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Year 4 - Paediatrics > Gastroenterology > Flashcards

Gastroenterology Flashcards

1
Q

What are the primary causes of constipation?

What is the % of these being the cause of all constipation cases?

A

1) Idiopathic constipation
2) Functional constipation

There is not a significant underlying cause other than simple lifestyle factors.

90-95% cases are due to functional constipation.

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2
Q

How does a child present with constipation?

A
  • less than 3 stools a week
  • hard stools difficult to pass
  • rabbit dropping stools
  • straining and painful passages of stools
  • abdominal pain
  • retentive posturing (holding abnormal posture)
  • rectal bleeding
  • faecal impacting causing overflow soiling
  • hard stools may be palpable in abdomen
  • loss of sensation of need to open bowels
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3
Q

What is the term for faecal incontinence/soiling?

A

Encopresis

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4
Q

What is encopresis a sign of?

A

A sign of chronic constipation where the rectum becomes stretched and loses sensation. Large hard stools remain in the rectum and only loose stools can bypass the blockage and leak out, causing soiling.

Rarer causes: spina bifida, Hirschprung’s disease, cerebral palsy, learning disability, psychosocial stress, abuse

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5
Q

What lifestyle factors contribute to constipation?

A
  • habitually not opening bowels
  • low fibre diet
  • poor fluid intake and dehydration
  • sedentary lifestyle
  • psychosocial problems e.g. difficult home/school environement
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6
Q

What is meant by desensitisation of the rectum?

A

Patients often develop a habit of not opening bowels when they need to and ignoring the sensation of a full rectum.
Over time, lose sensation of needing to open their bowels and they open their bowels even less often.
Start to retain faeces in the rectum which leads to faecal impaction where a large, hard stool blocks the rectum.
Over time, the rectum stretches as it fills with more and more faeces leading to further desensitisation of the rectum.
The longer this continues, the more difficult it is to treat the constipation and reverse the problem.

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7
Q

What are secondary causes of constipation?

A
  • hischsprung’s disease
  • cystic fibrosis (meconium ileus)
  • hypothyroidism
  • spinal cord lesions
  • sexual abuse
  • intestinal obstruction
  • anal stenosis
  • cow’s milk intolerance
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8
Q

What are red flags for constipation that prompt further investigations and referral to specialist?

A
  • not passing meconium within 48 hours of birth (CF/Hirschsprung’s)
  • neurological signs, esp in lower limbs (cerebral palsy/spinal cord lesion)
  • vomiting (intestinal obstruction/Hirschsprung’s)
  • ribbon stool (anal stenosis)
  • abnormal anus (anal stenosis, IBD, sexual abuse)
  • abnormal lower back/buttocks (spina bifida, SC lesion, sacral agenesis)
  • failure to thrive (coeliac disease, hypothyroidism, safeguarding)
  • acute severe abdo pain and bloating (obstruction or inussusception)
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9
Q

What are complications of constipation?

A
  • pain
  • reduced sensation
  • anal fissures
  • haemorrhoids
  • overflow and soiling
  • psychosocial morbidity
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10
Q

What is the management for constipation?

A
  • correct reversible contributing factors e.g. good fibre diet, hydration
  • start laxatives (stool softener e.g. movicol, lactulose; stimulant e.g. senna, sodium picosulfate)
  • disimpaction regimen if faecal impaction
  • encourage and praise using the toilet - scheduling visits, bowel diary, star chart
  • continue laxatives long term and slowly wean off as child develops a normal, regular bowel habit
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11
Q

What is coeliac disease?

A

Autoimmune condition where exposure to gluten causes an immune reaction that creates inflammation in the small intestine.

Autoantibodies are created in response to exposure to gluten which target the epithelial cells of the small intestine leading to inflammation.

Inflammation of the small bowel (duodenum and jejunum) causes atrophy of the intestinal villi. This leads to malabsorption of nutrients and disease-related symptoms.

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12
Q

Which antibodies are involved in coeliac disease?

A

Anti-TTG (anti-transglutaminase)
Anti-EMA (anti-endomysial)
Anti-DGPs (deaminated gliadin peptides)

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13
Q

How does coeliac disease present?

A
  • often asymptomatic so have low threshold for testing
  • failure to thrive in young children
  • diarrhoea
  • fatigue
  • weight loss
  • mouth ulcers
  • anaemia secondary to iron, B12, folate deficiency
  • dermatitis herpetiformis

Rare:

  • peripheral neuropathy
  • cerebellar ataxia
  • epilepsy
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14
Q

What condition is highly linked to coeliac disease?

