Gastroenterology Flashcards
1
Q
What is the most common cause of abdominal pain?
A
Appendicitis
- Rare in <3yo
2
Q
What are the signs and symptoms of appendicitis?
A
- Anorexia
- Vomiting
- Nausea
- Umbilical → RIF pain
- Fever
- Generalised abdominal tenderness
3
Q
What are the appropriate investigations for appendicitis?
A
- FBC
- Pregnancy test - if female
- AXR ± CTAP
4
Q
What is the management of appendicitis?
A
- GAME
- Group & Save
- Abx IV
- MRSA screen
- Eat & drink - must be NBM
- Appendicectomy
5
Q
What are the possible diagnoses for the ‘red flag’ symptoms of bile-stained vomit?
A
- Intestinal obstruction
- Intussusception
- Malrotation
- Strangulated inguinal hernia
6
Q
What are the possible diagnoses for the ‘red flag’ symptoms of haematemesis?
A
- Oesophagitis
- Peptic ulcer
7
Q
What are the possible diagnoses for the ‘red flag’ symptoms of projectile vomit at 2-7 weeks old?
A
- Pyloric stenosis
8
Q
What are the possible diagnoses for the ‘red flag’ symptoms of vomiting at end of paroxysmal coughing?
A
- Whooping
9
Q
What are the possible diagnoses for the ‘red flag’ symptoms of abdominal tenderness?
A
- Surgical abdomen
10
Q
What are the possible diagnoses for the ‘red flag’ symptoms of abdominal distension?
A
- Intestinal obstruction
- Strangulated inguinal hernia
11
Q
What are the possible diagnoses for the ‘red flag’ symptoms of hepatosplenomegaly?
A
- Chronic liver disease
- Inborn error of metabolism
12
Q
What are the possible diagnoses for the ‘red flag’ symptoms of blood in stool?
A
- Intussusception
- Gastroenteritis
- Ssalmonella
- Campylobacter
13
Q
What are the possible diagnoses for the ‘red flag’ symptoms of severe dehydration/shock?
A
- Systemic infection
- DKA
14
Q
What are the possible diagnoses for the ‘red flag’ symptoms of bulging fontanelle/seizures?
A
- Increased ICP
14
Q
What are the possible diagnoses for the ‘red flag’ symptoms of bulging fontanelle/seizures?
A
- Increased ICP
15
Q
What are the possible diagnoses for the ‘red flag’ symptoms of failure to thrive?
A
- CORD
- Coeliac disease
- Chronic GI
16
Q
What are the causes of vomiting in infants?
A
- GO reflux
- Feeding problems
- Infection
- Dietary protein intolerance
- Intestinal obstruction
- Inborn errors of metabolism
- Congenital adrenal hyperplasia
- Renal failure
17
Q
What are the causes of vomiting in pre-school aged children?
A
- Gastroenteritis
- Appendicitis
- Intestinal obstruction
- Increased ICP
- Coeliac
- Renal failure
- Testicular torsion
18
Q
What are the causes of vomiting in school aged children?
A
- Gastroenteritis
- Infection
- Peptic ulcer
- Appendicitis
- Migraines
- Increased ICP
- Coeliac disease
- Renal failure
- DKA
- Alcohol/drugs
- Cyclical vomiting syndrome
- Bulimia/anorexia
- Pregnancy
- Testicular torsion
19
Q
What are the possible diagnoses for the ‘red flag’ symptoms of failure to pass meconium in first 24hrs?
A
- Hirschsprung’s
20
Q
What are the possible diagnoses for the ‘red flag’ symptoms of failure to thrive or growth failure?
A
- Hypothyroid
- Coeliac
21
Q
What are the possible diagnoses for the ‘red flag’ symptoms of gross abdominal distension?
A
- Hirschsprung’s
- Other GI dysmotility
22
Q
What are the possible diagnoses for the ‘red flag’ symptoms of abnormal lower limb neurology or deformation?
A
- Lumbosacral pathology
23
Q
What are the possible diagnoses for the ‘red flag’ symptoms of sacral dimple above nasal cleft?
A
- Spina bifida occulta
24
What are the possible diagnoses for the ‘red flag’ symptoms of perianal fistulae/abscess/fissure?
* Perianal Crohn's
25
What are the normal bowel habits of an infant?
* Can be highly variable
* Infants = 4/day to 2/day by 1yo
* Breast fed infants may not pass stools for several days
* By age 4 = normal adult pattern = 3/day to 3/week
26
What are the normal feeding habits of an infant?
* Newborn = 45-90ml per 2-3 hours
* 2 months = 120-150ml per 3-4 hours
* 6 months = solids can be started to be introduced
* Point at which they have double their birthweight and can sit up → will still need milk until 1 year old
27
What are the causes of constipation in babies?
* Hirschsprung’s
* Anorectal abnormality
* Hypothyroid
* Hypercalcemia
* Idiopathic
28
What are the causes of constipation in non-infant children?
* Toilet training issues
* Stress
* Follows acute febrile illness
29
What are the complications of constipation?
* Overdistended rectum
* Loss of feeling the need to defecate → involuntary soiling with overflow
30
What are the possible diagnoses for the ‘red flag’ symptoms of perianal bruising or multiple fissures?
* Sexual abuse
31
What is the management of constipation?
