be cerebral palsy or spinal cord lesion)
  • Vomiting (intestinal obstruction or hirschsprungs)
  • Ribbon stool (anal stenosis)
  • Abnormal anus (anal stenosis, IBD, sexual abuse)
  • Abnormal lower back or buttocks
  • Acute severe abdominal pain & distension (obstruction or intussusception)

*NOTE: failure to thrive (coeliac, hypothyroidism) is an amber flag as is constipation triggered by introduction of cows milk and concerns about possibility of child maltreatment

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15
Q

Does functional constipation require any investigations?

A

As long as have ruled out red flags, then can make diagnosis of idiopathic or functional constipation based on history.

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16
Q

Discuss the management of functional & idiopathic constipation

A
  • Advise on diet: high fibre & plenty of fluids
  • Advise regular exercise
  • Encourage & praise for using toilet e.g. have scheduled visits, keep a bowel diary, toileting reward charts (e.g. ERIC toilet tool)
  • Laxatives
    • First line= movicol
    • Second line= add stimulant e.g. senna, picosulphate
    • Others e.g. lactulose, docusate if stool is hard
    • Continue then gradually reduce once regular bowel habits established
  • Faecal impaction may require disimpaction regimen (with increasing doses of laxatives over a period of 7-10 days)

*NOTE: don’t just give lifestyle advice on it’s own

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17
Q

State some potential complications of constipation

A
  • Pain
  • Anal fissures
  • Haemorrhoids
  • Reduced sensation in rectum
  • Overflow & soiling
  • Rectal prolapse
  • Megarectum
  • Distress for child & family (discomfort, missed school, social isolation etc…)
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18
Q

Summary of NICE guidance for diagnosing constipation in children

A
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19
Q

It is normal for babies to reflux feeds; true or false?

A

TRUE: their lower oesophageal sphincter is immature hence allows stomach contents to easily reflux into oesophagus,(and throat and mouth). Provided they are growing and well it is not a problem. It is called GOR if it is asymptomatic. It is called GORD if it is symptomatic or there are complications. 90% stop refluxing by 1yr of age.

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20
Q

What is posseting?

A

Most reflux is swallowed back into the stomach, but occasionally babies will vomit it out of their mouth (which is sometimes called posseting or regurgitation.

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21
Q

State some risk factors for GORD

A
  • Prematurity
  • Obesity
  • FH of GORD
  • Hiatus hernia
  • Neurodisability (e.g. cerebral palsy)
  • History of repaired diaphragmatic hernia
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22
Q

State some signs of problematic reflux in infants

A
  • Distress or unsettled after feeding
  • Reluctance to feed
  • Poor weight gain
  • Hoarse cry
  • Chronic cough
  • Pneumonia

Children >1yr may experience similar symptoms to adults (retrosternal, epigastric pain, bloating, nocturnal cough)

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23
Q

Discuss the management of GORD- consider differences for breast fed and formula fed babies, children >1yrs and severe cases

A
  • General advice:
    • Small, frequent meals
    • Burp/wind regularly
    • Don’t overfeed
    • Feed with head at 30 degrees
    • Keep baby upright after feeding

Breast fed

  1. 1-2 week trial of gaviscon (mixed with water after feed)
  2. If successful continue treatment but stop every 2 weeks to see if symptoms improve and treatment can be stopped
  3. If unsucessful, 4 week trial or omeprazole or ranitidine

Formula fed (1-2 week trial of each of the following)

  1. Reducing feeds (shouldn’t have more than 150ml/kg/day)
  2. Decrease feed volume each sitting and increase frequency of feeds
  3. Thickened feeds (thickener or pre-thickened formula e.g. carobel)
  4. Stop thickener and add alginate to formula
  5. If unsuccessful, 4 week trial omeprazole or ranitidine

Children >1yrs/not breast or formula fed and still experiencing GORD

  • 4 week trial omeprazole or ranitidine

Severe cases

  • Surgical fundoplication
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24
Q

State some potential complications of GORD in infants

A
  • Aspiration leading to pneumonia
  • Failure to thrive
  • Frequent otitis media
  • Dental erosion in older children
  • Apnoea (rare)
25
Q

What is coeliac disease?

