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Gastroenterology Flashcards

1
Q

What is the most common cause of abdominal pain?

A

Appendicitis

  • Rare in <3yo
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2
Q

What are the signs and symptoms of appendicitis?

A
  • Anorexia
  • Vomiting
  • Nausea
  • Umbilical → RIF pain
  • Fever
  • Generalised abdominal tenderness
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3
Q

What are the appropriate investigations for appendicitis?

A
  • FBC
  • Pregnancy test - if female
  • AXR ± CTAP
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4
Q

What is the management of appendicitis?

A
  • GAME
    • Group & Save
    • Abx IV
    • MRSA screen
    • Eat & drink - must be NBM
  • Appendicectomy
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5
Q

What are the possible diagnoses for the ‘red flag’ symptoms of bile-stained vomit?

A
  • Intestinal obstruction
    • Intussusception
    • Malrotation
    • Strangulated inguinal hernia
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6
Q

What are the possible diagnoses for the ‘red flag’ symptoms of haematemesis?

A
  • Oesophagitis
  • Peptic ulcer
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7
Q

What are the possible diagnoses for the ‘red flag’ symptoms of projectile vomit at 2-7 weeks old?

A
  • Pyloric stenosis
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8
Q

What are the possible diagnoses for the ‘red flag’ symptoms of vomiting at end of paroxysmal coughing?

A
  • Whooping
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9
Q

What are the possible diagnoses for the ‘red flag’ symptoms of abdominal tenderness?

A
  • Surgical abdomen
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10
Q

What are the possible diagnoses for the ‘red flag’ symptoms of abdominal distension?

A
  • Intestinal obstruction
  • Strangulated inguinal hernia
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11
Q

What are the possible diagnoses for the ‘red flag’ symptoms of hepatosplenomegaly?

A
  • Chronic liver disease
  • Inborn error of metabolism
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12
Q

What are the possible diagnoses for the ‘red flag’ symptoms of blood in stool?

A
  • Intussusception
  • Gastroenteritis
    • Ssalmonella
    • Campylobacter
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13
Q

What are the possible diagnoses for the ‘red flag’ symptoms of severe dehydration/shock?

A
  • Systemic infection
  • DKA
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14
Q

What are the possible diagnoses for the ‘red flag’ symptoms of bulging fontanelle/seizures?

A
  • Increased ICP
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15
Q

What are the possible diagnoses for the ‘red flag’ symptoms of failure to thrive?

A
  • CORD
  • Coeliac disease
  • Chronic GI
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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
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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
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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
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19
Q

What are the possible diagnoses for the ‘red flag’ symptoms of failure to pass meconium in first 24hrs?

A
  • Hirschsprung’s
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20
Q

What are the possible diagnoses for the ‘red flag’ symptoms of failure to thrive or growth failure?

A
  • Hypothyroid
  • Coeliac
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21
Q

What are the possible diagnoses for the ‘red flag’ symptoms of gross abdominal distension?

A
  • Hirschsprung’s
  • Other GI dysmotility
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22
Q

What are the possible diagnoses for the ‘red flag’ symptoms of abnormal lower limb neurology or deformation?

A
  • Lumbosacral pathology
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23
Q

What are the possible diagnoses for the ‘red flag’ symptoms of sacral dimple above nasal cleft?

A
  • Spina bifida occulta
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24
Q

What are the possible diagnoses for the ‘red flag’ symptoms of perianal fistulae/abscess/fissure?

A
  • Perianal Crohn’s
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25
Q

What are the normal bowel habits of an infant?

A
  • 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
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26
Q

What are the normal feeding habits of an infant?

A
  • 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
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27
Q

What are the causes of constipation in babies?

A
  • Hirschsprung’s
  • Anorectal abnormality
  • Hypothyroid
  • Hypercalcemia
  • Idiopathic
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28
Q

What are the causes of constipation in non-infant children?

A
  • Toilet training issues
  • Stress
  • Follows acute febrile illness
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29
Q

What are the complications of constipation?

A
  • Overdistended rectum
  • Loss of feeling the need to defecate → involuntary soiling with overflow
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30
Q

What are the possible diagnoses for the ‘red flag’ symptoms of perianal bruising or multiple fissures?

A
  • Sexual abuse
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31
Q

What is the management of constipation?

A
  • 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
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32
Q

What are the types of laxatives?

A
  • 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
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33
Q

What counselling should be given to parents with a child with constipation?

A
  • 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
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34
Q

What are the causes of acute abdominal pain?

A
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35
Q

What are the causes of gastroesophaegael reflux in children?

