Gastroenterology Flashcards
medical causes of abdominal pain in children
- Constipation
- UTI
- Coeliac disease
- IBD
- IBS
- Mesenteric adenitis
- Abdominal migraine
- Pyelonephritis
- Henoch-Schonlein purpura
- Tonsilitis
- DKA
- Infant colic
causes of abdominal pain in adolescent girls
- Dysmenorrhoea
- Mittelschmerz
- Ectopic preg
- PID
- Ovarian torsion
- Pregnancy
surgical causes of abdominal pain in children
- Appendicitis
- Intussusception- colicky non specific abdo pain w/ redcurrent jelly stools
- Bowel obstruction
- Testicular torsion
what are some red flags for abdo pain in children
- Persistent or bilious vomit
- Severe chronic diarrhoea
- Fever
- Rectal bleeding
- Weight loss or faltering growth
- Dysphagia
- Nighttime pain
- Abdominal tenderness
what initial investigations may be done for abdominal pain in children and why?
- Anaemia can indicate IBD or coeliac disease
- Raised inflammatory markers can indicate IBD
- Raised anti-TTG or anti- EMA antibodies can indicate coeliac
- Raised faecal calprotectin IBD
- Positive urine dip - UTI
what is recurrent abdo pain in children?
Repeated episodes of abdominal pain without identifiable cause. Non-organic or Functional. Common and can lead to psychological problems, such as missed days at school and parental anxiety. Overlap between diagnoses recurrent abdo pain, abdominal pain, IBS and functional abdominal pain.
Recurrent abdominal pain often responds to stressful life events, such as loss of a relative and bullying. Lead theory= increased sensitivity and inappropriate pain signals from visceral nerves.
how is recurrent abdominal pain managed in children?
Management= Careful explanation and reassurance. To help:
- Distracting child from pain with other activities and interests
- Encourage pt not to ask about or focus on the pain
- Advice about sleep, reg meals, healthy balanced diet, staying hydrated, exercise and reducing stress
- Probiotic substances may help IBS
- Avoid NSAIDs
- Address psychological triggers and exacerbating factors
- Support from a school counsellor or child psychologist
what are abdominal migraines?
episodes of central abdominal pain lasting >1 hour
occur in children before they develop traditional migraines as they get older
what are some features of abdominal migraines?
- Central abdominal pain lasting >1 hour
- N&V
- Anorexia
- Pallor
- Headache
- Photophobia
- Aura
how are abdominal migraines managed?
- Low stimulus environment- quiet dark room
- Paracetamol
- Ibuprofen
- Sumatriptan
what preventative measures for abdominal migraines can be used?
- Pizotifen- serotonin agonist- withdraw slowly as associated withdrawal symptoms- depression, anxiety, poor sleep, tremor
- Propanalol
- Cyproheptadine- antihistamine
- Flunarazine- CCB
what is idiopathic/functional constipation?
no significant underlying cause other than lifestyle factors
name 3 important secondary causes of constipation in children?
Hirschsprung’s disease
CF
hypothyroidism
how does constipation present in children?
- <3 stools per week
- Hard stools that are difficult to pass
- Rabbit dropping stools
- Straining and painful passing of stools
- Abdominal pain
- Holding an abnormal posture, referred to as retentive posturing
- Rectal bleeding associated with hard stools
- Faecal impaction causing overflow soiling, with incontinence of particularly loose smelly stools
- Hard stools may be palpable
- Loss of sensation of the need to open bowels
what is encopresis?
Term for faecal incontinence. Not considered pathological until 4 years of age. Usually, a sign of chronic constipation where the rectum becomes stretched and loses sensation. Large stools remain in the rectum and only loose stools able to bypass the blockage and leak out, causing soiling.
what are some lifestyle factors that impact constipation in children?
- habitually not opening the bowels
- low fibre diet
- poor fluid intake and dehydration
- sedentary lifestyle
- psychosocial problems such as a difficult home or school environment (keep safeguarding in mind)
describe desensitisation of the rectum
Habit of not opening bowels when they need to and ignoring the sensation of a full rectum= lose sensation overtime and open less frequently faecal impaction rectum stretches and desensitised= more difficult to treat and reverse problem
what are some secondary causes other than Hirschsprungs, CF and hypothyroidism?