* Treat the underlying cause
* Medications for dis-impaction or mild constipation
* Step 1 = **Movicol Paediatric Plain**
* Polyethylene glycol (osmotic laxative) + electrolyte escalating dose for 2 weeks
* Step 2 = Add a **stimulant laxative** for dis-impaction or **stimulant laxative** for mild constipation
* Step 3 = Maintain for 6 months
32
What are the types of laxatives?
* 1st line = Osmotic - Polyethylene Glycol 3350/Movicol, lactulose
* 2nd line = Stimulant - Bisacodyl, Senna, sodium picosulphate
* Bulk-forming = fybogel, methylcellulose
* Stool-softener = arachis oil, docusate sodium
33
What counselling should be given to parents with a child with constipation?
* Explain it is simple constipation and that it is very common
* Explain treatment - want to break the cycle of a hard stool being difficult to pass
* Explain that Movicol takes time to work
* Disimpaction = escalating dose for 2 weeks
* Maintenance = can be a long time until bowel habits are re-established
* Advise encouraging the child to sit on the toilet after mealtimes (reflex)
* Advise behavioural intervention (star chart) to aid motivation
34
What are the causes of acute abdominal pain?
35
What are the causes of gastroesophaegael reflux in children?
* Inappropriate relaxation of LOS → most resolve by 1yo
* If persistent = GORD
36
What are the appropriate investigations for gastroesophageal reflux in children?
* Clinical diagnosis
* 24hr LOS pH monitoring - *normally remains mostly above 4*
* OGD
37
What are the reasons for a same day referral for gastroesophageal reflux?
* Haematemesis
* Melaena
* Dysphagia present
38
What are the reasons for assessment by a paediatrician for gastroesophageal reflux?
* Red flag symptoms
* Faltering growth
* Unexplained distress
* Unresponsive to medical therapy
* Feeding aversion
* Unexplained IDA
* No improvement after 1 year of age
* Suspected Sandifer's syndrome
39
What are the complications of gastroesophageal reflux in a child?
* Recurrent aspiration pneumonia
* Apnoea
* Epileptic seizure-like events
* Upper airway inflammation
* Dental erosion with neurodisability
* Recurrent acute otitis media
40
What is the management of gastroesophageal reflux in a child?
* Initial Management
* If breast-fed
* 1st = breastfeeding assessment
* 2nd = consider trial of alginate for 1-2 weeks
* 3rd = pharmacological
* If formula-fed
* 1st = review feeding history
* 2nd = trial smaller, more frequent feeds
* 3rd = trial of thickened formula
* 4th = trial of alginate therapy
* 5th = pharmacological
* Pharmacological Management = GORD
* Gaviscon (a form of alginate therapy)
* Omeprazole
* Ranitidine
* Dunno → so refer to get metoclopramide
41
What counselling should be given to parents with a child with gastroesophageal reflux?
* Explain diagnosis - immaturity of the gullet leading to food coming back the wrong way
* Reassure that this is common and usually gets better with time
* Breastfeeding: offer assessment ± alginate therapy
* Formula: review feeding history → smaller, more frequent feeds → thickeners ± alginate therapy
* Safety net: keep an eye on the vomitus (if it’s blood-stained or green seek medical attention)
42
Define Pyloric Stenosis.
Hypertrophy of the pyloric muscle causing gastric outlet obstruction.
43
What is associated with pyloric stenosis?
Turner's syndrome
44
What are the signs and symptoms of pyloric stenosis?
* Projectile Vomiting - non-bilious
* Increases in frequency and forcefulness over time, ultimately becoming projectile)
* Occurs ~30 minutes after a feed
* Present at 2-8 weeks - *boys \> girls*
* Palpable ‘olive’ mass in RUQ
* Visible peristalsis in upper abdomen
* Hunger → dehydration → loss of interest in feeding → weight loss + depressed fontanelle
45
What are the appropriate investigations for pyloric stenosis?
* Test feed → observe for gastric peristalsis
* USS confirmation – target lesion, \>3mm thickness
* *Hypochloraemia hypokalaemic metabolic alkalosis*
* *Low [Cl-], Low [H+]; Low [K+] and [Na+]*
* *HCO3- is elevated = metabolic alkalosis*
* *May progress to a dehydrated lactic acidosis (opposite biochemical picture)*
* *ABG isn't routinely done*
46
What is the management of pyloric stenosis?
* IV slow fluid resuscitation + correct any disturbances = 1.5x maintenance rate +5% dextrose + 0.45% saline
* **Laparoscopic Ramstedt pyloromyotomy**
47
Define Infant Colic.
Describes a common abdominal symptom complex → *40% of babies in the first few months of life*
48
What are the signs and symptoms of infant colic?
* Manifests as random inconsolable crying and drawing up on the hands and feet
* Resolves by 3-12 months
49
What is the management of infant colic?
* Soothe infant – hold with gentle motion, optimal winding technique, white noise
* If persistent → consider cow’s milk protein allergy or reflux consider
* 2-week trial of whey hydrolysate formula; followed by
* 2-week trial of anti-reflux treatment
* Support:
* Self-help support groups
* Get support from health visitor, family, friends and other parents
50
Define Intussusception.
Invagination of proximal bowel into distal component.
* 95% ileum through to caecum through ileocecal valve
* Stretching and constriction of the mesentery → venous obstruction → engorgement and bleeding from the bowel mucosa, fluid loss → bowel perforation, peritonitis and gut necrosis
51
What are the causes and associations of intussusception?