A
  • Inappropriate relaxation of LOS → most resolve by 1yo
  • If persistent = GORD
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36
Q

What are the appropriate investigations for gastroesophageal reflux in children?

A
  • Clinical diagnosis
  • 24hr LOS pH monitoring - normally remains mostly above 4
  • OGD
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37
Q

What are the reasons for a same day referral for gastroesophageal reflux?

A
  • Haematemesis
  • Melaena
  • Dysphagia present
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38
Q

What are the reasons for assessment by a paediatrician for gastroesophageal reflux?

A
  • 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
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39
Q

What are the complications of gastroesophageal reflux in a child?

A
  • Recurrent aspiration pneumonia
  • Apnoea
  • Epileptic seizure-like events
  • Upper airway inflammation
  • Dental erosion with neurodisability
  • Recurrent acute otitis media
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40
Q

What is the management of gastroesophageal reflux in a child?

A
  • 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
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41
Q

What counselling should be given to parents with a child with gastroesophageal reflux?

A
  • 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)
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42
Q

Define Pyloric Stenosis.

A

Hypertrophy of the pyloric muscle causing gastric outlet obstruction.

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43
Q

What is associated with pyloric stenosis?

A

Turner’s syndrome

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44
Q

What are the signs and symptoms of pyloric stenosis?

A
  • 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
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45
Q

What are the appropriate investigations for pyloric stenosis?

A
  • 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
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46
Q

What is the management of pyloric stenosis?

A
  • IV slow fluid resuscitation + correct any disturbances = 1.5x maintenance rate +5% dextrose + 0.45% saline
  • Laparoscopic Ramstedt pyloromyotomy
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47
Q

Define Infant Colic.

A

Describes a common abdominal symptom complex → 40% of babies in the first few months of life

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48
Q

What are the signs and symptoms of infant colic?

A
  • Manifests as random inconsolable crying and drawing up on the hands and feet
  • Resolves by 3-12 months
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49
Q

What is the management of infant colic?

A
  • 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
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50
Q

Define Intussusception.

A

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
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51
Q

What are the causes and associations of intussusception?

A
  • Causes
    • Idiopathic
    • Enlarged Peyer’s patches after gastroenteritis
    • Lead points
    • Cardiac hypertrophy
  • Associations
    • Lymphoma
    • Gastroenteritis
    • HSP
    • CF
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52
Q

What are the signs and symptoms of intussusception?

A
  • 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
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53
Q

What are the appropriate investigations for intussusceptions?

A
  • 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
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54
Q

What is the management of intussusception?

A
  • 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
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55
Q

What is the prognosis of intussusception?

A
  • 5% recurrence
  • If recurrent = investigate for a lead point
    • Meckel’s diverticulum
    • Polyps
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56
Q

Define Meckel’s Diverticulum.

A

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.

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57
Q

What are the signs and symptoms of Meckel’s diverticulum?

A
  • 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
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58
Q

What are the appropriate investigations for Meckel’s diverticulum?

A
  • Technetium scan (Meckel’s scan) = indicates increased uptake by gastric mucosa in 70% of cases
  • AXR or abdominal USS ± laparoscopy
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59
Q

What is the management of Meckel’s diverticulum?

A
  • 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
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60
Q

What is the ‘Rule of 2’s’ in Meckel’s diverticulum?

A
  • (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)
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61
Q

Define Volvulus.

A

A loop of intestine twists around itself and the mesentery that supports it, resulting in a bowel obstruction.

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62
Q

What predisposes an infant to volvulus/malrotation?

A
  • 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
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63
Q

What are the signs and symptoms of volvulus/malrotation?

A
  • 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)
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64
Q

What are the appropriate investigations for suspected volvulus in an infant?

A
  • Upper GI contrast study → assess patency if bilious vomiting
  • USS
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65
Q

What is the management of volvulus in an infant?

A
  • Urgent laparotomy - Ladd’s procedure if signs of vascular compromise
    • Untwist volvulus
    • Mobilize duodenum
    • Place bowel in non-rotated position
    • Remove necrotic bowel
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66
Q

Define Irritable Bowel Syndrome (IBS).

A

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
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67
Q

What are the signs and symptoms of IBS?

A
  • Abdominal pain – often worse before or relieved by defecation
  • Explosive loose or mucus stools
  • Bloating
  • Feeling of incomplete defecation – tenesmus
  • Constipation
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68
Q

What are the causes of recurrent abdominal pain in children?

A
  • 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
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69
Q

What signs and symptoms suggest an organic disease instead of IBS?

A
  • 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
Q

What are the causes of gastroenteritis?