Remind yourself of the pathophysiology

A
  • Autoimmune reaction to the gliadin fraction of gluten
  • The antibodies, anti-tissue transglutaminase (anti-TTG) and anti-endomysial (anti-EMA), target the epithelial cells of the intestine causing inflammation
  • Inflammation mainly affects small bowel- particularly jejunum
  • Causes atrophy of intestinal villi leading to malabsorption and symptoms
26
Q

State some conditions associated with coeliac disease

A
  • T1DM
  • Thyroid disease
  • Autoimmune hepatitis
  • Primary biliary cirrhosis
  • Primary sclerosing cholangitis
  • Down’s syndrome
27
Q

Coeliac disease is often asymptomatic so must have low threshold for testing. If symptomatic, state some potential symptoms

A
  • Failure to thrive
  • Diarrhoea
  • Abdominal distension
  • Mouth ulcers
  • Fatigue
  • Weight loss
  • Anaemia (secondary to Fe, B12 or folate deficiency)
  • Dermatitis herpetiformis (itchy, blistering skin rash typically on abdomen)
  • Neurological symptoms (e.g. peripheral neuropathy, cerebellar ataxia, epilepsy- RARE)
28
Q

How do we diagnose coeliac disease?

A

Investigations must be done while patient is eating gluten:

  • Antibodies (must check total IgA levels to exclude IgA deficiency as both anti-TTG and anti-EMA are IgA):
    • First line: anti-tissue transglutaminase
    • Anti-endomysial antibodies
    • If IgA deficient, test for IgG version of the above or IgG deamidated gliadin peptide antibodies (anti-DGPs)
  • If serology positive do duodenal biopsy (=GOLD STANDARD)
29
Q

Antibodies, anti-TTG and anti-EMA, correlate with disease activity in coeliac disease; true or false?

A

True; rise in more active disease

30
Q

We always test for coeliac disease when we diagnose what other endocrine autoimmune condition?

A

T1DM

31
Q

What two genes is coeliac disease strongly associated with?

A

HLA-DQ2 (95%)

HLA-DQ8 (80%)

32
Q

What findings, on duodenal or jejunal biopsy, would support diagnosis of coeliac disease

A
  • Villous atrophy
  • Crypt hyperplasia
  • Increase in intraepithelial lymphocytes
  • Lamina propria infiltrated with lymphocytes
33
Q

Discuss the management of coeliac disease

A
  • Life long gluten free diet
  • Immunisations (due to hyposplenism. Offer pneumococcal to all and give influenza on individual basis)
34
Q

State some complications of untreated coeliac disease

A
  • Vitamin deficiency
  • Hyposplenism
  • Anaemia
  • Osteoporosis
  • Subfertility
  • Enteropathy associated T-cell lymphoma (EATL) of the intestine
  • Non-Hodgkin lymphoma
  • Small bowel adenocarcinoma (rare)
35
Q

Compare and contrast Crohn’s and UC in terms of:

  • Symptoms
  • Extra-intestinal symptoms
  • Complications
  • Pathology
  • Histology
  • Endoscopy
  • Radiological findings
A
36
Q

Another summary of symptoms for Crohn’s & UC

A
37
Q

State some potential extra-intestinal features of IBD

A
  • Erythema nodosum
  • Pyoderma gangrenosum
  • Episcleritis & iritis
  • Inflammatory arthritis
  • Finger clubbing
  • PSC (UC)
38
Q

What investigations would you do if you suspected IBD?

A

Bedside

  • Stool culture
  • Faecal calprotectin

Bloods

  • FBC: anaemia
  • LFTs: hepatitis
  • U&Es: renal func
  • CRP: raised
  • ESR: raised
  • Ferritin, TIBC, transferrin saturation: Fe deficiency
  • B12
  • Folate

Imaging

  • Endoscopy (OGD & colonscopy) with biopsy = GOLD STANDARD
  • MRI: look for complications e.g. fistulas, abscesses
  • CT: look for complications e.g. fistulas, abscesses
  • Ultrasound: look for complications e.g. fistulas, abscesses
39
Q

Discuss the general management for both Crohn’s and UC

A
  • MDT management (paediatrician, specialist nurse, dieticians, surgeons)
  • Monitor growth & pubertal development
  • Education
40
Q

