Gastroenterology Flashcards
What are the typical features suggesting constipation?
Less than 3 stools a week Hard stools difficult to pass Rabbit dropping stools Straining and painful Abdominal pain Holding abnormal posture - retentive posturing Rectal bleeding with hard stools Overflow soiling with faecal impaction Hard stools palpable in abdomen Loss of sensation of need to open bowels
What is encopresis?
Faecal incontinence
Not considered pathological until 4 years of age
Sign of chronic constipation because rectum is stretched and loses sensation
Loose stools leak out
What are rarer causes of encopresis?
Spina bifida Hirschsprung's disease Cerebral palsy Learning disability Psychosocial stress Abuse
What lifestyle factors can cause constipation?
Habitually not opening bowels Low fibre diet Poor fluid intake and dehydration Sedentary lifestyle Psychosocial problems
What are secondary causes of constipation?
Hirschsprung's Cystic fibrosis - meconium ileus Hypothyroidism Spinal cord lesions Sexual abuse Intestinal obstruction Anal stenosis Cows milk intolerance
What are the red flags indicating a serious condition causing constipation?
Not passing meconium within 48 hours of birth - CF or Hirschsprung’s
Neurological signs or symptoms - lower limbs
Vomiting - obstruction
Ribbon stool - anal stenosis
Abnormal anus
Abnormal lower back or buttocks
Failure to thrive - coeliac, hypothyroid, safeguarding
Acute severe abdominal pain and bloating
What are the complications of constipation?
Pain Reduced sensation Anal fissures Haemorrhoids Overflow and soiling Psychosocial morbidity
What is the NICE guidelines on management of constipation if faecal impact is present?
Polyethylene glycol and electrolytes - Movicol Paediatric Plan
Add stimulant if does not lead to disimpaction after 2 weeks
Substitute with osmotic laxative e.g. lactulose if not tolerated
What is the maintenance therapy for constipation?
Movicol
Add stimulant laxative if no response
Substitute stimulant if not tolerated
Continue at maintenance dose for several weeks after regular bowel habit established
What are the red flag clinical features in the vomiting child?
Bile stained - obstruction
Haematemesis - oesophagi’s, ulceration, oral/nasal bleeding
Projectile - pyloric stenosis
Vomiting at end of coughing - whooping cough
Abdo distention - obstruction
Hepatosplenomegaly - chronic liver disease
Bulging fontanelle or seizures - raised ICP
Failure to thrive - GORD, coeliac
What is GORD?
Where contents of stomach reflux through lower oesophageal sphincter
In babies is normal due to immaturity of LOS; provided otherwise well and growing
What is the presentation of GORD?
Signs of problematic reflux: Chronic cough Hoarse cry Distress, crying, unsettled Reluctance to feed Pneumonia Poor weight gain
What advise is given to relieve GORD?
Small frequent meals
Burping regularly to help milk settle
Not overfeeding
Keeping baby upright after feeding
Who is more severe GORD a problem in?
Children with cerebral palsy or other neurodevelopment disorders
Preterm infants, especially if have bronchopulmonary dysplasia
Following surgery for oesophageal atresia or diaphragmatic hernia
What are complications of GORD?
Failure to thrive Oesophagitis Iron deficiency anaemia Recurrent pulmonary aspiration Cough or wheeze, apnoea Dystonic neck posturing Apparent life threatening events
What investigations are required for GORD?
Usually clinical diagnosis
May be indicated if history atypical, complications or failure to respond to tx
24 hour oesophageal pH monitoring
24 hour impedance monitoring
Endoscopy with biopsies for oesophagitis
What is the management of problematic cases of GORD?
Gaviscon mixed with feeds
Thickened milk or formula
Ranitidine
Omeprazole
What is Sandifer’s syndrome?
Rare condition
Causes brief episodes of abnormal movements associated with GORD
Torticollis - forceful contraction of neck muscles causing twisting of neck
Dystonia - abnormal muscle contractions causing twisting movements, arching of the back, unusual postures
What is colic?
Paroxysmal inconsolable crying or screaming
Accompanied with drawing up of the knees
Passage of excessive flatus
Typically occurs in first few weeks and resolves by 4 months
What are surgical causes of acute abdominal pain?