A
  • Rotavirus infection - most common cause (60%)
  • Campylobacter jejuni
  • Shigella
  • Salmonella
  • Cholera
  • E. coli
  • Protozoan (Giardia, Cryptosporidium)
71
Q

What organisms cause bloody diarrhoea in infants?

A
  • CHESS
    • Campylobacter
    • Haemorrhagic E. coli (O157:H7)
    • Entamoeba histolytica
    • Salmonella
    • Shigella
72
Q

What organisms causes severe abdominal pain and bloody stool?

A

Campylobacter jejuni

73
Q

What organisms causes blood/pus in stool, pain, tenesmus and fever?

A
  • Shigella
  • Salmonella
74
Q

What organisms causes dehydrating diarrhoea?

A
  • Cholera
  • E. coli
75
Q

What are the signs and symptoms of gastroenteritis?

A
  • 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
Q

What are the appropriate investigations for suspected gastroenteritis?

A
  • AXR and exclude other causes
  • Stool sample analysis
    • Young/viral cause = stool electron microscopy
    • Older/bacterial cause = stool culture
77
Q

What is the management of gastroenteritis?

A
  • 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
Q

How is dehydration assessed in a child?

A
  • 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
Q

What are the signs and symptoms of hypernatraemia?

A
  • Full OF SALT
    • Flushing
    • Oedema
    • Fever
    • Seizures
    • Agitation / jittery movements
    • Low urine output
    • Thirst
80
Q

What are the signs and symptoms of hyponatraemia?

A
  • SALT LOSS
    • Stupor
    • Anorexia (+ N&V)
    • Limp tone
    • Tendon reflexes reduced
    • Lethargy
    • Orthostatic hypotension
    • Seizures
    • Stomach cramps
81
Q

What are the appropriate investigations for suspected dehydration?

A
  • Clinical Examination
  • U&E
  • FBC
  • Stool M&C
    • Only if bloody diarrhoea / CHESS organisms
82
Q

What is the management of dehydration in a child?

A
  • 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
Q

What is neonatal fluid resuscitation maintenance requirements?

A

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
Q

How is DKA fluid resuscitation different from others?

A
  1. Always give bolus in DKA
  2. Deficit calculated from pH of blood gas
  3. Dextrose not given in immediate infusion
85
Q

How is hypernatraemic dehydration fluid managed?

A
  • 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
Q

How are anti-diarrheal and anti-emetics used in childhood dehydration?

A
  • 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
Q

How are antibiotics used in childhood dehydration/diarrhoea?

A
  • 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
Q

What is post-gastroenteritis syndrome?

A
  • Introduction of a normal diet results in a return of the watery diarrhoea following gastroenteritis
  • Treatment = oral rehydration therapy
89
Q

Define Crohn’s Disease.

A

Inflammation, in patches, to any part of the GI tract from mouth to anus.

90
Q

Which segment of bowel is most commonly affected in Crohn’s?

A

Distal ileum and Proximal colon

91
Q

What are the signs and symptoms of Crohn’s disease?

A
  • 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
Q

What are the appropriate investigations for suspected Crohn’s disease?

A
  • 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
Q

What is the management of active Crohn’s disease in a child?

A
  • 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
Q

What is the management to maintain remission of Crohn’s disease in a child?

A
  • 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
Q

What are the complications of surgery for Crohn’s disease?

A
  • Obstruction
  • Fistula
  • Abscess
  • Severe localized disease unresponsive to treatment
96
Q

What counselling should be given to child/parents with a child with Crohn’s disease?

A
  • 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
Q

Define UC.

A

Inflammation and ulcers of the colon and rectum, progressing from the rectum in a continuous pattern to the colon.

  • Partial thickness
  • Crypt damage
98
Q

What are the signs and symptoms of UC?

A
  • Classic presentation is:
    • Rectal bleeding
    • Diarrhoea
    • Abdominal pain
  • Weight loss and growth failure
  • Erythema nodosum
  • Arthritis
99
Q

What are complications/associations with UC?

A
  • PSC
  • Toxic megacolon
  • Perforation
  • Enteric arthritis
  • Haemorrhage
  • Bowel cancer
100
Q

What are the appropriate investigations for suspected UC?

A
  • 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
Q

What grading system is used in UC?

A
  • Paediatric Ulcerative Colitis Activity Index (PUCAI)
    • Severe = >65 points
    • Mild-Moderate = 10-64 points
  • Truelove and Witts score
102
Q

What is the management of UC?

A
  • 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
Q

What is the management of severe/fulminating UC?

A

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
Q

What counselling should be given to child/parents with a child with UC?

A
  • 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
Q

Define Toddler Diarrhoea.

A

Chronic and non-specific diarrhoea caused by underlying maturational delay in intestinal mobility.

