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Paediatrics > Gastroenterology > Flashcards

Gastroenterology Flashcards

1
Q

8 causes of vomiting

A
  1. Overfeeding
  2. Gastro-oesophageal reflux
  3. Intestinal obstruction: Pyloric stenosis (projective vomiting), Intussusception, Inguinal hernias, Hirschsprung, Malrotation, Atresia, Volvulus
  4. Sepsis
  5. Gastritis or gastroenteritis
  6. Appendicitis
  7. Infections such as UTI, tonsillitis or meningitis
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2
Q

Red flag features of vomiting

A
  • Projectile or forceful vomiting (pyloric stenosis or intestinal obstruction)
  • Vomiting at end of paroxysmal cough (whooping cough)
  • Bile stained vomit (intestinal obstruction)
  • Haematemesis (peptic ulcer, oesophagitis or varices)
  • Abdominal distention (intestinal obstruction)
  • Reduced consciousness, bulging fontanelle or neurological signs (meningitis or raised intracranial pressure)
  • Respiratory symptoms (aspiration and infection)
  • Blood in the stools (gastroenteritis or cows milk protein allergy)
  • Signs of infection (pneumonia, UTI, tonsillitis, otitis or meningitis)
  • Rash, angioedema and other signs of allergy (cows milk protein allergy)
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3
Q

What is difference between GOR and GORD in infants

A
  • GOR: gastric contents into oesophagus (+/- regurg, vomiting). [Normal for baby to reflux feeds. Not a problem if normal growth and otherwise well. Usually stops after 1 year.]
  • GORD: presence of troublesome symptoms and/or complications of persistent GER.
    [Under year doesn’t usually experience same symptoms as children over 1 year/adults: heartburn, acid regurgitation, epigastric pain, bloating.]
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4
Q

Cause of GOR in infants

A
  • immaturity of lower oesophageal sphincter leads to inappropriate relaxation.
  • predominantly fluid diet, mainly horizontal posture, short intraabdominal length of oesophagus
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5
Q

Problematic features of GORD

A
  • faltering growth/failure to thrive/ IDA
  • oesophagitis +/- stricture
  • apnoea
  • aspiration, wheezing
  • seizure like events
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6
Q

Treatment of uncomplicated reflux in infants (under 1)

A
  • parental reassurance
  • small, frequent meals
  • Keeping baby upright
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7
Q

Treatment of problematic GORD

A
  • gaviscon
  • thickened milk
  • ranitidine (h2 receptor antagonist)
  • omeprazole (proton pump inhibitor)
  • nissen fundiplication
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8
Q

What age does malrotation, pyloric stenosis and intussusception typically present?

A

malrotation: 24 hours, pyloric stenosis: 4 weeks, intussusception: 6 months

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9
Q

Why is color of vomiting important in diagnosis and what are the causes of bilious vomiting?

A
  • If non-bilious then caused by obstruction above ampulla of vater (junction of bile ducts + duodenum)
  • bilious: malrotation/volvulus, hirschsprung, intestinal atresia, intussusception (+/-, depend on site) , strangulated hernia
  • non-bilious: pyloric stenosis, intussusception (+/-), inhaled foreign body
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10
Q

Pathology of pyloric stenosis

A

hypertrophy of the pyloric muscle causing gastric outlet obstruction. Increasing peristalsis as tries to push into duodenum but eventually so powerful pushes food back up and causes projectile vomit.

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11
Q

Features of pyloric stenosis

A
  • presents 2-7 weeks
  • projectile, milky, vomiting
  • hungry, dehydrated, thin, pale baby. Failure to thrive
  • firm, round mass in upper abdomen. ‘Olive-like’
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12
Q

What does blood gas analysis show in pyloric stenosis (common exam q)

A
  • hypocholoraemic (low chloride) metabolic alkalosis
  • low plasma sodium (hyponatremia) and potassium (hypokalaemia)
  • due to vomiting of Hydrochloric acid from stomach
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13
Q

How to tell metabolic acidosis/alkalosis against respiratory acidosis/alkalosis

A

pH: Low = acidodis, High = alkalosis
HCO3- High/Low = metabolic alkalosis/metabolic acidosis
CO2 High/Low = respiratory acidosis/respiratory alkalosis

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14
Q

Diagnosis and treatment of pyloric stenosis

A

Abdo US. Rehydration + correction of electrolyte imbalance followed by Pyloromotomy surgery.

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15
Q 
Character of abdo pain in:
Appendicitis
Intusussception
Bowel obstruction
Testicular torsion
A
  • Appendicitis: central abdominal pain spreading to the right iliac fossa
  • Intussusception: colicky non-specific abdominal pain with redcurrant jelly stools
  • Bowel obstruction: pain, distention, absolute constipation and vomiting
  • Testicular torsion: sudden onset, unilateral testicular pain, nausea and vomiting
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16
Q

What age is acute appendicitis very unlikely

A

Under 3 years old

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17
Q

Presentation of appendicitis

A
  • Symptoms: vomiting, abdo pain - central and colicky then right iliac fossa, fever, persistent tenderness with guarding in right iliac fossa
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18
Q

Mx of appendicitis - uncompl + complic.