* Causes
* Idiopathic
* Enlarged Peyer’s patches after gastroenteritis
* Lead points
* Cardiac hypertrophy
* Associations
* Lymphoma
* Gastroenteritis
* HSP
* CF
52
What are the signs and symptoms of intussusception?
* Colic
* Vomit - *may be bile stained depending on the site of the intussusception*
* Present 3 months to 2 years
* Late sign = red-currant jelly stool (bloody mucus)
* Abdominal distension (± sausage-shaped mass) and shock
* Sausage-shaped mass on physical examinationin RUQ
* Dance’s sign = emptiness on palpation in RLQ
53
What are the appropriate investigations for intussusceptions?
* 1st line = Abdominal USS → “Target Mass”
* 2nd line = Abdominal X-Ray → paucity of air in RUQ + large bowel, thickened wall (oedema), poorly defined liver edge, dilated small bowel loops
* 3rd line = barium enema
54
What is the management of intussusception?
* **Drip and Suck**
* **Surgery**
* **1st line = rectal air insufflation / barium/gastrograffin enema**
* Process = barium trickled in, assess location + treat
* *Success rate 75% → 25% require operation*
* **2nd line / Perforation = surgical reduction**
* **Broad-spectrum antibiotics**
* Clindamycin + gentamicin
* Tazocin
* Cefoxitin + vancomycin
55
What is the prognosis of intussusception?
* 5% recurrence
* If recurrent = investigate for a lead point
* Meckel's diverticulum
* Polyps
56
Define Meckel's Diverticulum.
An ileal remnant of the vitello-intestinal duct on anti-mesenteric border containing ectopic gastric mucosa *(i.e. can form gastric ulcers that bleed)* or pancreatic tissue.
57
What are the signs and symptoms of Meckel's diverticulum?
* PAINLESS MASSIVE PR bleeding - dark red
* Present at 1-2 years old
* Bilious vomiting
* Dehydration
* Intractable constipation
* May present in addition to:
* Intussusception
* Volvulus
* Diverticulitis
58
What are the appropriate investigations for Meckel's diverticulum?
* **Technetium scan** (Meckel’s scan) = indicates increased uptake by gastric mucosa in 70% of cases
* AXR or abdominal USS ± laparoscopy
59
What is the management of Meckel's diverticulum?
* Asymptomatic / Incidental imaging finding = **no treatment**
* Symptomatic:
* Bleeding = **excision of diverticulum with blood transfusion** (if haemodynamically unstable)
* Obstruction = **excision of diverticulum and lysis of adhesions**
* Perforation/peritonitis = **excision or small bowel segmental resection with perioperative antibiotics**
* *Cefotaxime, clindamycin/metronidazole*
60
What is the ‘Rule of 2’s' in Meckel's diverticulum?
* (1 to) 2-years-old
* 2% population
* 2x more common in boys
* 2 feet from ileocecal valve (2 feet for adult)
* 2 inches long
* 2 different mucosae (gastric and pancreatic)
61
Define Volvulus.
A loop of intestine twists around itself and the mesentery that supports it, resulting in a bowel obstruction.
62
What predisposes an infant to volvulus/malrotation?
* **Mesentery not fixed to duodenal flexure or ileo-ceacal region**
* Can occur during rotation of the GI tract during foetal development → shorter base with volvulus ± Ladd bands obstruct duodenum → biliary vomiting
* **Exomphalos**
* **Congenital diaphragmagmatic hernia**
63
What are the signs and symptoms of volvulus/malrotation?
* Asymptomatic and present at any age with volvulus
OR
* Present in first few days of life with obstruction ± compromised blood supply
* Abdominal pain
* Bilious vomiting
* Peritonism
* Scaphoid abdomen (i.e. concave abdomen)
64
What are the appropriate investigations for suspected volvulus in an infant?
* **Upper GI contrast study** → assess patency if bilious vomiting
* **USS**
65
What is the management of volvulus in an infant?
* **Urgent laparotomy** - Ladd’s procedure if signs of vascular compromise
* Untwist volvulus
* Mobilize duodenum
* Place bowel in non-rotated position
* Remove necrotic bowel
66
Define Irritable Bowel Syndrome (IBS).
Altered GI mobility and abnormal sensation ± psychosocial stress and anxiety effect.
* Often a FHx component
* Coeliac’s/UC/Crohn's must be excluded → diagnosis of exclusion
* Symptoms may be precipitated by GI infection
67
What are the signs and symptoms of IBS?
* Abdominal pain – *often worse before or relieved by defecation*
* Explosive loose or mucus stools
* Bloating
* Feeling of incomplete defecation – tenesmus
* Constipation
68
What are the causes of recurrent abdominal pain in children?
* Somatisation / No structural causes - \>90%
* Gastrointestinal
* IBS
* Constipation
* Non-ulcer dyspepsia / Peptic ulceration / Gastritis
* Abdominal migraine
* Eosinophilic oesophagitis
* IBD
* Malrotation / Volvulus
* Gynaecological
* Dysmenorrhoea
* Ovarian cysts
* PID
* Abuse / Bullying
* Hepato-pancreatic
* Hepatitis
* Gallstones
* Pancreatitis
* Urinary tract
* UTI
* PUJ obstruction
69
What signs and symptoms suggest an organic disease instead of IBS?