Acute appendicitis Intestinal obstruction Intussusception Inguinal hernia Peritonitis Inflamed Meckel's Pancreatitis Trauma
What are medical causes of acute abdominal pain?
Gastroenteritis UTI, pyelonephritis Hydronephritis Renal calculus HSP DKA Sickle cell anaemia Hepatitis IBD Constipation Psychological Lead poisoning
What are extra-abdominal causes of acute abdominal pain?
Upper respiratory tract infection
Lower lobe pneumonia
Torsion of testes
Hip and spine
What is mesenteric adenitis?
Swollen inflamed lymph nodes in the abdomen
Diagnosis can only be made definitively if large mesenteric nodes and normal appendix in laparotomy/laparoscopy
What is recurrent abdominal pain?
Pain sufficient to interrupt normal activities
Lasts for at least 3 months
What are causes of recurrent abdominal pain?
>90% no cause IBS, constipation, dyspepsia Abdominal migraine, ulcers Dysmenorrhoea, cysts, PID Psychosocial Hepatitis, gallstones UTI, PUJ obstruction
What are signs and symptoms which suggest an organic disease as cause for recurrent abdominal pain?
Epigastric pain at night Haematemesis - ulcer Diarrhoea, weight loss Growth failure Blood in stools Vomiting Jaundice - liver disease Dysuria, secondary enuresis Bilious vomiting, abdo distension
What are the symptoms of IBS?
Abdominal pain, often worse before or relieved by defecation Explosive, loose or mucous stools Bloating Feeling of incomplete defecation Constipation
What is functional dyspepsia?
Symptoms of peptic ulceration, abdo pain, nausea
More non specific symptoms
Early satiety
Bloating
Post prandial vomiting
Delayed gastric emptying due to gastric dysmotility
Treatment with hypoallergenic diet
What are the symptoms of duodenal ulcers?
Less common in kids
H pylori causes nodular antral gastritis
Epigastric pain waking them at night
FH of peptic ulceration
What conditions can mimic gastroenteritis?
Sepsis, meningitis RTI, otitis media, Hep A Pyloric stenosis Intussusception Acute appendicitis NEC DKA Haemolytic uraemic syndrome Coeliac disease Cow's milk protein intolerance
What is the most frequent cause of gastroenteritis in developed world?
Rotavirus
Also adenovirus, norovirus
Bacteria less common, blood in stools if so
Campylobacter jejuni
Shigella - high fever
E coli - dehydrating diarrhoea
What children are at an increased risk of dehydration?
Infants under 6 months or low birth weight
Passed >6 diarrhoeal stools in past 24 hours
Vomited three or more times in previous 24 hours
Unable to tolerate fluids
Malnourished
What occurs in hypernatraemic dehydration?
Water loss exceeds relative sodium loss
Due to high insensible water losses e.g. high fever, hot/dry environment
Depression of fontanelle
Reduced tissue elasticity
Sunken eyes are all less obvious
Water drawn out of brain and cerebral shrinkage
Leads to jittery movement, increased muscle tone
Hyperreflexia, seizures
What are the red flag signs of dehydration suggestive the child is at risk of shock?
Appears unwell or deteriorating Altered responsiveness Sunken eyes Tachycardia Tachypnoea Reduced skin turgor
How can disorders causing malabsorption manifest in children?
Abnormal stools
Failure to thrive or poor growth
Specific nutrient deficiencies
What is the cause of coeliac disease?
Antibodies:
anti-tissue transglutaminase
anti-endomysial anti-EMA
Inflammation in small intestine, atrophy of intestinal villi
What is the presentation of coeliac disease?
Failure to thrive Diarrhoea Fatigue Weight loss Mouth ulcers Anaemia secondary to iron, B12 or folate deficiency Dermatitis herpetiformis
Rarely can present with neurological symptoms e.g. neuropathy, cerebellar ataxia, epilepsy
What condition is coeliac often tested alongside at diagnosis?
Type 1 diabetes
What are the genetic associated with coeliac?
HLA-DQ2
HLA-DQ8
What are the auto antibodies in coeliac?
anti TTG
anti EMA
Deaminated gliadin peptides antibodies
Important to test total immunoglobulin A levels, if total IgA is low coeliac test will be negative even when they have the condition
Can then test for IgG version
How is coeliac diagnosed?