A

T1DM

Always test patients with a new diagnosis of T1DM for coeliac disease, even if asymptomatic, as conditions often linked.

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15
Q

What are the genetic associations for coeliac disease?

A

HLA-DQ2 gene (90%)

HLA-DQ8 gene

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16
Q

What immunoglobulin is linked with coeliac disease? And what is the issue with this deficiency?

A

IgA

Both anti-TTG and anti-EMA are IgA.
Some patients have IgA deficiency so when test for these antibodies, must test IgA levels too. If total IgA levels are low, the coeliac test will be negative even if the patient has the condition.

Test for IgG version of anti-TTG or anti-EMA antibodies or do an endoscopy and biopsy.

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17
Q

What investigations do you do for coeliac disease?

A
  • ensure patient remains on a diet containing gluten otherwise may not detect antibodies of bowel inflammation
  • coeliac serology and IgA levels (first line is raised anti-TTG then anti-EMA)
  • OGD and duodenal biopsy
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18
Q

What 3 features are found on a biopsy in coeliac disease?

A
  • Villous atrophy
  • Crypt hyperplasia
  • Increased intra-epithelial lymphocytes
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19
Q

What other conditions is coeliac disease associated with?

A
  • T1DM
  • Thyroid disease
  • Autoimmune hepatitis
  • Primary biliary cirrhosis
  • Primary sclerosing cholangitis
  • Down’s syndrome
20
Q

What are the complications of untreated coeliac disease?

A
  • Vitamin deficiency
  • Anaemia
  • Osteoporosis
  • Ulcerative jejunitis
  • Enteropathy-associated T-cell lymphoma of the intestine
  • Non-hodgkin lymphoma
  • Small bowel adenocarcinoma (RARE)
21
Q

What is the management for coeliac disease?

A
  • lifelong gluten free diet
  • check coeliac antibodies to monitor the disease
  • relapse can occur on consuming gluten again
22
Q

What is gastro-oesophageal reflux?

A

Where the contents from the stomach reflux through the lower oesophageal sphincter into the oesophagus, mouth and throat.

23
Q

Why does GOR occur in babies?

A

Due to the immaturity of the lower oesophageal sphincter which allows the stomach contents to easily reflux into the oesophagus.

24
Q

Is GOR normal in babies?

A

Yes.
It is normal for a baby to reflux feeds and provided there is normal growth and the baby is otherwise well this is not a problem.
It usually improves as they grow and 90% of infants stop having reflux by 1 year.

25
Q

How does GOR present?

A

It is normal for babies to have some reflux after larger feeds but becomes more troublesome when this causes them to become distressed.

  • chronic cough
  • hoarse cry
  • distress, crying or unsettled after feeding
  • reluctance to feed
  • pneumonia
  • poor weight gain
  • arched back

Children >1 year may experience similar symptoms to adults:

  • heartburn
  • acid regurgitation
  • restrosternal/epigastric pain
  • bloating
  • nocturnal cough
26
Q

What are some causes of vomiting?

A
  • overfeeding
  • gastro-oesophageal reflux
  • pyloric stenosis (projectile vomiting)
  • gastritis/gastroenteritis
  • appendicitis
  • infections e.g. UTI, tonsilitis, meningitis
  • intestinal obstruction
  • bulimia
27
Q

What is the management for gastro-oesophageal reflux?

A

Conservative management:

  • explanation, reassurance, practical advice
  • small, frequent meals
  • burping regularly to help milk settle
  • not overfeeding
  • keep the baby upright after feeding (i.e. not lying flat)

Medical management if more problematic:

  • gaviscon mixed with feeds
  • feed thickener or formula
  • ranitidine
  • omeprazole (PPI) if ranitidine is inadequate
28
Q

Are there any investigations for GOR?

A

Rarely but in severe cases:

  • barium swallow (series of x-rays to examine GI tract for any abnormalities)
  • endoscopy
  • surgical fundoplication (very severe cases)
29
Q

What can rare cases of GOR lead to?

A

Sandifer’s syndrome

30
Q

What is Sandifer’s syndrome?

A

Rare condition causing brief episodes of abnormal movements associated with GOR in infants.
Infants normally neurologically normal.

31
Q

What are the key features of Sandifer’s syndrome?