* Night-time epigastric pain, haematemesis → duodenal ulcer
* Diarrhoea, weight loss/growth failure, blood in stools → IBD
* Vomiting → pancreatitis
* Jaundice → liver disease
* Dysuria, secondary enuresis → UTI
* Bilious vomiting, abdominal distension → volvulus/malrotation
70
What are the causes of gastroenteritis?
* Rotavirus infection - *most common cause (60%)*
* Campylobacter jejuni
* Shigella
* Salmonella
* Cholera
* E. coli
* Protozoan (Giardia, Cryptosporidium)
71
What organisms cause bloody diarrhoea in infants?
* **CHESS**
* **C**ampylobacter
* **H**aemorrhagic E. coli (O157:H7)
* **E**ntamoeba histolytica
* **S**almonella
* **S**higella
72
What organisms causes severe abdominal pain and bloody stool?
Campylobacter jejuni
73
What organisms causes blood/pus in stool, pain, tenesmus and fever?
* Shigella
* Salmonella
74
What organisms causes dehydrating diarrhoea?
* Cholera
* E. coli
75
What are the signs and symptoms of gastroenteritis?
* Sudden change to loose-stools and accompanied by vomiting
* Potential travel history
* Complications = dehydration → shock
* *Increased risk if*
* *\<6m old*
* *\>5 diarrhoeal stools in \<24hrs*
* *\>2 vomits in \<24hrs*
* *Cannot tolerate extra fluids or malnourished*
76
What are the appropriate investigations for suspected gastroenteritis?
* AXR and exclude other causes
* Stool sample analysis
* Young/viral cause = stool electron microscopy
* Older/bacterial cause = stool culture
77
What is the management of gastroenteritis?
* **Rehydration advice**
* Maintenance fluid volumes
* 0-10 kg = 100ml/kg
* 10-20kg = 1000ml + 50ml/kg for each kg over 10kg
* 20+ kg = 1500ml + 20ml/kg for each kg over 20kg
* Modes of rehydration:
* \<5yo = 50 ml/kg IV fluids over 4 hours as well as maintenance with oral rehydration solution
* 5+ years = 200 mL after each loose stool
* Do not drink sugary or carbonated drinks
* **Pain management / Calpol** - if appropriate
* **Do not give anti-diarrhoeals to \<5yo**
* **Give advice on preventing spread and follow-up**
* *Notify the Health Protection Unit if:*
* *Campylobacter*
* *Listeria*
* *E. coli O157*
* *Shigella*
* *Salmonella*
* **Safety net**
* Diarrhoea = usually 5-7d → most stop within 2 weeks
* Vomiting = usually 1-2d → most stop within 3 days
78
How is dehydration assessed in a child?
* **Weight loss is the most accurate marker**
* \<5% loss of body weight = no clinically detectable dehydration
* 5-10% = clinical dehydration
* \>10% = shock
* Can use clinical signs to estimate degree of dehydration
79
What are the signs and symptoms of hypernatraemia?
* **F**ull **OF SALT**
* Flushing
* Oedema
* Fever
* Seizures
* Agitation / jittery movements
* Low urine output
* Thirst
80
What are the signs and symptoms of hyponatraemia?
* **SALT LOSS**
* Stupor
* Anorexia (+ N&V)
* Limp tone
* Tendon reflexes reduced
* Lethargy
* Orthostatic hypotension
* Seizures
* Stomach cramps
81
What are the appropriate investigations for suspected dehydration?
* Clinical Examination
* U&E
* FBC
* Stool M&C
* Only if bloody diarrhoea / CHESS organisms
82
What is the management of dehydration in a child?
* Clinical dehydration = **oral rehydration solution**
* Oral rehydration solution contains glucose → absorption in gut → water follows glucose
* Shock / deterioration / persistent vomiting / sick child = **IV fluids**
* Shock = bolus fluids
* 20mL/kg 0.9% NaCl over 15 minutes most situations
* 10mL/kg 0.9% NaCl over 60 minutes trauma, fluid overload, heart failure
* Dehydration corrections (over 24 hours)
* Add to maintenance fluids
* Weigh child (or estimate weight)
* *3% weight lost in 20kg child*
* *20kg = 20,000 ml fluid*
* *3% weight lost = 600ml*
* Normal maintenance = “4:2:1 Approach”
* *Male = 2,500ml/day, female = 2,000ml/day*
* *5% dextrose*
* *0.9% sodium chloride*
* 4x≤10 + 2x≤10 + 1xRest of weight
* *2kg (2,0,0) = 4x2 + 2x0 + 1x0 = 8ml/hour (192ml/day)*
* *12kg (10,2,0) = 4x10 + 2x2 + 1x0 = 44ml/hour (1,056ml/day)*
* *70kg (10,10,50) = 4x10 + 2x10 + 1x50 = 110ml/hour (2,640mL/day à 2,500mL/day)*
83
What is neonatal fluid resuscitation maintenance requirements?
For term neonates use isotonic crystalloids with 10% dextrose
* Day 0 = 60 ml/kg/day
* Day 1 = 90 ml/kg/day
* Day 2 = 120 ml/kg/day
84
How is DKA fluid resuscitation different from others?
1. Always give bolus in DKA
2. Deficit calculated from pH of blood gas
3. Dextrose not given in immediate infusion
85
How is hypernatraemic dehydration fluid managed?
* Oral rehydration solution
* If IV fluids
* Take care with cerebral oedema / central pontine myelinolysis
* Fluid deficit replaced over at least 48 hours and the plasma sodium should be measured regularly → no faster adjustment than 8-10mg/L
86
How are anti-diarrheal and anti-emetics used in childhood dehydration?