Discuss the management of crohn’s, include:

  • Inducing remission
  • Maintaining remission
  • Surgical
A

DON’T SMOKE

Inducing remission

  • First line= enteral feeds/liquid diet
  • Second line= steroids (e.g. oral predniosolone or IV hydrocortisone)
  • Immunosuppressant e.g. azathioprine, mercaptopurine, methotrexate
  • Biologics e.g. infliximab, adalimumab, vedolizumab, ustekinumab

Maintaining remission

  • First line= azathioprine, mercaptopurine
  • Alternatives= methotrexate, infliximab, adalimumab, vedolizumab, ustekinumab

Surgical

  • Surgery for strictures, fistulas, perianal disease
  • Surgery to remove part of bowel
41
Q

State some potential complications of crohn’s disease

A
  • Small bowel cancer
  • Colorectal cancer
  • Osteoporosis
42
Q

Discuss the management of ulcerative colitis, include:

  • Inducing remission
  • Maintaining remission
  • Surgical
A

Inducing remission

  • Mild to moderate disease:
    • First line drug= aminosalicyclate (e.g. mesalazine oral or rectal)
    • Second line= corticosteroids
  • Severe disease
    • First line= IV corticosteroids (e.g. hydrocortisone)
    • Second line= IV ciclosporin

Maintaining remission

  • Aminosalicyclate
  • Aazthioprine
  • Mercaptopurine

Surgery

  • Panproctocolecotmy will remove the disease; either leave with permanent ileostomy or an ileo-anal anastomosis (J-pouch)
43
Q

State some potential complications of ulcerative colitis

A
  • Toxic megacolon
  • Colorectal carcinoma
  • Osteoporosis
44
Q

What is gastroenteritis?

Is it contagious?

A
  • Inflammation of stomach and intestines presenting with nausea, vomiting & diarrhoea.
  • Viral gastroenteritis (which is most common cause) is highly contagious hence family members or contacts are often affected and must isolate if in hospital
45
Q

State some potential causes of gastroenteritis in children, highlighting the most common one

A
  • Viral
    • Rotavirus
    • Norovirus
    • Adenovirus (more subacute presentation)
  • Escherichia coli (certain strains e.g. E.coli 0157)
  • Campylobacter jejuni
  • Shigella
  • Salmonella typhi
  • Bacillus cereus
  • Yersinia enterocolitica
  • Staphylococcus aureus toxin
  • Giardia lamblia
46
Q

For E.coli, discuss:

  • How it is spread
  • What E.coli 0157 produces and what this leads to
  • Whether should use abx
A
  • Normal intestinal bacteria and only certain strains cause gastroenteritis. Spread via contact with infected faeces, unwashed salads or contaminated food
  • E.coli 0157 produces shiga toxin which leads to dysentery and haemolytic uraemic syndrome
  • Use of abx increases risk of HUS so avoid if suspect E.coli gastroenteritis
47
Q

For campylobacter jejuni, discuss:

  • Gram stain & shape
  • How it is spread
  • Whether abx are given
A
  • Gram -ve curved/spiral shape
  • Spread: raw or improperly cooked poultry, untreated water, unpasteurised milk
  • Symptoms usually resolve after 3-6 days but abx may be considered after have confirmed diagnosis and pt has risk factors (e.g. immunosuppression, co-morbidities) or severe symptoms. Abx are: azithromycin or ciprofloxacin.
48
Q

For shigella, discuss:

  • Gram stain & shape
  • How it is spread
  • What it produces and what this can cause
  • Whether abx are used
A
  • Gram -ve rod
  • Spread via faeces contaminated water, swimming pools & food.
  • Can produce shiga toxin causing HUS
  • Usually resvolves in 1 week but may use abx for severe cases e.g. azithromycin or ciprofloxacin
49
Q

For salmonella, discuss:

  • Gram stain & shape
  • How it is spread
  • Whether abx are given
A
  • Gram -ve rod
  • Spread via raw eggs, poultry or food contaminated with infected faeces of small animals
  • Symptoms usually resolve within 1 week; abx only given in severe cases
50
Q

For Bacillus cereus, discuss:

  • Gram stain & shape
  • How it is spread
  • What toxin does it produce
  • Typical course of bacillus cereus
A
  • Gram positive rod
  • Spread via inadequately cooked food; typical food is rice left out at room temp
  • Produces cereulide toxin while growing on food (when it arrives at intestines produces different toxins)
  • Abdo cramping & vomiting within 5hrs then diarrhoea after 8 hrs, resolution within 24hrs
51
Q

For Yersinia enterocolitica, discuss:

  • Gram stain & shape
  • How it is spread
  • How it typically presents in children
  • How it typically presents in adults
  • Whether abx are used
A
  • Gram -ve rod
  • Spread by eating raw or undercooked pork, contamination of food/water with faeces of other infected small mammals (e.g. rats, rabbits)
  • Most frequently affects children causing watery or bloody diarrhoea, abdo pain, fever & lymphadenopathy. Incubation 4-7 days. Symptoms can last 3 weeks or more.
  • Older children & adults can present with right sided abdo pain due to mesenteric lymphadenitis and fever (giving impression of appendicitis)
  • Abx only in severe cases
52
Q

For Staphylococcus aureus toxin, discuss:

  • How it is spread
  • Typical course
A
  • S. Aureus can produce enterotoxins when growing on food such as egg, dairy & meat. Toxins can cause intestinal inflammation.
  • Symptoms start hrs after ingestion and resolve in 12-24hrs
53
Q

For Giardiasis, discuss:

  • What it is
  • How it is spread
  • Presentation
  • Whether abx are given
A
  • Caused by Giardia lamblia (a microscopic parasite) that lives in small intestine of mammals (pets, farmyard animals or humans)
  • Releases cysts in stools which then contaminate food or water (faecal oral transmission)
  • May not cause any symptoms or may cause chronic diarrhoea
  • Treat with metronidazole
54
Q

Discuss the principles of managing gastroenteritis

A
  • Good hygiene e.g. regular handwashing, using separate bathrooms, cleaning regularly
  • Isolation & barrier nursing in hospital
  • Children must stay off school until 48hrs after symptoms completely resolved
  • Stool culture for M,C&S
  • Ensuring they remain hydrated (can do fluid challenge to see if can tolerate fluids; if can tolerate, can be managed at home with safety net advice. Can use rehydration fluids. If child is dehydrated or fails fluid challenge will need IV fluids)
  • Light diet can be reintroduced (dry foods often better)
  • Antibiotics may be considered in some cases (e.g. if at risk of complications and causative organism confirmed)

*Most children make full recovery with supportive management but beware gastroenteritis can be fatal in at risk groups e.g. very young, immunosuppressed, comorbidities

55
Q

Are antidiarrhoeal medications (e.g. loperamide) & anti-emetic medications (e.g. metoclopramide) recommended in gastroenteritis in children?

A
  • Generally not recommended (but may use in some cases)
  • Anti-diarrhoeal are particularly avoided in E.coli 0157, Shigella infections, if there is bloody diarrhoea or high fever
56
Q

State some potential complications of gastroenteritis in children

A
  • Reactive arthritis
  • Guillain-Barre syndrome
  • HUS
  • IBS
  • Lactose intolerance
57
Q

State some causes of acute liver failure in children

A
  • Viruses (e.g. HSV, EBV, CMV, varicella, hepatitis A, B, E)
  • Wilson disease
  • Galactosaemia
  • Mitochondrial disease
  • Toxins (e.g. paracetamol overdose)
  • Medications (e.g. valproate, phenytoin, rifampicin, isoniazid, erythromycin)
  • Illicit drugs (ecstasy, toxic mushrooms)
  • Autoimmune hepatitis
  • Heart disease
58
Q

State some causes of chronic liver failure in children

A
  • Chronic hepatitis (e.g. hepatitis C, NAFLD)
  • Haemochromatosis
  • Biliary atresia
  • Alpha-1 antitrypsin deficiency
  • Mitochondrial disorders
59
Q

Presentation of liver failure in children & investigations are similar those in adults.

Management of liver failure in children depends on underlying cause.

A

Management:

  • Treat underlying cause
  • Supportive e.g. diuretics, vitamins, lactulose for hepatic encephalopathy
  • Liver transplant

Yr4: Child Health (21 decks)

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