106
Q

What are the signs and symptoms of toddler diarrhoea?

A
  • 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
Q

What is the commonest cause of loose stool in pre-school children?

A

Toddler diarrhoea

108
Q

What is the management of toddler diarrhoea?

A
  • Increased fibre and fat in diet
    • Whole milk, yoghurts, cheeses → relieve symptoms
  • Avoid fruit juice and squash
109
Q

Define Anal Fissure.

A

Tears in skin around the anus, usually as a side effect of constipation → sphincter stretches to allow hard dry stool out

110
Q

What are the signs and symptoms of anal fissure?

A
  • Painful passing of stool
  • Bright red blood on tissue
  • Can examine for fissures
    • DRE
    • Protoscopy
111
Q

What is the management of anal fissures?

A
  • 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
Q

Define Hirschprung’s Disease.

A

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
Q

What are the complications of Hirschprung’s disease?

A
  • Meconium plug syndrome
  • Hirschprung’s enterocolitis - perforated colon
114
Q

What are the risk factors for Hirschprung’s disease?

A
  • Down’s
  • MEN2a
  • Male
  • Del(Chr10)
115
Q

What are the signs and symptoms of Hirschprung’s disease?

A
  • 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
Q

What are the appropriate investigations for suspected Hirschprung’s disease?

A
  • 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
Q

What is the management of Hirschprung’s disease?

A
  • 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
Q

What are the signs and symptoms of threadworm infection?

A
  • Itching around the anus or vagina - worse at night
  • Irritability - due to waking up during the night
119
Q

What is the management of threadworm infection?

A
  • 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
Q

What is the pathophysiology of lactose intolerance?

A

Lactase deficiency → lactose ferments in gut → ↑ waste gas → pain and bloating

  • Lactose converts glucose and galactose
121
Q

What are the risk factors for lactose intolerance?

A
  • FHx
  • Ethnicity
    • Affects up to 75% of world’s population
    • More Asian, African and Hispanic
    • Less in Caucasian
122
Q

What are the causes of lactose intolerance?

A
  • Primary (70%)
    • Deficient lactase (Asian, African, Hispanics)
  • Secondary
    • Damage to gut
    • Temporary lactase deficiency
      • Gastroenteritis
      • Crohn’s
      • Coeliac
      • Alcoholism
123
Q

What are the signs and symptoms of lactose intolerance?

A
  • Wind
  • Diarrhoea
  • Bloating with lactose ingestion
  • Abdominal rumblings
  • Abdominal pain
124
Q

What are the appropriate investigations for suspected lactose intolerance?

A
  • 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
Q

What is the management of lactose intolerance?

A
  • 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
Q

Define Coeliac’s Disease.

A

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
Q

What are associated with Coeliac’s disease?

A
  • HLA DQ2 - 95%
  • DQ8 - 80%
128
Q

What are the signs and symptoms of Coeliac’s disease?

A
  • 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
Q

What are the appropriate investigations for suspected Coeliac’s disease?

A
  • 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
Q

What is the management of Coeliac’s disease?

A
  • 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
Q

What are the complications of non-adherent Coeliac’s disease?

A
  • Micronutrient deficiency (vitamin D, iron)
  • Osteoporosis
  • EATL
  • Hyposplenism
132
Q

What is the cause of mesenteric adenitis?

A
  • Recent viral/bacterial infection
    • Common cause of abdominal pain → mainly in <15yo
133
Q

What are the signs and symptoms of mesenteric adenitis?

A
  • Abdominal pain – central or RIF
  • Nausea ± diarrhoea
  • ↓ appetite
  • Infectious picture
    • High temperature
    • Lymphadenopathy
    • ↑ WCC often preceded by UTI
134
Q

What are the appropriate investigations for mesenteric adenitis?

A
  • Diagnosis of exclusion
    • Laparoscopy is a bit much
    • Exclude appendicitis → bloods, urine MC&S
  • Laparoscopy = definitive
    • Large mesenteric lymph nodes with normal appendix
135
Q

What is the management of mesenteric adenitis?

A
  • Simple analgesia - symptoms usually resolve in a few days, maximum 2 weeks
  • Antibiotics - rare
  • Safety net for increased pain, deterioration, etc.
136
Q

Define Encopresis.

A

Soiling of underwear with stool in children who are past the age of toilet training (>4yo)

  • Usually due to constipation with overflow
137
Q

What is the management of encopresis?

A
  • Enquire about:
    • Psych stressors
    • Changes in medications
    • Food intolerances
138
Q

What are the types of Hernia?

A
  • Indirect inguinal
  • Umbilical
  • Epigastric
  • Femoral
139
Q

What is the pathophysiology of indirect inguinal hernias?