* **NOT** used in children
* Ineffective
* May prolong the excretion of bacteria in the stools
* Can be associated with side-effects
* Add unnecessarily to cost
* Focus attention away from oral rehydration
87
How are antibiotics used in childhood dehydration/diarrhoea?
* Not routinely required to treat gastroenteritis
* Indications
* Suspected or confirmed **sepsis**
* **Extra-intestinal spread** of bacterial infection
* **Malnourished**
* **Immunocompromised**
* Specific bacterial or protozoal infections
* **C. difficile** associated with pseudomembranous colitis
* **Salmonella** (\<6 months)
* **Cholera**
* **Shigellosis**
* **Giardiasis**
88
What is post-gastroenteritis syndrome?
* Introduction of a normal diet results in a return of the watery diarrhoea following gastroenteritis
* Treatment = oral rehydration therapy
89
Define Crohn's Disease.
Inflammation, in patches, to any part of the GI tract from mouth to anus.
90
Which segment of bowel is most commonly affected in Crohn's?
**Distal ileum** and **Proximal colon**
91
What are the signs and symptoms of Crohn's disease?
* Abdominal pain
* Diarrhoea
* Weight loss/growth failure/delayed puberty
* Fever
* Lethargy
* Aphthous ulcers
* Perianal skin tags
* Uveitis
* Arthralgia
* Erythema nodosum
* Complications → inflamed thickened bowel is susceptible to strictures and fistulae
92
What are the appropriate investigations for suspected Crohn's disease?
* Bloods
* FBC (including iron, B12 and folate)
* CRP and ESR
* **Faecal calprotectin**
* **Colonoscopy and biopsy** (cobblestones)
* Histology
* Mucosal inflammation/ulceration,
* Crypt damage
* Fistulas / sinus tracts
* Deep ulcerations
* Marked lymphocytic infiltration
* Serositis
* Granulomas
* Upper GI and small bowel contrast scan
93
What is the management of active Crohn's disease in a child?
* Nutritional management → effective in 85-100% patients
* Replace diet with whole **protein modular diet** – excessively liquid, for 6-8 weeks
* May need NG if the child struggles to drink that much
* Products are easily digested, provide all nutrients needed to replace lost weight
* Pharmacological management → **steroids (prednisolone)**
94
What is the management to maintain remission of Crohn's disease in a child?
* **Aminosalicylates** (e.g. mesalazine)
* **Immunosuppressive drugs** - azathioprine, methotrexate, mercaptopurine
* Azathioprine cannot be given to people with a TPMT mutation
* Must not have live vaccines
* Must have pneumococcal and influenza vaccines
* **Anti-TNF antibodies** in biologic therapies (e.g. infliximab)
* **Diet and education**
* **Management of linked conditions** - anaemia etc
* Assess **impact on daily functioning** (anxiety, depression)
* **Stopping smoking** (reduce risk of relapse)
* Assess risk of **osteoporosis**
95
What are the complications of surgery for Crohn's disease?
* Obstruction
* Fistula
* Abscess
* Severe localized disease unresponsive to treatment
96
What counselling should be given to child/parents with a child with Crohn's disease?
* **Explain diagnosis** → a disease with an unknown cause that causes inflammation of the digestive system leading to malabsorption and bloody diarrhoea
* Explain that it is a **life-long condition** and there is always a risk of relapse
* **Reassure there are many medications to settle down inflammation** any time it flares up
* Explain that they will be **seen by a gastroenterologist**
* Explain **complications** (malabsorption and bowel cancer)
* **Support groups**: Crohn’s and Colitis UK
97
Define UC.
Inflammation and ulcers of the colon and rectum, progressing from the rectum in a continuous pattern to the colon.
* Partial thickness
* Crypt damage
98
What are the signs and symptoms of UC?
* Classic presentation is:
* **Rectal bleeding**
* **Diarrhoea**
* **Abdominal pain**
* Weight loss and growth failure
* Erythema nodosum
* Arthritis
99
What are complications/associations with UC?
* PSC
* Toxic megacolon
* Perforation
* Enteric arthritis
* Haemorrhage
* Bowel cancer
100
What are the appropriate investigations for suspected UC?
* Bloods
* FBC (including iron, B12 and folate)
* CRP and ESR
* **Colonoscopy and biopsy**
* Mucosal inflammation/ulceration,
* Crypt damage
* Small bowel imaging to rule out extra-colonic Crohn's manifestations
101
What grading system is used in UC?
* **Paediatric Ulcerative Colitis Activity Index (PUCAI)**
* Severe = \>65 points
* Mild-Moderate = 10-64 points
* **Truelove and Witts score**
102
What is the management of UC?
* 1st line = topical → oral **aminosalicylates**
* Often used to maintain remission
* Can use oral azathioprine or mercaptopurine if aminosalicylates insufficient
* 2nd line = topical → oral **corticosteroid**
* Prednisolone
* Beclomethasone
* 3rd line = oral **tacrolimus**
* 4th line: **biological agents**
* Infliximab, adalimumab and golimumab
* 5th line = **surgery** - colectomy with ileostomy or ileojejunal pouch
* Medical education / support
* Crohn’s and Colitis UK
* UC is associated with an increased risk of bowel cancer
* Regular screening performed after 10 years of diagnosis
103
What is the management of severe/fulminating UC?
