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.
What is pyloric stenosis?
Hypertrophy of the pyloric sphincter of the stomach, leading to obstruction. After feeding there is increased peristalsis of the stomach, but since the food can’t move to the duodenum it is forced out of the oesophagus- projectile vomiting.
Presents within first few wks of life with thin, hungry baby who is failing to thrive.
How is pyloric stenosis investigated and managed?
Abdomen can feel a hard ‘olive sized’ mass- hypertrophic pyloric sphincter.
Blood gas will show hypochloric metabolic alkalosis (vomit stomach HCl)
USS of abdomen to see a hypertrophic pyloric sphincter
Managed with laparoscopic pyloromyotomy- remove part of the SM of the PS- very good prognosis.
What are the signs and symptoms of Appendicitis? (RECAP)
Central pain which becomes RIF McBurneys point tenderness (1/3 distance from ASIS to umbilicus) Loss of appetite N+V Rebound tenderness (suggesting rupture) Rovsings sign- palpae in LIF will cause pain in RIF Gurading Percussion tenderness
What are the key differentials for appendicitis? (RECAP)
Ectopic pregnancy
Ruptured/torsion of ovarian cyst
Meckels diverticulum- can cause volvulus or intussusception, if ruptured of inflamed
Mesenteric adenitis- inflamed abdominal LN often associated with tonsillitis or URTI
How is appendicitis managed in children?
What are the complications?
Need appendicectomy.
If <10yrs need to be under paediatric surgeon.
>10yrs can be under adult surgeons provided there is a paediatric unit.
Post surgery complications include- Bleeding Infection Pain Scars Damage to surrounding organs Removal of normal appendix VTE
What is intussusception?
How does a patient present?
Part of the bowel telescopes/invaginates into another part of bowel. This makes the bowel wall appear thicker and the lumen more narrow so stool will not be able to pass through the bowel.
Common in 6 months to 2yrs old.
Presentation- Redcurrent jelly like stool Non specific colicky abdominal pain RUQ sausage shaped mass (stool) Vomiting Intestinal obstruction May have had a recent viral infection I.e. URTI
What is intussusception often associated with?
Concurrent viral infection Henoch Cystic fibrosis Intestinal polyps Meckels diveritculum
How is intussusception investigated?
How is intussusception managed?
Investigate with USS or contrast enema.
Management-
Need to reduce intussusception.
Either therapeutic enema I.e. water, contrast or air is forced up the colon to force the bowel to move out of itself.
If this fails then surgical repositioning.
If the blood supply is compromised and leads to gangrenous bowel, or there is a bowel perforation then need surgical resection.
What are the complications of intussusception?
Bowel perforation
Bowel gangrenous
Death
Bowel obstruction
What is the pathophysiology of Hirschsprung’s?
Normal bowel has myenteric plexus, which controls the peristalsis. During normal development the parasympathetic cells travel distally down the GI tract. In Hirschsprung’s these parasympathetic cells don’t travel completely down and so part of the colon and rectum are left without parasympathetic innervation. If the entire colon is affected this is total colonic aganglionosis.
Bowel without parasympathetic cannot relax therefore in a state of constriction. Stool can’t get past, and so proximal to this constriction get stool collection and bowel dilation.
What are the associations with Hirschsprung’s?
Usually stand alone.
Strong FHx.
Can be associated with Downs, neurofibromatosis and MEN II.
How does Hirschsprung’s present?
Some neonates born with bowel obstruction.
Features- Don’t pass meconium within first 24-48hrs Vomiting Distended abdomen Chronic constipation since birth Poor growth and failure to thrive
How is Hirschsprung’s investigated?
How is Hirschsprung’s managed?
Diagnosed with a rectal biopsy- will show absence of ganglionic cells.
Can also use and X-ray to look for obstruction or features of HAEC
Manage with bowel resection. Will go on to live normal lives but have life long bowel function disturbances and some may have incontinence issues.
What is HAEC?
How is it managed?
Hirschsprung’s associate enterocolitis.
Inflammation of the bowel, in a pt with Hirschsprung’s. This leads to fever, abdominal distension, diarrhoea (often bloody) and sepsis features. This can lead to toxic mega colon and perforation.
Investigate with X-ray.
Manage with fluids, Abx, decompression surgery.
What are the signs of bowel obstruction? (RECAP)
Abdominal distension
Abdominal pain
Vomiting
Absolute constipation
Also hear tinkling bowel sounds early on which become absent later
What are some causes of bowel obstruction?
