Gastroenterology Flashcards
What are the different causes of abdominal pain?
Medical
Surgical
Functional
What are the medical causes of abdominal pain?
Constipation- don't forget! UTI IBD IBS Coeliac Pyelonephritis
In adolescent girls- Dysmenorrhoea Mittelschmerz Ovarian torsion PID Pregnancy Ectopic pregnancy
What are the surgical causes of abdominal pain?
Testicular torsion- sudden onset, one sided, N+V
Bowel obstruction- Absolute constipation, vomiting, abdominal pain, abdominal distension
Appendicitis- Generalised then RIF
Intussusception- Red jelly like stools, non specific, colicky pain
What are the functional causes of abdominal pain?
Very common in >5yrs old
Get recurrent abdominal pain, without a physical cause.
Pt not making it up but could be in response to psychological stress.
Can overlap with abdominal migraine.
How is functional abdominal pain managed?
Encourage distraction activities for the child
Educate parents to not remind or ask the child about the pain
Find stressors and better manage them
Avoid NSAIDs
Encourage good sleep, healthy meals, exercise, hydration
Inform school counsellor
What are the Red Flags for abdominal pain?
How do you investigate abdominal pain?
Red Flags- Persistent or bilious vomiting Chronic severe diarrhoea Wt loss Fever Rectal bleeding Dysphagia Ab pain Night time pain
Investigations- Anaemia- IBD, Coeliac Raised CRP/ESR- IBD Raised Faecal Calprotectin- IBD Urine dip- UTI Raised Anti-TTG or Anti-EMA- Coeliacs
What is an abdominal migraine?
How is it managed?
Episodes of central abdominal pain lasting an hour. Common in children, may develop migraine in adulthood.
May be associated with N+V, anorexia, pallor, headache, aura, photophobia.
Manage acute- Dark quiet room Ibuprofen Paracetamol Sumatriptan
Prevention-
Commonly use Pizotifen. But withdraw slowly due to withdrawal effects of anxiety, depression, poor sleep and tremor.
What are the causes of constipation?
Commonly it is primary where the cause is functional/idiopathic. Can also have secondary causes: Hirschsprung's Cystic Fibrosis Hypothyroidism Sexual abuse Anal stenosis CMPI
What are the features of constipation?
Stools <3x week Rabbit dropping Overflow/soiling Abdominal pain Hard stools Rectal bleeding with difficult stools Stool felt in abdomen Retentive posturing- i.e. in a way to stop the stools Straining and painful to pass stools Reduced sensation in needing to open the bowel
What is encopresis?
Refers to faecal incontinence.
Not normal after 4yrs old.
There has been chronic constipation so the hard impacted stool have stretched the rectum, leading to desensitisation. Hard stools will remain impacted, whilst smaller will pass by and leak out.
Causes include: Herschsprungs Spina bifida Learning disability Cerebral palsy Abuse
Which lifestyle factors can influence constipation?
Low fibre diet Dehydration Sedentary lifestyle Habitually not opening bowels Psychological stressors- consider safeguarding
What is desensitisation of the rectum?
Pt has a habit of holding in stool or not reacting to full sensation of rectum
Over time loses sensation of rectal fullness so open bowel less frequently
More stool accumulates- faecal impaction
Rectum stretches
Leads to further desensitisation of the rectum
The longer this continues the more difficult it becomes to treat and reverse the constipation.
What are red flags of constipation?
Not passing meconium within first 24-48hrs of life- HS, CF
Ribbon like stool- Anal stenosis
Abnormal anus- Anal stenosis, Sexual abuse
Neurological i.e. lower limbs affected- Cerebral palsy, spinal cord lesion
Vomiting- HS, bowel obstruction
Failure to thrive- Coeliac, hypothyroidism, safeguarding
Acute abdominal pain and bloating- Intussusception or bowel obstruction
What are the complications of constipation?
Pain Anal fissure Haemorrhoids Reduced sensation Overflow/soiling Psychological morbidity
How is constipation managed?
It is possible to diagnose functional/idiopathic constipation without investigation, as long as red flags have been considered. Educate parents/pt that treatment is a long process
Manage reversible factors i.e. increase fibre intake, increase water intake
First line laxative is Movicol.
If faecal impaction then disimpaction regimen with high dose laxatives
Encourage toilet trips, star charts, bowel diary
Wean off laxatives slowly one normal bowel habits have been established.
What are the differentials of vomiting?
Overfeeding GORD Gastroenteritis Other infections i.e. meningitis, tonsillitis, UTI Pyloric stenosis Intestinal obstruction Bulimia Appendicitis
How does GORD present?
Babies don’t fully develop their LOS until 1 yrs old so reflux is common amongst most <1yrs. Considered normal as long as baby’s growth is unaffected and they are otherwise well.
GORD- Hoarse cry Chronic cough Distressed after feeding Reluctant to feed Poor weight gain Pneumonia
> 1yrs can present similar to adults with a night cough, acid reflux and retrosternal pain.
How is GORD managed?
Encourage: Small regular feeds Avoid overfeeding Sit upright after feed Burping regularly to help settle milk
Gaviscon- coats the milk in the stomach to stop it from coming back up
Thickened milk/thickener
Ranitidine
Lansoprazole
Rarely may need to investigate with a barium swallow and endoscopy
What are the red flags which could suggest underlying pathology of reflux?
Haematemesis/melaena- peptic ulcer, varices
Fresh rectal bleeding- CMPA,
Projectile vomiting- Bowel obstruction, pyloric stenosis
Inability to keep food down- Bowel obstruction, pyloric stenosis
Rash, angioedema- CMPA
Respiratory symptoms- Aspiration, infection
Reduced consciousness, bulging fontanelles- meningitis
Bile stained vomit- Bowel obstruction
Abdominal distension- Bowel obstruction
Apnoea is very serious and needs immediate investigations.
What is Sandifer’s syndrome?
Reflux with associated torticollis and dystonia.
Will resolve itself.
Needs investigating to rule out more serious epilepsy.