- Spinal cord lesions
- Sexual abuse
- Intestinal obstruction
- Anal stenosis
- Cows milk intolerance
what are some red flags for constipation?
no meconium w/in 48H birth (CF or Hirschsprung’s)
Neurological (cerebral palsy or spinal cord lesion)
Vomiting
ribbon stool
abnormal anus
abnormal lower back or buttocks
failure to thrive
Acute severe abdo pain and bloating
complications of constipation
- Pain
- Reduced sensation
- Anal fissures
- Haemorrhoids
- Overflow and soiling
- Psychosocial morbidity
how is constipation managed?
diagnosis of idiopathic constipation can be made without investigations, provided red flags are considered.
important to provide adequate explanation of the diagnosis and management as well as reassure parents about the absence of concerning underlying causes.
Explain that treating constipation can be a prolonged process, potentially lasting months.
- Correct any reversible contributing factors, recommend high fibre+ good hydrate
- Start laxatives (Movicol)
- Impaction= disimpaction regimen with high doses laxatives at first
- Encourage and praise visiting the toilet. This could involve scheduling visits, bowel diary and star charts.
Slow ween off as child develops a normal- regular bowel habit.
what are the 4 types of laxatives and name examples of each
stool softeners
stimulant laxatives
bulk forming agents
osmotic laxatives
what is GOR?
gastro oesophageal reflux
immaturity of the lower oesophageal sphincter
allows contents to easily reflux into oesophagus. Normal for baby to reflux feeds and provided there is normal growth, and the baby is otherwise well, there is no problem. Usually improves and 90% of infants stop having reflux by 1 year.
how does GOR present?
normal to have reflux with large feeds
problem when is causes them to be distressed
- Chronic cough
- Hoarse cry
- Distress, crying or unsettles after feeding
- Reluctance to feed
- Pneumonia
- Poor weight gain
what are some other causes fo vomiting in children?
- Overfeeding
- GORD
- pyloric stenosis (projectile vomit)
- gastritis or gastroenteresis
- appendicitis
- infection- UTI, tonsillitis or meningitis
- Intestinal obstruction
- Bulimia
what are some red flags for vomiting in children?
- not keeping down any feed
- projectile or forceful vomiting
- bile stained, haematemesis or melaena
- abdominal distension
- reduced consciousness
- bulging fontanelle or neuro signs (meningitis or raised ICP)
- respiratory symptoms
- blood in stools (gastroenteritis or cows milk protein allergy)
- signs infection, rash/angioedema- sign allergy
- Apnoea
how is GOR managed?
- small frequent meals
- burping to help settle milk
- not over-feeding
- keep baby upright when feeding
- more problematic:
- gaviscon mixed with feeds
- thickened milk/formula
- Ranitidine
- Omeprazole where ranitidine inadequate
rare severe cases - barium meal and endoscopy
surgical fundoplication can be considered in v severe cases but rarely done
what is Sandifer’s syndrome?
RARE condition causing brief episodes of abnormal movements associated w/ GORD in infants. Usually neurologically normal.
Features:
- Torticollis- forceful contraction of the neck muscles when twisting the neck
- Dystonia- abnormal muscle contractions causing twisting movements, arching of the back and unusual postures.
Tends to resolve as the reflux is treated or improves. Generally, the outcome is good.
refer to specialist for assessment as DDx include infantile spasms aka west syndrome and seizures
what is pyloric stenosis?
pyloric sphincter is ring of smooth muscle that forms canal between stomach and duodenum
it can hypertrophy and become narrowed = stenosis
powerful peristalsis to push feed into duodenum but cant pass through stenosis so peristalsis causes projectile vomiting
what are some features of pyloric stenosis
- Thin
- Pale
- Failing to thrive
- Projectile vomiting
what can be seen on examination of a baby with pyloric stenosis?
after feeding - peristalsis can be seen by observing the abdomen
firm round mass can be felt in upper abdomen
what ABG finding will be present in pyloric stenosis?