A

Uncomplicated: appendicectomy
Complicated: perforation - fluid resus, IV Abx, then appendicetomy

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19
Q

What is non-specific/functional abdo pain

A
  • Non-organic or functional abdominal pain is very common in children over 5 years. This is where no disease process can be found to explain the pain.
  • Less severe than in e.g. appendicitis
  • DDx: chronic functional pain, IBS, Functional dyspepsia, abdominal migraine
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20
Q

What is intussusception and what sex + age is it most common in?

A

The bowel invaginates/telescopes in on itself

- male + 3month-2 years

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21
Q

Presentation of intussusception

A
  • colicky abdo pain, vomiting (may be bile stained), constipation (bowel obstr.)
  • sausage shaped mass in abdomen
  • redcurrant jelly stool
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22
Q

Dx of intussusception

A

Ultrasound or contrast enema

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23
Q

Mx of intussusception

A
  • enema (contrast, water or air) to pump out invagination
  • surgical reduction
  • if gangrenous or perforated bowel then resection
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24
Q

Complications of intussusception

A

obstruction, gangrenous bowel, perforation, sepsis/shock

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25
Q

What is malrotation and volvulus?

A
  • Malrotation - failure of the bowel to assume its normal place in the abdomen during intrauterine development.
  • Volvulus - complication of malrotation where the bowel twists around itself causing a blockage so contents cant pass through. Can also cut off blood supply.
26
Q

Px of malrotation and volvulus?

A
  • Malrotation can be asym. if no twisting.
  • volvulus: bilious vomiting, abdominal pain, constipation.
  • usually presents within first 24 hours of life but can present at any age
27
Q

Mx and Tx of malrotation with volvulus

A
  • urgent upper GI contrast study

- surgical correction

28
Q

Why can malrotation be life threatening

A

complete volvulus with compromised blood supply can lead to intestinal ischemia, mucosal necrosis and sepsis..

29
Q

What is an inguinal hernia

A

An inguinal hernia comprises a protrusion of abdominal contents through the fascia of the abdominal wall, through the internal inguinal ring.

30
Q

Inguinal hernia presentation

A
  • usually male
  • bulge in groin area
  • swelling in scrotum
  • pain. May appear with straining/lifting.
31
Q

What is a strangulated inguinal hernia

A
  • contents of hernia (e.g. part of intestines) become twisted, compromising the blood supply. Can cause infarction and bowel obstruction.
32
Q

Mx of inguinal hernia

A

surgery

33
Q

What is Meckel diverticulum and how treat

A
  • malformation of the distal ileum. Usually asymptomatic, but can bleed, become inflamed, rupture or cause a volvulus or intussusception.
  • Tx = surgical resection
34
Q

How is IBS diagnosed and what are the features?

A
  • symptom-based diagnostics without presence of an organic cause.
  • [A]bdominal pain (+2of)
  • [B]loating
  • [C]hange of bowel habit, form, frequency
  • [D]iarhoea or constipation intermittent.
35
Q

Causes of gastroenteritis in children

A
  • Mostly viral: rotavirus, noravirus, adenovirus (more subacute).
  • Bacterial: (suggestive by blood in stools). Camplyobacter, Shigella, Salmonella.
    Cholera +E coli associated with rapidly dehydrating diarrhea.
36
Q

Presentation of gastroenteritis

A
  • loose or watery stools and/or vomiting
  • febrile
  • close contacts, travel, contamination
  • blood -> usually camply or e.coli
  • assess for dehydration or shock
37
Q

Signs of dehydration

A
  • weight loss most accurate
  • deterioating condition
  • altered responsiveness (lethargic, irritable)
  • sunken eyes, dry mucous membranes, reduced skin turgor
  • tachypnoea, tachycardia
38
Q

Signs of shock

A
  • deteriorating, decreased consciousness
  • pale or mottled skin
  • grossly sunken eyes, reduced skin turgor
  • tachycardia, tachypnoea, weak pulses, prolonged cap refill, hypotension
39
Q

Fluid management of dehydration in gastroenteritis

A
  • no dehy: continue breast feed or milk feed, encourage fluid intake, consider ORS
  • dehy: ORS/fluid replacement. Consider IV therapy.
    If hypernatremic dehydration - use ORS IV slowly reducing plasma sodium.
  • shock: IV therapy (NaCl)
40
Q

In hypernatremic dehydration patient why not reduce ORS with low sodium straight away

A
  • want to slowly wean or will lead to shift of water into cerebral cells and may result in seizures and cerebral oedema.
41
Q