EMERGENCY
* MDT approach (medics and surgeons)
* IV corticosteroids or ciclosporin and assess likelihood of needing surgery
* Increased likelihood of needing surgery if:
* Stool frequency \> 8 per day
* Pyrexia
* Tachycardia
* AXR showing colonic dilatation
* Low albumin
* Low Hb
* High platelets/CRP
104
What counselling should be given to child/parents with a child with UC?
* **Explain diagnosis →** condition of unknown cause that leads to inflammation of bowel, which leads to symptoms
* Explain it **isn’t common** but is a **well-known** disease (1 in 420)
* Explain that there is **no cure** and it is a condition that tends to come and go in **flare-ups every so often** - surgery can cure
* **Medications can reduce likelihood and treat flare-ups**
* Explain the **complications** (growth issues, bowel cancer)
* Explain that they will be seen by a **gastroenterologist**
* **Support groups**: Crohn’s and Colitis UK
105
Define Toddler Diarrhoea.
Chronic and non-specific diarrhoea caused by underlying maturational delay in intestinal mobility.
106
What are the signs and symptoms of toddler diarrhoea?
* Varying consistency stools
* Well-formed to explosive and loose ± presence of undigested vegetables in stool
* Child is well and thriving
* No precipitating dietary factors
* Normal examination
107
What is the commonest cause of loose stool in pre-school children?
Toddler diarrhoea
108
What is the management of toddler diarrhoea?
* Increased fibre and fat in diet
* Whole milk, yoghurts, cheeses → relieve symptoms
* Avoid fruit juice and squash
109
Define Anal Fissure.
Tears in skin around the anus, usually as a side effect of constipation → sphincter stretches to allow hard dry stool out
110
What are the signs and symptoms of anal fissure?
* Painful passing of stool
* Bright red blood on tissue
* Can examine for fissures
* DRE
* Protoscopy
111
What is the management of anal fissures?
* **Conservative = ensure stools are soft** and easy to pass
* *Increase dietary fibre*
* *Increase fluid intake*
* *Manage pain – simple analgesia; sit in shallow, warm bath*
* *Topical anaesthetics can be used (i.e. lidocaine)*
* *Anal hygiene*
* *Advise against stool withholding*
* **Consider constipation treatment pathway**
* Safety net → seek further help if not healed within 2 weeks
112
Define Hirschprung's Disease.
An absence of ganglion cells from the myenteric and submucosal plexuses → begins at the rectum and spreads proximally for a variable distance (75% rectosigmoid), ending at normally innervated, dilated colon.
113
What are the complications of Hirschprung's disease?
* Meconium plug syndrome
* Hirschprung’s enterocolitis - perforated colon
114
What are the risk factors for Hirschprung's disease?
* Down's
* MEN2a
* Male
* Del(Chr10)
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What are the signs and symptoms of Hirschprung's disease?
* Failure to pass meconium \<24hrs
* Abdominal distension
* Bile-stained vomiting
* Explosive passage of liquid/foul stools
* May present later in first few weeks of life with severe, life-threatening Hirschsprung enterocolitis (C. diff)
116
What are the appropriate investigations for suspected Hirschprung's disease?
* Initial
* AXR - *if obstruction*
* Contrast/barium enema → dilated distal segment + narrowed proximal segment
* Definitive
* Suction-assisted full-thickness rectal biopsy → absence of ganglion cells, ACh +ve nerve trunks
117
What is the management of Hirschprung's disease?
* Initial management = **Bowel irrigation**
* Afterwards = **Endorectal pull-through** – *colostomy followed by anastomosing normally innervated bowel*
* Total colonic agangliosis would require initial ileostomy with later corrective surgery
* Other procedures
* Recto-sigmoidectomy
* Retro-rectal trans-anal pull-through
* Ano-rectal myomectomy
118
What are the signs and symptoms of threadworm infection?
* Itching around the anus or vagina - worse at night
* Irritability - due to waking up during the night
119
What is the management of threadworm infection?
* Single dose of an anti-helminth = mebendazole
* *Dose may be repeated in 2 weeks if infection persists*
* Advise rigorous hygiene for 2 weeks if on mebendazole or 6 weeks if using hygiene measures alone
* *Hand washing*
* *Cut fingernails regularly, avoid biting nails and scratching around anus*
* *Shower each morning, including the perineal area, to remove eggs from skin*
* *Change bed linin and nightwear daily for several days after treatment*
* *Thoroughly dust and vacuum*
* Exclusion from school/nursery is NOT required
* Children \<6 months should be treated with hygiene measures alone for 6 weeks - *seek advice from ID specialist*
* Consider treating all household contacts
120
What is the pathophysiology of lactose intolerance?
Lactase deficiency → lactose ferments in gut → ↑ waste gas → pain and bloating
* *Lactose converts glucose and galactose*
121
What are the risk factors for lactose intolerance?
* **FHx**
* **Ethnicity**
* Affects up to 75% of world’s population
* More Asian, African and Hispanic
* Less in Caucasian
122
What are the causes of lactose intolerance?
* Primary (70%)
* Deficient lactase (Asian, African, Hispanics)
* Secondary
* Damage to gut
* Temporary lactase deficiency
* Gastroenteritis
* Crohn’s
* Coeliac
* Alcoholism
123
What are the signs and symptoms of lactose intolerance?