hypochloric hypokalemic metabolic alkalosis due to vomiting HCL
how is pyloric stenosis diagnosed?
abdominal uss to visualise thickened pyloric sphincter
how is pyloric stenosis managed?
laparoscopic pyloromyotomy - Ramstedts’s operation
inscision made through the SM of the pylorus to widen canal allowing for food to pass from stomach to duodenum as normal
prognosis is good
baby cab feed after 6 h
what is coeliac disease?
autoimmune condition where exposure to gluten causes an immune reaction that creates inflammation in small intestine
Usually develops in early childhood but can start any age.
what are the 2 main antibodies involved?
anti-tissue transglutaminase (anti- TTG) and anti-endomysial (anti-EMA)
they correlate to disease activity and may disappear with effective treatment
what is the pathophysiology of coeliac disease?
Inflam SI especially the jejunum. Causes atrophy intestinal villi. Inflam- malabsorption of nutrients and disease related symptoms.
how does coeliac present?
Often asymptomatic
- Failure to thrive in young children
- Diarrhoea
- Fatigue
- Weight loss
- Mouth ulcers
- Anaemia secondary to iron, B12 or folate deficiency
- Dermatitis herpetiformis is an itchy blistering skin rash that typically appears on the abdomen
Rarely can present w/ neurological symptoms:
- Peripheral neuropathy
- Cerebellar ataxia
- Epilepsy
patients newly diagnosed with what condition are also tested for ceoliac and why?
type 1 DM as heavily linked
what are some genetic associations with coeliac?
HLA - DQ2 gene
HLA - DQ8 gene
what antibodies are involved? and what is the significance of IgA abs?
- Tissue transglutaminase antibodies (anti-TTG)
- Endomysial antibodies (EMAs)
- Deaminated gliadin peptides antibodies (anti-DGPs)
Anti-TTG and anti-EMA antibodies are IgA. Some patients have an IgA deficiency. When you test for these antibodies, it is important to test for total Immunoglobulin A levels because if total IgA is low the coeliac test will be negative even when they have the condition. In this circumstance you can test for the IgG version of the anti-TTG or anti-EMA antibodies or do an endoscopy with biopsies.
how is coeliac disease diagnosed?
investigatiosn must be carried out whilst person is still eating gluten
check total IgA levels to exclude IgA deficiency before checking coeliac disease specific antibodies
endoscopy and intestinal biopsy will show crypt hypertrophy and villous atrophy
what conditions are associated with coeliac disease?
- Type 1 diabetes
- Thyroid disease
- Autoimmune hepatitis
- Primary biliary cirrhosis
- Primary sclerosing cholangitis
- Down’s syndrome
what are some complications of untreated coeliac disease?
- Vitamin deficiency
- Anaemia
- Osteoporosis
- Ulcerative jejunitis
- Enteropathy-associated T-cell lymphoma (EATL) of the intestine
- Non-Hodgkin lymphoma (NHL)
- Small bowel adenocarcinoma (rare)
how is coeliac disease managed?
Lifelong gluten free diet essentially curative. Checking antibodies can be helpful in monitoring disease
what is biliary atresia?
Congenital condition where a section of the bile duct is either narrowed or absent. Results in cholestasis. Conjugated bilirubin is excreted in bile and therefore biliary atresia stops this.
Presents shortly after birth.
how does biliary atresia present?
- Shortly after birth
- Sig jaundice due to high conjugated bilirubin levels - liver is processing but cant be excreted
- Persistent jaundice >14 days in term babies and 21days in premature babies
what investigations are done for ? biliary atresia?
Conjugated and unconjugated bilirubin.
high proportion of conjugated bilirubin suggests that the liver is processing it but it is unable to be excreted
how is biliary
Surgery- Kasai portoenterostomy involves attaching a section of small intestine to the opening of the liver, where the bile duct normally attaches. This is somewhat successful and can clear the jaundice and prolong survival. Often patients require a full liver transplant to resolve the condition.
what is intestinal obstruction?
blockage in the bowel
back pressure - vomiting and absolute constipation
causes of intestinal obstruction?
meconium ileus
Hirschsprung’s disease
Oesophageal atresia
Duodenal atresia
intussusception
imperforate anus
malrotation of intestines= volvulus
Strangulated hernia
how does intestinal obstruction present?
