Gastroenterology

Question 1

Gastroenteritis 
Causative organisms
-Previous most comomon = 
- Now most common = 
- 3 other viruses 

• 3/4 Bacterial pathogens
• 2 Parasites

Assessment of Dehydration + fluid

• Most accurate way of assessing?
• Some draw backs 4
• % linked to no dehydration, dehydration and shock

Clinical Features of shock in infant all 12!

Management

• No clinical dehydration 3
• Dehydration 3
• Shock, give… how many times before…. where….

Answer 1

Causative organisms

• Previously most common but dec due to vaccine: Rotavirus
• Now most common but less severe: Norovirus
• Sapovirus
• Enteric Adenovirus
• Astrovirus

Bacteria

• Campylobcater jejuni
• shigela
• C. Diffe
• E.colo or Cholera with profuse rapid diarrhoea

Protizoan Parasite

• Gardia
• Cryptosporidium

Assessment of Dehydration + fluid
- Most accurate: weight loss during period of illness
(Has its down falls of different weighing scales, clothes, accuracy and reproducibility)

History and Examination:

• No clinically detected weight loss < 5% loss of body weight
• Clinical Dehydration 5-10% loss of body weight
• Shock > 10% loss of body weight

Clincial features of shock in infant: HEAD TO TOE

• Does the child look well? Alert?
• Anterior fontanelle sunken (check parent if normal)
• Sunken eyes
• Dry mucous membranes
• Crying but no tears
• Sternal refill time < 2 secs
• Tachycardic
• Tachypnoea ( > 30-40 RR)
• Skin on tummy tugour
• Cold peripheries
• Urine output dec
• Pale/ mottled

Management
No Clinical Dehydration: therefore look to prevent
- Keep feeding
- encourage fluid intake
- Oral Rehydration supplements (eg Diorlite)

Clinical Dehydration

• Give fluid deficit replacement based on 5% body weight
• Give ORS in small amounts
• Continue breast feeding but if cant keep down vomit then NG tube

Shock

• IV therapy
• Give bolus 10ml/kg body weight of balanced isotonic crystalloids such as plasma - lyte or Hartmann’s, 0.9% Saline
• Repeat this x4 times if no improvement send to Intensive Care Unit and will need Mechanical Ventilation

Question 2

Gastro-oesophageal reflux

What is it?
Why does it happen regularly in infants? 4

-
-

Management

Answer 2

What is it?
involuntary passage of gastric contents into oesophagus

Why does it happen regularly in infants?

• Functional immaturity of lower oesophageal sphincter
• Predominantly fluid diet
• Mainly Horizontal Posture
• Short intra-abdominal length of oesophagus

Usually normal but if it causes significant problems it is termed GORD and is treated

Investigations- Normally don’t do them but if atypical, complications, failure to respond to treatment

• 24hr oesophageal pH monitoring
• endoscope for pH + biopsy to see oesophagitits
• contrast upper GI tract not recommended!

Management 
• Parental Reassurance – usually resolves by age 1
• Feeding Assessment
• Smaller, more frequent feeding
• Feed thickeners (carobel) 

• Alginate Therapy (Gaviscon)
- 4 week trial of PPI or H2 Receptor antagonist (omeprazole)

Question 3

Appendicitis

Very uncommon under what age?

Symptoms:
5

Signs
3
Localised to where?

Investigations
3

Management
4 (one is monitor obs)

Complications
4

Answer 3

V. Uncommon under 3y/o

Symptoms
• Abdominal pain
• Initially central and colicky
• Later localises to RIF
• Anorexia
• Vomiting
Signs
• Fever
• Pain aggravated by movement
• Tenderness and guarding in 
Where? RIF (McBurney's point) 2/3 between line from umbilicus to Right Ant. Sup. Iliac Spine 

Investigations
• Full Blood Count - ↑wcc
• CRP
• Ultrasound Scan

Management
• Monitor observations
• Analgesia
• Fluid resuscitation and IV antibiotics (if 
unwell/concerns of perforation)
• Appendicectomy 

Complications

• Perforation
• Sepsis
• Appendical mass - via great ommentum, can be quick as it’s not developed yet
• Abscess- if mass doesn’t resolve