Remain on gluten diet
Check total immunoglobulin A to exclude IgA deficiency
Raised anti-TTG antibodies
Raised anti-endomysial
Crypt hypertrophy and villous atrophy on biopsy
What conditions is coeliac disease associated with?
Type 1 diabetes Thyroid disease Autoimmune hepatitis Primary biliary cirrhosis Primary sclerosing cholangitis Down's
What are the complications of untreated coeliac disease?
Vitamin deficiency Anaemia Osteoporosis Ulcerative jejunitis Enteropathy associated T cell lymphoma of intestine Non-Hodgkin lymphoma Small bowel adenocarcinoma
What are the features of Crohn’s?
No blood or mucus Entire GI tract Skip lesions Terminal ileum most affected Transmural - full thickness inflammation Smoking is a risk factor
Also associated with weight loss, strictures, fistulas
What are the features of ulcerative colitis?
Continuous inflammation Limited to colon, rectum Only superficial mucosa Smoking is protective Excrete blood and mucus Use aminosalicylates Primary sclerosis cholangitis
What is the presentation of Crohn’s in children?
Growth failure
Puberty delayed
Abdominal pain, diarrhoea, weight loss
General ill health - fever, lethargy, weight loss
What are the extra-intestinal manifestations of Crohn’s in children?
Oral lesions Perianal skin tags Uveitis Arthralgia Erythema nodosum
What investigations are helpful in confirming Crohn’s or diagnosing a relapse?
Raised inflammatory markers - platelet count, ESR, CRP
Iron deficiency anaemia
Low serum albumin
What is seen on endoscopy in Crohn’s?
Hallmark is presence of non-caseating epithelioid cell granulomata
Small bowel imaging may reveal narrowing, fissuring, mucosal irregularitis
Bowel wall thickening
How is remission in Crohn’s induced?
Steroids - oral prednisolone or IV hydrocortisone
Second line - azathioprine, mercaptopurine, methotrexate, infliximab
How is remission maintained in Crohn’s?
First line - azathioprine, mercaptopurine
Or methotrexate, infliximab, adalimumab
When is surgery required in Crohn’s?
If affecting distal ileum, can surgically resect to prevent further flares
Treat strictures and fistulas
What is used to induce remission in ulcerative colitis?
Mild/mod disease - aminosalicylate e.g. mesalazine, or corticosteroids
If severe -
IV corticosteroids first line
or IV ciclosporin
What is used to maintain remission in ulcerative colitis?
Aminosalicylate e.g. mesalazine oral or rectal
Azathioprine
Mercaptopurine
When can surgery be offered in ulcerative colitis?
Panproctocolectomy will remove the disease
Left with ileostomy or oleo-anal anastomosis U pouch
What is the presentation of ulcerative colitis in children?
Children often have pancolitis
Rectal bleeding, diarrhoea, colicky pain
Weight loss and growth failure less common
What is seen on histology in ulcerative colitis?
Confluent colitis
Mucosal inflammation
Crypt damage - cryptitis, abscesses, crypt loss
Ulceration
What are the clinical features of liver disease in children?
Encephalopathy Jaundice Epistaxis Cholestasis - pruritus, pale stools, dark urine Ascites, hypotonia, neuropathy Rickets Varices, portal HTN Spider naevi Muscle wasting - malnourished Splenomegaly Liver palms, clubbing
What are the causes of conjugated prolonged neonatal jaundice?
Bile duct obstruction - biliary atresia or choledochal cyst
Neonatal hepatitis syndrome
Intrahepatic biliary hypoplasia
What are the causes of neonatal hepatitis syndrome?
Congenital infection Inborn errors of metabolism A1 antitrypsin deficiency Galactosaemia Tyrosinaemia Errors of bile acid synthesis Progressive familial intrahepatic cholestasis CF Intestinal failure associated liver disease
What are the clinical features of viral hepatitis?
Nausea Vomiting Abdominal pain Lethargy Most children don't develop jaundice Large tender liver 30% have splenomegaly Liver transaminases elevated
What are the types of viral hepatitis and their transmission?