* Wind
* Diarrhoea
* Bloating with lactose ingestion
* Abdominal rumblings
* Abdominal pain
124
What are the appropriate investigations for suspected lactose intolerance?
* **Clinical diagnosis** - trial lactose-free diet for 2 weeks and monitor symptoms
* **Breath hydrogen test** *- raised H2*
* FBC - rule out secondary disease → anaemia, ↑WCC
* Exclude alternate diagnosis
* Gastroenteritis - **stool sample**
* Crohn’s - **faecal calprotectin, colonoscopy**
* Coeliac’s - **anti-tTG/EMA**
125
What is the management of lactose intolerance?
* **Dietician referral**
* **Avoid milk and dairy products**
* **Provide calcium and vitamin-D supplementation**
* For primary LD:
* Experiment with diet – different with each child, need to discover individual lactose threshold
* Potential foods:
* High-fat dairy (lower lactose)
* Hard cheeses
* Milk substitutes (almond, soya, coconut)
* For secondary LD:
* Cut out dairy and allow gut time to heal
* Digestive enzymes can be taken in a capsule before eating lactose until gut heals/matures
126
Define Coeliac's Disease.
Autoimmunity to gliadin resulting in shorter villi, flat mucosa and damage to proximal small intestinal mucosa.
* Rate of migration of absorptive cells moving up the villi is massively increased but insufficient to compensate for increased cell loss from the villous tips
127
What are associated with Coeliac's disease?
* HLA DQ2 - *95%*
* DQ8 - *80%*
128
What are the signs and symptoms of Coeliac's disease?
* **Malabsorption syndrome** - presents 8-24m after wheat introduction to diet
* Failure to thrive
* Abdominal distension
* Bloating
* Irritability
* **Malnutrition** *(picture)*
* Wasted buttocks
* Distended abdomen
* **Dermatitis herpetiformis** - *pathogenomic*
* Pruritic papulovesicular elbow/knee rash)
129
What are the appropriate investigations for suspected Coeliac's disease?
* Serology
* Most sensitive = **IgA tissue transglutaminase (anti-tTG)**
* Less sensitive = IgA anti-endomysial (anti-EMA)
* *If IgA deficient = IgG DGP*
* FBC - *iron deficient, vitamin B12/folate deficient, vitamin D deficient*
* Blood smear
* Confirmation of diagnosis (grading with the ‘Marsh’ system):
* Older children / adults = **OGD + jejunal biopsy**
* *Villous atrophy, crypt hyperplasia, ↑ IELs*
* Very young children = no histopathological confirmation
130
What is the management of Coeliac's disease?
* **Remove all products containing wheat, rye and barley**
* Dietician referral - *if problems with adhering to the diet and annual review*
* Regular checks of height, weight and BMI – *check at home*
* Review symptoms
* Review adherence to diet
* Consider blood tests (coeliac serology, FBC, TFT, LFT, vitamin D, B12, folate, calcium, U&E)
* Support sources - Coeliac UK
* Explain the importance of keeping to a strict gluten-free diet
131
What are the complications of non-adherent Coeliac's disease?
* Micronutrient deficiency (vitamin D, iron)
* Osteoporosis
* EATL
* Hyposplenism
132
What is the cause of mesenteric adenitis?
* **Recent viral/bacterial infection**
* Common cause of abdominal pain → mainly in \<15yo
133
What are the signs and symptoms of mesenteric adenitis?
* Abdominal pain – central or RIF
* Nausea ± diarrhoea
* ↓ appetite
* Infectious picture
* High temperature
* Lymphadenopathy
* ↑ WCC often preceded by UTI
134
What are the appropriate investigations for mesenteric adenitis?
* Diagnosis of exclusion
* Laparoscopy is a bit much
* Exclude appendicitis → bloods, urine MC&S
* Laparoscopy = definitive
* Large mesenteric lymph nodes with normal appendix
135
What is the management of mesenteric adenitis?
* **Simple analgesia** - *symptoms usually resolve in a few days, maximum 2 weeks*
* Antibiotics - rare
* Safety net for increased pain, deterioration, etc.
136
Define Encopresis.
Soiling of underwear with stool in children who are past the age of toilet training (\>4yo)
* Usually due to constipation with overflow
137
What is the management of encopresis?
* Enquire about:
* Psych stressors
* Changes in medications
* Food intolerances
138
What are the types of Hernia?
* Indirect inguinal
* Umbilical
* Epigastric
* Femoral
139
What is the pathophysiology of indirect inguinal hernias?
* During development, the testicles develop inside the abdomen and towards the end of the pregnancy, each testicle creates a passage (process vagialis) as it travels into the scrotum
* Failure of this passage to close → abdominal lining and bowel protrude through defect
* If bowel remains trapped → could become damaged due to increased pressure on the blood supply to the area → bowel death → serious infection and bowel disorders
140
What are the risk factors for an indirect inguinal hernia?
* Male
* Prematurity
* Connective tissue disorder
141
What are the signs and symptoms of indirect inguinal hernias?
* Scrotal sac enlarged → containings palpable loops of bowel and/or fluid
* Pain
* Swelling or bulge may be intermittent → can appear on crying or straining
142
What are the appropriate investigations for a suspected indirect inguinal hernia?
* **Clinical diagnosis**
* Exclude hydrocele → use torch → hydrocele always transluminates
* Determine type of hernia → examine supine and standing, try to reduce it
* More commonly on right (60%) due to delayed descent of right testicle
143
What are the signs and symptoms of an incarcerated indirect inguinal hernia?