- Persistent vomiting, may be bilious containing bright green bile
- Abdo pain and distension
- Failure to pass stools or wind
- Abnormal bowel sounds. Can be high pitched and tinkling early in obstruction but absent later
how is intestinal obstruction diagnosed?
AXR may show dilated loops of bowel proximal to obstruction and absence of air in the rectum
(fluid level= Hirchsprungs and none= Meconium ileus)
how is intestinal obstruction managed?
- paediatric surgical unit as an emergency
- them NBM and inserting NGT to help drain stomach and stop vomiting.
- Also require IVF to correct electrolyte imbalance and keep them hydrated
what is hirschsprungs disease?
Congenital condition where the nerve cells of the myenteric plexus are absent in the distil bowel and rectum. Myenteric plexus aka Auerbach’s plexus forms enteric nervous system, brain of the gut. Responsible for peristalsis of large bowel (circular muscle layer).
pathophys of hirchsprung’s disease?
absence of parasympathetic ganglion cells as in embryology these cells start higher up in GI tract and migrate down and if don’t travel all the way down, then part of the bowel left without any parasympathetic ganglion cells = Hirschsprung’s.
Length of colon without innervation varies:
- When entire= total colonic aganglionosis.
- Part w/o innervation= does not relax and becomes constricted= obstruction
Submucosa- Meissner’s plexus- secretion and blood flow
what are some genetic associations of hirschsprungs disease
family hx
downs syndrome
neurofibromatosis
Waardenburg Syndrome
multiple endocrine neoplasia type II
how does hirschsprung’s disease present?
Severity of presentation and the age at diagnosis varies significantly depending on individual and amount of bowel affected. Acute intestinal obstruction after birth or gradual
- >24H delay in passing meconium
- Chronic constipation since birth
- Abdo pain and distention
- Vomiting
- Poor weight gain and failure to survive
what is hirschsprung-associated enterocolitis?
Inflam and obstruction of intestine occurring in around 20% neonates with the disease.
Typically presents w/in 2-4 weeks of birth w/ fever, abdo distension, diarrhoea (often w/ blood) and features of sepsis.
Life threatening and can lead to toxic megacolon and perforation of the bowel.
Requires ABX, fluid resuscitation and decompression of obstructed bowel.
how is hirschsprungs investigated?
AXR can be helpful in diagnosing intestinal obstruction and demonstrating features HAEC
Rectal biopsy is used to confirm the diagnosis.
Bowel histology = absence of ganglionic cells.
how is hirschsprung’s disease managed?
unwell and those with enterocolitis - IVF and management like obstruction
definitive management is by surgical removal of aganglionic section of bowel.
Most live normal life after corrective surgery, although they can have long term disturbances in bowel function and may be left with some degree of incontinence.
what is intersussception?
condition where the bowel “invaginates” or “telescopes” into itself
Thickens bowel and narrows lumen, leading to a palpable mass in the abdomen and obstruction to the passage of faeces through the bowel.
Typically occurs in infants 6 months to 2 years and is more common in boys.
what are some associated conditions with intussusception?
- Concurrent viral illness
- Henoch- Schonlein purpura
- CF
- Intestinal polyps
- Meckel diverticulum
how does intussusception present?
- Severe colicky abdominal pain
- Pale, lethargic, and unwell child
- Redcurrant jelly stool
- RUQ mass on palpation- sausage shaped
- Vomiting
- Intestinal obstruction
what is the initial investigation of choice for intussusception?
USS or contrast enema
how is intussusception managed?
Therapeutic enemas can be used to try and reduce intussusception.
Contrast, water or air are pumped into the colon to force the folded bowel out of the bowel into a normal position.
Surgical reduction may be necessary if enemas don’t work
If gangrenous or perforated surgical resection is required
what are some complications of intussusception?