A
  • 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
Q

What are the risk factors for an indirect inguinal hernia?

A
  • Male
  • Prematurity
  • Connective tissue disorder
141
Q

What are the signs and symptoms of indirect inguinal hernias?

A
  • 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
Q

What are the appropriate investigations for a suspected indirect inguinal hernia?

A
  • 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
Q

What are the signs and symptoms of an incarcerated indirect inguinal hernia?

A
  • Tender, firm mass
  • Vomiting
  • Obstruction
  • Poor feeding
  • Erythematous/discoloured skin overlying
144
Q

What is the management of indirect inguinal hernias?

A
  • 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
Q

What are the risk factors for umbilical hernias?

A
  • Afro-Caribbean
  • Down’s
  • Mucopolysaccharide diseases
146
Q

What is the management of umbilical hernias?

A
  • <1yo = watch and wait
  • >1yo
    • Large or symptomatic = surgical repair 2-3yo
    • Small or asymptomatic = surgical repair 4-5yo
147
Q

What are the signs and symptoms of a femoral hernia?

A
  • 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
Q

Define Gastroschisis.

A

Paraumbilical abdominal wall defect resulting in abdominal contents outside the body, without peritoneal covering.

149
Q

What is the management of gastroschisis?

A

Immediate surgery → cover with cling-film

150
Q

Define Omphalocele.

A

Bowel protruding out the body with a peritoneal covering / umbilical attached.

151
Q

What is the management of omphalocele?

A
  • Staged closure
    • Starting immediately and finishing at 6-12 months
152
Q

What is associated with omphalocele?

A
  • Chromosomal abnormalities in 15% of cases
    • Trisomy 13 (Patau’s)
    • Trisomy 18 (Edward’s)
    • Trisomy 21 (Down’s)
    • Turner’s
153
Q

Define Acute liver failure.

A

Massive hepatic necrosis with loss of liver function ± hepatic encephalopathy.

154
Q

What are the causes of acute liver failure in a child under 2?

A
  • Infection - HSV
  • Metabolic disease
  • Seronegative hepatitis
  • Drug-induced
  • Neonatal haemochromatosis
155
Q

What are the causes of acute liver failure in a child over 2?

A
  • 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
Q

What are the signs and symptoms of Wilson’s disease?

A
  • Kayser-Fleischer rings
  • Psychosis
  • Jaundice
157
Q

What is Wilson’s disease?

A

Excess copper build-up.

158
Q

What are the signs and symptoms of acute liver failure?

A
  • Jaundice
  • Encephalopathy
    • Irritable → confusion/drowsiness episodes
  • Coagulopathy
  • Hypoglycaemia
  • Electrolyte disturbance
  • Aggressive / unusually difficult → older children
159
Q

What are the appropriate investigations for suspected acute liver failure?

A
  • 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
Q

What is the management of acute liver failure?

A
  • 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
Q

What are the features of a poor prognosis due to acute liver failure?

A
  • Shrinking liver
  • Rising bilirubin
  • Coma
  • Falling transaminases
  • Worsening coagulopathy
162
Q

What are the complications of acute liver failure?

A
  • Hepatic encephalopathy
  • Cirrhosis
  • Portal HTN
163
Q

What is the management of hepatic encephalopathy?

A
  • Supportive
  • Reduce N2 → lactulose and antibiotics
164
Q

What is the management of cirrhosis and/or portal hypertension?

A
  • Fluid restrict
  • Diuretics
165
Q

What antibodies are present in PBC?

A

Anti-mitochondrial

166
Q

What antibodies are present in PSC?

A
  • pANCA
  • Anti-smooth muscle
167
Q

What is the management of autoimmune hepatitis?

A
  • Prednisolone and azathioprine
  • Liver transplants may be considered in severe cases
  • Sclerosing cholangitis = ursodeoxycholic acid (aids bile flow)
168
Q

What is the management of Wilson’s disease?

A
  • 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
Q

What is the management of non-alcoholic fatty liver disease?

A
  • Weight loss
  • Treatment of insulin resistance and diabetes
  • Statins
  • Vitamin E and C
  • Ursodeoxycholic acid - improved bile flow
170
Q

What is the management of paracetamol overdose?

A
  • <1 hour = activated charcoal
    • N-acetylcysteine if paracetamol level ≥4 hours still dangerously raised after ingestion
  • >1 hour = N-acetylcysteine
171
Q

What are the possible diagnoses for the ‘red flag’ symptoms of bulging fontanelle/seizures?

A
  • Increased ICP

a Paediatrics by themes (26 decks)

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