* Tender, firm mass
* Vomiting
* Obstruction
* Poor feeding
* Erythematous/discoloured skin overlying
144
What is the management of indirect inguinal hernias?
* **Urgent Surgical correction** (lap or open) = Elective herniorrhaphy (risk of strangulation/incarceration)
* \<6w old = correct within 2 days
* \<6m old = correct within 2 weeks
* \<6yo = correct within 2 months
145
What are the risk factors for umbilical hernias?
* Afro-Caribbean
* Down’s
* Mucopolysaccharide diseases
146
What is the management of umbilical hernias?
* \<1yo = watch and wait
* \>1yo
* Large or symptomatic = surgical repair 2-3yo
* Small or asymptomatic = surgical repair 4-5yo
147
What are the signs and symptoms of a femoral hernia?
* Scrotal sac enlarged below the inguinal canal → containings palpable loops of bowel and/or fluid
* Pain
* Swelling or bulge may be intermittent → can appear on crying or straining
* Difficult to differentiate from indirect hernia → often done so during operation
148
Define Gastroschisis.
Paraumbilical abdominal wall defect resulting in abdominal contents outside the body, without peritoneal covering.
149
What is the management of gastroschisis?
Immediate surgery → cover with cling-film
150
Define Omphalocele.
Bowel protruding out the body with a peritoneal covering / umbilical attached.
151
What is the management of omphalocele?
* Staged closure
* Starting immediately and finishing at 6-12 months
152
What is associated with omphalocele?
* Chromosomal abnormalities in 15% of cases
* Trisomy 13 (Patau’s)
* Trisomy 18 (Edward’s)
* Trisomy 21 (Down’s)
* Turner’s
153
Define Acute liver failure.
Massive hepatic necrosis with loss of liver function ± hepatic encephalopathy.
154
What are the causes of acute liver failure in a child under 2?
* **Infection - HSV**
* **Metabolic disease**
* Seronegative hepatitis
* Drug-induced
* Neonatal haemochromatosis
155
What are the causes of acute liver failure in a child over 2?
* **Paracetamol overdose**
* **Viral infection - HBV, HCV**
* **Autoimmune - hepatitis, sclerosing cholangitis**
* **Non-alcoholic fatty liver disease**
* Wilson's disease
* Seronegative hepatitis
* Fibropolycystic liver disease
* CF
* A1AT deficiency
* Drug-induced
156
What are the signs and symptoms of Wilson's disease?
* Kayser-Fleischer rings
* Psychosis
* Jaundice
157
What is Wilson's disease?
Excess copper build-up.
158
What are the signs and symptoms of acute liver failure?
* Jaundice
* Encephalopathy
* *Irritable → confusion/drowsiness episodes*
* Coagulopathy
* Hypoglycaemia
* Electrolyte disturbance
* Aggressive / unusually difficult → older children
159
What are the appropriate investigations for suspected acute liver failure?
* **LFTs**
* Massively raised = AST and ALT - *liver inflammation*
* Raised = ALP
* **Clotting/INR** – abnormal - liver function
* **Plasma ammonia** - raised
* **EEG and CT** – acute hepatic encephalopathy and cerebral oedema
160
What is the management of acute liver failure?
* Referral to a national paediatric liver centre
* **Treat the cause** of acute liver failure
* Steps to stabilise the child
* Maintaining blood glucose (\> 4 mmol/L) = **IV dextrose**
* Prevent sepsis = **broad-spectrum antibiotics and antifungals**
* Prevent haemorrhage = **IV vitamin K** and **H2 antagonists/PPIs**
* Prevent cerebral oedema = **fluid restriction** and **mannitol**
161
What are the features of a poor prognosis due to acute liver failure?
* Shrinking liver
* Rising bilirubin
* Coma
* Falling transaminases
* Worsening coagulopathy
162
What are the complications of acute liver failure?
* Hepatic encephalopathy
* Cirrhosis
* Portal HTN
163
What is the management of hepatic encephalopathy?
* Supportive
* Reduce N2 → lactulose and antibiotics
164
What is the management of cirrhosis and/or portal hypertension?
* Fluid restrict
* Diuretics
165
What antibodies are present in PBC?
Anti-mitochondrial
166
What antibodies are present in PSC?
* pANCA
* Anti-smooth muscle
167
What is the management of autoimmune hepatitis?
* **Prednisolone** and **azathioprine**
* **Liver transplants** may be considered in severe cases
* *Sclerosing cholangitis = ursodeoxycholic acid (aids bile flow)*
168
What is the management of Wilson's disease?
* **Zinc** - *block intestinal zinc absorption*
* **Trientine** / **Penicillamine** - *increases urinary copper excretion*
* **Pyridoxine** (vitamin B6)
* **Symptomatic treatment** for tremor, dystonia and speech impediment
* **Liver transplantation** in children with end-stage liver disease
169
What is the management of non-alcoholic fatty liver disease?
* Weight loss
* Treatment of insulin resistance and diabetes
* Statins
* Vitamin E and C
* Ursodeoxycholic acid - *improved bile flow*
170
What is the management of paracetamol overdose?
* \<1 hour = **activated charcoal**
* N-acetylcysteine if paracetamol level ≥4 hours still dangerously raised after ingestion
* \>1 hour = **N-acetylcysteine**