Hirschsprung’s Intussusception Oesophageal atresia Meconium ileus Imperforate anus
How is bowel obstruction investigated?
How is bowel obstruction managed?
Investigated with an AXR- dilated loops of bowel proximal to the obstruction, collapsed loops of bowel distal to the obstruction. Absence of air in the rectum.
Manage by paediatric surgical unit admission. Suck and drip- insert NG tube to ‘suck out’ from the bowel, give IV fluids.
What is biliary atresia?
Bile duct is either narrowed partially or completely; the bile can not be excreted out of the liver. Usually conjugated bilirubin from the liver is excreted in the bile, so this leads to a build up of conjugated bilirubin.
How is biliary atresia investigated?
How is biliary atresia managed?
Suspect if >14 days jaundice in term baby or >21 days jaundice in premature baby.
Measure the proportion of conjugated bilirubin compared to unconjugated. Higher conjugated suggests biliary atresia.
Management is surgery. Kasai portoenterostomy- take part of the small intestine and insert it onto the liver where the bile duct would usually attached. It is effective but many patients will go on to need full liver transplant.
What are the extra-intestinal manifestations of IBD?
Clubbing Episcleritis and iritis Inflammatory arthritis Erythema nodusum Pyoderma gangrenosum
UC- ascending cholangitis (check LFTs)
How is IBD investigated?
FBC (anaemia, thrombocytosis as a sign of inflammation), LFTs (albumin as nutrition marker, AC), CRP, TFTs, U+Es.
Faecal calprotectin.
Gold standard is an OGD and colonoscopy in children to get the most information.
Can further image with USS, CT or MRI
How is Crohns managed in children?
Inducing remission-
First line is by a full liquid diet for minimum of 6 wks to reverse the acute flare.
This is the best method and should always be trialled before steroids.
2nd line by a long way is steroids I.e. IV hydrocortisone or oral prednisolone.
3rd line would be immunosuppressants I.e. azathioprine.
Maintaining remission-
Azathioprine
Methotrexate
Mercaptopurine
Surgery to manage strictures and fistulas. Since Crohns contains skip lesions, surgical resection is only effective if the distal ileum alone is affected.
How is UC managed in children?
Inducing remission-
First line is mesalazine (aminosalicylate)
Second line is corticosteroid.
In more severe disease first line is corticosteroid, second line is IV ciclosporin.
Maintaining remission-
Mesalazine
Azathioprine
Surgery-
Can remove the entire rectum and colon- create an ileostomy or j-bag for the stool to leave. J bag involves using the ileum to act as a rectum.
What is coeliacs disease?
What diseases is it associated with?
Exposure to gluten causes inflammation of the small intestine, particularly the jejune. This leads to villous atrophy and crypt hypertrophy.
The antibodies involved are IgA antibodies Anti-TTG and Anti-EMA. Thought HLA-DHQ 2 gene (mainly) and DHQ-8 are also involved.
Associated with- T1DM Thyroid disease Autoimmune hepatitis Down’s syndrome
How does coeliacs disease present?
Asymptomatic Or Fatigue Wt loss Mouth ulcers Failure to thrive (young children) Diarrhoea Anaemia due to deficiency or iron, B12 or folate Dermatitis herpatiformis
Rarely can get neurological features-
Cerebellar ataxia
Peripheral neuropathy
Epilepsy
How is coeliacs diagnosed?
Need to still be on a gluten diet.
Test total IgA levels.
Test with anti-TTG, anti-EMA and HLA type.
Anti-TTG and anti-EMA are IgA; some patients can have IgA deficiency so will have negative coeliacs test even though they are positive. Test for the IgG levels of these antibodies.
Can also conduct endoscopy with biopsy.
ALWAYS TEST PATIENTS DIAGNOSED WITH T1DM EVEN IF THEY DON’T HAVE SYMPTOMS.
How is coeliacs managed?
Gluten free diet life long.
What are the complications of coeliacs?
Anaemia Vitamin deficiency Osteoporosis Ulcerative jejunitis Non Hodgkin lymphoma
What is gastroenteritis?
How is it managed?
Inflammation of the stomach and intestines leading to nausea, vomiting and diarrhoea.
Will self resolve.
Need to ensure patient is not dehydrated. Encourage oral fluids, but if not tolerated and dehydrated then IV fluids.
Anti diarrhoeal and antibiotics are not indicated.
Child should not go school fro 48hrs, on wards should be isolated.
Commonly caused by virus- contagious.
What are the complications of gastroenteritis?
Lactose intolerance
IBS
GBS
Reactive arthritis