A

Torticollis: forceful contraction of the neck muscles causing twisting of the neck

Dystonia: abnormal muscle contractions causing twisting movements, arching of the back or unusual postures

32
Q

How is Sandifer’s syndrome treated?

A

Tends to resolve as the reflux is treated or improves.

Generally outcome is good.

33
Q

Why should you refer a patient with symptoms of Sandifer’s syndrome to a specialist for assessment?

A

Because differential diagnoses include more serious conditions:

  • infantile spasms (West syndrome)
  • seizures
34
Q

What is inflammatory bowel disease?

A

An umbrella term for the two main diseases that cause inflammation of the GI tract: ulcerative colitis and Crohn’s disease.

IBD involves inflammation of walls of the GI tract and are associated with periods of remission and exacerbation.

35
Q

What are some features of Crohn’s disease?

A

(mneumonic - crows NESTS)

N - no blood of mucus
E - entire GI tract can be affected
S - skip lesions (on endoscopy)
T - terminal ileum most affected (ileocaecal valve); Transmural inflammation (full thickness)
S - smoking is a risk factor

Weight loss
Strictures
Fistulas

36
Q

What are some features of ulcerative colitis?

A

(mneumonic - u c CLOSEUP)

C - continuous inflammation
L - limited to colon and rectum
O - only superficial mucosa affected
S - smoking is protective
E - excrete blood and mucus
U - use aminosalicylates
P - primary sclerosing cholangitis
37
Q

What features would make you suspect IBD?

A
  • perfuse diarrhoea
  • abdominal pain
  • PR bleeding
  • weight loss
  • anaemia

May be systemically unwell during flares:

  • fever
  • malaise
  • dehydration
38
Q

What are some extra-intestinal manifestations of IBD?

A
  • pyoderma gangrenosum
  • erythema nodosum
  • finger clubbing
  • episcleritis and iritis
  • inflammatory arthritis
  • primary sclerosing cholangitis (UC)
39
Q

What investigations should be done for IBD?

A

Bloods:

  • FBC (Hb for anaemia, WCC for infection)
  • CRP (active infection)
  • TFTs
  • LFTs
  • U&Es
  • faecal calprotectin (inflammation of the bowel)

Endoscopy
- OGD/colonoscopy and biopsy

Imaging
- USS/MRI/CT for complications e.g. fistulas, abscesses, strictures

40
Q

What is the general management for IBD?

A
  • MDT - paediatricians, specialist nurses, pharmacists, dieticians, surgeons
  • monitor growth and pubertal development (particularly if having exacerbations or steroid treatment)
  • management involves inducing remission during flares and maintaining remission when well
  • dietician involvement
  • monitor and support growth/development
41
Q

What is the management of Crohn’s disease?

A

Inducing remission:

  • STEROIDS first line (PO prednisolone or IV hydrocortisone)
  • add immunosuppressant if steroids alone don’t work (azathioprine, mercaptopurine, methotrexate, infliximab, adalimumab)

Maintaining remission:

  • azathioprine/mercaptopurine (first line)
  • alternatives: methotrexate, infliximab, adalimumab

Surgery:

  • if only distal ileum is affected, it is possible to resect this area to prevent further flares BUT typically involves entire GI tract
  • treat strictures and fistulas secondary to Crohn’s disease
42
Q

What is the management of ulcerative colitis?

A

Inducing remission:
Mild/moderate:
- aminosalicylate (e.g. mesalazine oral or rectal) = first line
- corticosteroids (e.g. prednisolone) = second line

Severe:

  • IV corticosteroids (e.g. hydrocortisone) = first line
  • IV ciclosporin = second line

Maintaining remission:

  • aminosalicylate (e.g. mesalazine oral or rectal)
  • azathioprine
  • mercaptopurine

Surgery:

  • panproctocolectomy (removal of colon and rectum as UC only affects these) removes the disease
  • left with permanent ileostomy or J-pouch (ileo-anal anastamosis - ileum folded back on itself, fashioned into a larger pouch that functions like a rectum, attached to the anus and collects stools prior to the person passing a motion)
43
Q

Why should a CXR be carried out prior to TNF alpha inhibitor use in UC?

A

TNF alpha inhibitors can reactivate TB so a CXR must be done to ensure there is no sign of TB.

T-SPOT TB should also be done.

44
Q

What age does functional constipation tend to start?

A

Around 2-3 years of age due to starting potty training.

45
Q

How is functional constipation diagnosed?

A

Clinical diagnosis - does not require investigations.

Year 4 - Paediatrics (13 decks)

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