Mnemonics to differentiate Crohns from UC

A
  • (crows NESTS) No blood or mucus, Entire GI tract, Skip lesions (endoscopy), Transmural inflammation, Smoking rf
  • (U-C-CLOSEUP) Continuous inflammation, Limited to colon and rectum, Only superficial mucosa, Smoking is protective, Excrete blood and mucus, Use aminosalicylates, PSC
42
Q

Classic presentation of IBD

A
  • diarrhoea, abdo pain, weight loss, anaemia, fever during flare ups
  • blood in stools (more common in UC as may have inflammation around rectum)
43
Q

Extra-intestinal manifestations of IBD

A

Crohns: oral lesion, erythema nodosum, clubbing, arthritis, eye problems
UC: erythema nodosum

44
Q

Ix for IBD

A
  • raised CRP (active inflamm.)
  • faecal calprotectin positive
  • endoscopy w/biopsy = gold standard
45
Q

Mx of IBD

A
  • Crohns: inducing remission - prednisolone or hydrocortison (1st line = steroid.) Maintaining remission - azathioprine (1), methotrexate
  • UC: aminosalicylate [mesalazine] (1), prednisolone (2). Maintaining - aminosalicylate
  • Surgery -> treat strictures and fistulas (2dary to crohns), remove colon and rectum (UC)
46
Q

What is Coeliac disease

A
  • AI condition, exposure to gluten causes autoantibodies to be produced that target epithelial cells of intestine, resulting of atrophy of intestinal villi in jejnum.
47
Q

Px of Coeliac disease

A
  • May be asym.
  • failure to thrive in young children
  • diarrhoea
  • fatigue
  • mouth ulcers
  • anaemia secondary to iron, B12, folate deficiency
  • Dermatitis herpetiformis -> itchy blistering skin rash on abdomen
  • rarely - neurological symptoms
48
Q

Ix of Coeliac disease

A
  • anti-TTG

- duodenal biopsy

49
Q

What is the pathophysiology behind Hirschsprungs

A
  • congenital condition where nerve cells of myenteric plexus absent in distal bowel and rectum.
  • > absence of parasympathetic ganglion cells
  • myenteric plexus responsible for stimulating peristalsis
50
Q

Px of Hirschsprungs

A
  • delay in passing meconium (24hrs+)
  • chronic constipation since birth
  • abdo pain and distension
  • vomiting
  • poor weight gain and failure to thrive
51
Q

What is hirschsprung associated enterocolitis and what can it lead to

A

HAEC - inflammation + obstruction of intestine.

- Hirschsprung Px + sepsis, toxic megacolon, perforation of bowel

52
Q

Mx of Hirschsprung

A
  • Rectal biopsy - absence of ganglionic cells
  • fluid resus and surgicla removal of aganglionic section of bowel
  • fluid resus, IV Abx in HAEC
53
Q

What is biliary atresia

A
  • Congenital condition where section of bile duct is narrowed or absent.
    = Cholestasis
54
Q

Px of biliary atresia

A
  • significant jaundice, persistant more than 14/21 days
55
Q

Ix of biliary atresia and Mx

A
  • High proportion of conjugated bilirubin. Persisting for 14/21+
  • Surgery - Kasai portoenterostomy -> clears jaundice and prolongs survival. Patients require liver transplant to resolve.
56
Q

Px of constipation + Ix

A
  • hard stools
  • difficult to pass, straining
  • abdo pain
  • faecal impaction causing overflow soiling
  • Ix = mass palpable in abdomen
57
Q

How does desensitisation of rectum cause faecal impaction, in constipation

A
  • Patients ignore sensation of full rectum and lose sensation of needing to open bowels.
  • Retain faeces which causes faecal impaction. Can cause overflow soiling
  • Over time rectum stretches as fills with more faeces -> leads to further desensitisation of rectum.
58
Q

Mx of constipation

A
  • high fibre diet + good hydration
  • laxatives -> movicol
  • faecal impaction -> disimpaction with high dose of macrogol laxative (movicol). Unsucc: Stimulant laxative -> Osmotic laxative
59
Q

Red flags of constipation due to underlying disease

A
  • Not passing meconium within 24 hrs (CF or Hirschsprung)
  • Neurol. signs (Cerebral palsy or spinal lesion)
  • Vomiting (Hirschsprung or intestinal obstruction)
  • Abnormal lower back (spina bifida)
  • Failure to thrive (coeliac disease)
60
Q

What is Cows milk protein allergy

A
  • hypersensitivity to protein in cows milk
  • May be IgE mediated (rapid reaction) or non-IgE mediated (slower reaction)
  • (different to lactose intolerance - lactose is a sugar not a protein and cows milk intolerance)
61
Q

Px of Cow’s milk protein allergy

A
  • usually presents before 1 year of age. May be when weaned off breast milk to cows milk
  • GI symptoms:
    bloating + wind, abdo pain, diarrhoea, vomiting
  • General allergic symptoms (rash, swelling, wheeze, sneezing, eczema)
  • anaphylaxis in severe cases

Paediatrics (14 decks)

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