Hep A - faecal oral, vaccination for travellers
Bed rest, change of diet
Hep B - Perinatal transmission Infected blood Needlestick injuries Renal dialysis Horizontal spread in families (Sexual transmission)
Chronic infection by vertical transmission, can cause risk of cirrhosis or hepatocellular carcinoma
Interferon therapy
Hep C -
High in drug users, vertical transmission more common if also have HIV
D - co infection or super infection, E - water
What are the causes of acute liver failure in children?
Fulminant hepatitis
Massive hepatic necrosis, loss of liver function with or without encephalopathy
Infection - viral hepatitis Poisons/drugs - Paracetamol, isoniazid, phalloides mushrooms Metabolic - Wilson's Autoimmune hepatitis Reye's syndrome
What are the signs of acute liver failure?
Jaundice Encephalopathy Coagulopathy Hypoglycaemia Electrolyte disturbances
Early signs of encephalopathy - alternate periods of irritability, confusion, drowsiness, aggression
What are some of the complications of acute liver failure?
Cerebral oedema
Haemorrhage from gastritis or coagulopathy
Sepsis
Pancreatitis
How can fulminant hepatitis be diagnosed?
Transaminases very raised Alkaline phosphatase increased Coagulation very abnormal EEG shows encephalopathy CT may show cerebral oedema
What is the management of acute liver failure?
Maintain blood glucose >4 with IV dextrose
Prevent sepsis; broad spectrum antibiotics and antifungals
Prevent haemorrhage, IV Vit K, FFP, cryoprecipitate, PPIs
Treat cerebral oedema by fluid restriction, mannitol
Urgent transfer to liver unit
What features of acute liver failure suggest poor prognosis?
Shrinking liver
Rising bilirubin and falling transaminases
Worsening coagulopathy
Progression to coma
Without transplantation, 70% likely to die
What is Reye syndrome?
Acute non inflammatory encephalopathy
Microvesicular fatty infiltration of liver
What are the causes of chronic liver disease in children?
Post viral Hep B, C Autoimmune hepatitis Drugs - nitrofurantoin, NSAIDs IBD PSC - +- ulcerative colitis Wilson's Alpha 1 antitrypsin def CF Neonatal liver disease Bile duct lesions
What is autoimmune hepatitis?
More common in girls
May present as acute hep, fulminant hep or CLD
Autoimmune features - rash, SLE, arthritis, haemolytic anaemia, nephritis
Respond to prednisolone, azathioprine
What is Wilson’s disease?
Autosomal recessive
Reduced synthesis of caeruloplasmin and defective excretion of copper in bile
Leads to copper in liver, brain, kidney, cornea
Liver disease, neuropsychiatric features, extrapyramidal signs
Kayser Fleischer rings from age 7
Tx with penacillamine, promotes copper excretion, zinc to reduce absorption
What occurs in cirrhosis?
End result of any liver disease, extensive fibrosis
May be asymptomatic if compensated, then:
palmar and plantar erythema
Spider naevi
Malnutrition, hypotonia
What are the investigations for cirrhosis?
Screen for known cause of chronic liver disease
Upper GI endoscopy to detect varices, gastritis
Abdominal ultrasound
Liver biopsy
What are some of the consequences of cirrhosis?
Portal hypertension Splenomegaly Oesophageal varices Ascites - umbilical hernias Spontaneous bacterial peritonitis - undiagnosed fever, pain, tenderness Encephalopathy Renal failure
What are the indications for transplantation in chronic liver failure?
Sever malnutrition unresponsive to intensive nutritional therapy
Recurrent complications
Failure of growth and development
Poor quality of life
What are some of the complications post liver transplantation?
Primary non function of liver Hepatic artery thrombosis Biliary leaks, strictures Rejection Sepsis
What is important in the management of children with liver disease?
Nutrition - high protein high carbohydrate, NG or TPN
Vit K, A, E, D
Pruritus - loose clothing, emollients, phenobarbital to stimulate bile flow, ursodeoxycholic acid
What occurs in Vitamin A deficiency?
Night blindness in adults
Retinal changes in infants
Give oral supplements
What occurs in Vitamin E deficiency?
Peripheral neuropathy
Haemolysis
Ataxia
High oral doses needed
What occurs in Vitamin D deficiency?
Rickets
Pathological fractures
Vit D resistant rickets indicates renal tubular acidosis