Question 4

Pyloric Stenosis
Why does it happen

Epidemiology:
- Usually present at what age?
-
-
-

-
-

Assessment
-
- Gastric peristalsis moves from ...
-
-
-
- 3 that are the same as complications

-
-

-
-

Answer 4

Why does it happen?
Hypertrophy of pyloric muscle causing Gastric Outlet Obstruction

Epidemiology:
Usually at 2-8 weeks
Males
• Firstborn child
• Family HIsotry (often maternal side) 

Presentation:
- Vomiting which gradually increases in frequency and forcefulness until projectile
• Hunger after vomiting
• Weight loss

Assessment
• Test feed
• Gastric peristalsis Wave moving from left to right
• Pyloric mass Olive shaped mass in RUQ 
• Capillary blood gas
• Hypochloraemic metabolic alkalosis
• Low sodium and potassium
• Ultrasound scan 

Management
• Rehydration
• Correct electrolyte imbalances
• Pyloromyotomy

Complications:

• Hypochloraemic metabolic alkalosis
• Low sodium (hyponatraemia)
• Hypokalaemia

Question 5

Coeliac Disease

What in Gluten causes immune response and where?

Classical presentation 4
2 extra which often present
- Rash where ad what is it called?

• Name of gene which is most associated?

Investigations 
-
-
-
- Biospy: what are the 3 mucosal changes you see? 

Management 1

Answer 5

Gliadin causes damaging immune response in proximal small intestinal mucosa

Presentation: Classical
• Malabsorption at 8-24 after weaning
• Faltering growth and buttock wasting
• Abdominal pain and distension
• Abnormal stools
Often:
• Non specific GI symptoms
• Anaemia (iron and/or folate deficiency)
- Dermititis Herpetiformis (rash on abdomen) 

Gene- HLA- DQ2

Investigations
• Bloods – Serological screening tests
• Anti-tTG (immunoglobulin A tissue transaminase antibodies)
• anti- EMA (anti- endomysial antibodies)
• Biopsy – Mucosal changes of small intestine such as:
- flattened villi
- lymphocyte infiltration
- Crypt hyperplasia

Management
• Life-long Gluten free diet under dietician supervision

Question 6

Constipation

Clinical Features
6

Examination
- Observant
-
-

Management
-
-
-
- Laxatives (4) 

RED FLAGS- Know 5 and what they imply

Answer 6

Clinical Features
• Infrequent bowel movements
• Straining
• Abdominal pain
• Loss of appetite
• Soiling
• Overflow diarrhoea

Examination
• Well child
• Abdomen soft
• Palpable faecal mass in lower abdomen

Management
- Encourage oral fluids
- Encourage healthy, fibre rich diet
- Toileting routine 
- Laxatives
• Disimpaction regime
• Stimulant 
• Osmotic
• Stool Softener

RED FLAGS

• Failure to pass meconium in 24 hours of life
Hirschprung’s

• Faltering growth
Hypothyroidism, Coeliac disease

• Abnormal lower limb neurology/deformity
Lumbosacral pathology

• Sacral dimple over natal cleft
Spina Bifida Occulta

• Perianal bruising
Sexual abuse

Question 7

IBD

2 types:
1) Brief description

2) Brief description

Presentation: 5
extra intestinal manifestations: 2/4

Investigations 3

Managment
1) 4

2) 3

Answer 7

1) Crohn’s disease affects any part of GI tract from mouth to anus. Non-caseating epitheloid cell granulomata

2) Ulcerative colitis is confined to the colon. Mucosal
inflammation and crypt cell damage.

Presentation
• Abdominal pain
• Diarrhoea
• Failure to thrive
• Weight loss
• Delayed puberty
• Extra-intenstinal manifestations: oral lesions, uveitis, 
arthralgia, erythema nodosum  

Investigations
• Full blood count
• CRP and ESR
• Fecal elastase
• Biopsy 

Management

Crohn's: 
Nutritional therapy 
Systemic Steroids 
Immunosupressants 
Anti-TNF (Infliximab) 

UC:
Aminosalicylates 
(Mesalazine) 
Topical or systemic steroids 
Immunosuppressants