- Gangrenous Bowel
- Obstruction
- Perforation
- Death
what is appendicitis?
Appendix is a small, this tube sprouting from the caecum. Becomes inflamed due to infection trapped in the appendix by obstruction at the point where the appendix meets the bowel. Inflammation can quickly proceed to gangrene and rupture. The appendix can rupture and release faecal content and infective material = peritonitis.
Peak incidence 10-12y/o
what are the clinical features of appendicitis?
- Migratory abdominal pain from central to RIF- tenderness McBurney’s point (1/3rd distance ASIS to umbilicus.
- Loss appetite
- N&V
- Rovsing’s sign- palpation LIF causes pain RIF
- Guarding on abdominal palpation
- Rebound tenderness
- Percussion tenderness
Rebound tenderness and percussion tenderness are signs of peritonitis from a ruptured appendix.
how is appendicitis diagnosed?
Clinical presentation and raised inflammatory markers
USS F patients to exclude ovarian and gynaecological pathology
CT scan
Clinical presentation but -ve investigations= Diagnostic laparoscopy to visualise appendix
key ddx for appendicitis?
ectopic preg
ovarian cyst
meckles diverticulum
mesenteric adenitis
appendix mass
what is an appendix mass?
occurs when the omentum surrounds and sticks to the inflamed appendix, forming a mass in the right iliac fossa.
This is typically managed conservatively with supportive treatment and antibiotics, followed by appendicectomy once the acute condition has resolved.
hepatitis B antibodies
- Surface antigen (HBsAg) – active infection
- E antigen (HBeAg) – marker of viral replication and implies high infectivity
- Core antibodies (HBcAb) – implies past or current infection
- Surface antibody (HBsAb) – implies vaccination or past or current infection
- Hepatitis B virus DNA (HBV DNA) – this is a direct count of the viral load
how is paediatric acute liver failure defined?
biochemical evidence of acute liver injury in a child, with no known evidence of chronic liver disease and at least 1 of the following:
- INR >1.5 with encephalopathy
- INR >2.0 without encephalopathy
what is peptic ulcer disease?
ulceration of the mucosa of the stomach (gastric ulcer) or the duodenum (duodenal ulcer).
Duodenal ulcers are most common.
what are the different types of volvulus?
Sigmoid (older, bed bound, key cause= constipation= lengthen mesentery causing it to go down and twist, also associated with a high fibre diet and the excessive use of laxatives)
Caecal- less common and tends to affect younger patients. Twist occurs in the caecum.
how is duodenal atresia diagnosed?
- Prenatal USS- polyhydramnios, dilation of stomach and duodenum= double bubble sign
- Postnatal XR- double bubble, gasless distil bowel
what is an omphalocele?
Ventral abdominal wall defect- congenital herniation of abdominal viscera through the abdominal wall at the umbilicus
Hernial sac covered in amniotic membrane and peritoneum
Impaired closure of the umbilical folds.
What is gastroschisis?
Ventral wall defect that results in paraumbilical herniation of the intestine through the abdominal wall without formation of a hernia sac.
Failed formation of a large peritoneal cavity=rupture or fail return
what is transoesophageal fistula associated with?
VACTERL anomalies
vertebral, anal, cardiac, tracheal, oesophageal, renal, limb defects
what is meckel’s diverticulum?
Congenital anomaly of the Gi tract and is caused by an incomplete obliteration of the omphalomesenteric duct.
what is the rule of 2s for meckels diverticulum?
2 inches long
2 feet from the ileocaecal valve
2% pop
2:1 M:F
presents <2yrs with painless lower GI bleeding.
2 types of mucosa - native ileal or ectopic (most common) could be gastric, pancreatic etc
what are the 2 types of hiatus hernia?
- Sliding Hiatus Hernia (80%)- GOJ, the abdo part of the oesophagus, and freq the cardia of the stomach slides upwards through the diaphragmatic hiatus into thorax
- Rolling or para-oesophageal- upward movement of the gastric fundus occurs to lie alongside a normally positioned GOJ= create a bubble of the stomach. True hernia with peritoneal sac.
describe the different causes of gastroenteritis
