Gastroenterology Flashcards
Medical causes of abdominal pain in both boys and girls?
Constipation is also very common
Urinary tract infection
Coeliac disease
Inflammatory bowel disease
Irritable bowel syndrome
Mesenteric adenitis
Abdominal migraine
Pyelonephritis
Henoch-Schonlein purpura
Tonsilitis
Diabetic ketoacidosis
Infantile colic
Additional causes of abdominal pain to consider in adolescent girls?
Dysmenorrhea (period pain)
Mittelschmerz (ovulation pain)
Ectopic pregnancy
Pelvic inflammatory disease
Ovarian torsion
Pregnancy
Surgical causes of abdominal pain to consider in children?
Appendicitis
Intussusception
Bowel obstruction
Testicular torsion
Where does pain present in appendicitis?
Central abdominal pain spreading to the right iliac fossa
Characteristic features of intussception?
Intussusception causes colicky non-specific abdominal pain with redcurrant jelly stools
Presentation of bowel obstruction?
Bowel obstruction causes pain, distention, absolute constipation and vomiting
Presentation of testicular torsion?
Testicular torsion causes sudden onset, unilateral testicular pain, nausea and vomiting
Red flags for serious causes of abdominal pain?
Persistent or bilious vomiting
Severe chronic diarrhoea
Fever
Rectal bleeding
Weight loss or faltering growth
Dysphagia (difficulty swallowing)
Nighttime pain
Abdominal tenderness
Initial investigations that may indicate the pathology causing abdominal pain in children?
Anaemia can indicate inflammatory bowel disease or coeliac disease
Raised inflammatory markers (ESR and CRP) can indicate inflammatory bowel disease
Raised anti-TTG or anti-EMA antibodies indicates coeliac disease
Raised faecal calprotectin indicates inflammatory bowel disease
Positive urine dipstick indicates a urinary tract infection
Management of recurrent abdominal pain in children?
A diagnosis of recurrent abdominal pain is made when a child presents with repeated episodes of abdominal pain without an identifiable underlying cause. The pain is described as non-organic or functional. This is common and can lead to psychosocial problems, such as missed days at school and parental anxiety. There is overlap between the diagnoses of recurrent abdominal pain, abdominal migraine, irritable bowel syndrome and functional abdominal pain.
Recurrent abdominal pain often corresponds to stressful life events, such as loss of a relative or bullying. The leading theory for the cause is increased sensitivity and inappropriate pain signals from the visceral nerves (the nerves in the gut) in response to normal stimuli.
Management involves careful explanation and reassurance. Measures that can help manage the pain are:
Distracting the child from the pain with other activities or interests
Encourage parents not to ask about or focus on the pain
Advice about sleep, regular meals, healthy balanced diet, staying hydrated, exercise and reducing stress
Probiotic supplements may help symptoms of irritable bowel syndrome
Avoid NSAIDs such as ibuprofen
Address psychosocial triggers and exacerbating factors
Support from a school counsellor or child psychologist
What is an abdominal migraine and how does it present?
Children are more likely than adults to suffer with a condition called abdominal migraine. This may occur in young children before they develop traditional migraines as they get older. Abdominal migraine presents with episodes of central abdominal pain lasting more than 1 hour. Examination will be normal.
There may be associated:
Nausea and vomiting
Anorexia
Pallor
Headache
Photophobia
Aura
Abdominal migraine: Management of the acute attack
Low stimulus environment (quiet, dark room)
Paracetamol
Ibuprofen
Sumatriptan
Abdominal migraine: Preventative medications?
Pizotifen, a serotonin agonist
Propranolol, a non-selective beta blocker
Cyproheptadine, an antihistamine
Flunarazine, a calcium channel blocker
Withdrawal of pizotifen?
It needs to be withdrawn slowly when stopping as it is associated with withdrawal symptoms such as depression, anxiety, poor sleep and tremor.
Most cases of consipation in children can be described how?
Most cases of constipation can be described as idiopathic constipation or functional constipation, meaning there is not a significant underlying cause other than simple lifestyle factors.
Important secondary causes of constipation in children?
Hirschsprung’s disease, cystic fibrosis or hypothyroidism.
Typical features in history and examination that suggest constipation?
Less than 3 stools a week
Hard stools that are difficult to pass
Rabbit dropping stools
Straining and painful passages 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 in abdomen
Loss of the sensation of the need to open the bowels
What is encopresis and when is it considered pathological?
Encopresis is the term for faecal incontinence. This is not considered pathological until 4 years of age.
What is the most common cause of encopresis in children?
It is usually a sign of chronic constipation where the rectum becomes stretched and looses sensation.
Large hard stools remain in the rectum and only loose stools are able to bypass the blockage and leak out, causing soiling.
Rarer but serious causes of encopresis in children?
Spina bifida
Hirschprung’s disease
Cerebral palsy
Learning disability
Psychosocial stress
Abuse
What lifestyle factors may contribute to constipation?
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 (always keep safeguarding in mind)
What is desensitisation of the rectum and why does it occur?
Often patients develop a habit of not opening their bowels when they need to and ignoring the sensation of a full rectum.
Over time they loose the sensation of needing to open their bowels, and they open their bowels even less frequently.
They start to retain faeces in their rectum.
This leads to faecal impaction, which is where a large, hard stool blocks the rectum.
Over time the rectum stretches as it fills with more and more faeces.
This leads to further desensitisation of the rectum.
The longer this goes on, the more difficult it is to treat the constipation and reverse the problem.
Secondary causes of constipation in children?
Hirschsprung’s disease
Cystic fibrosis (particularly meconium ileus)
Hypothyroidism
Spinal cord lesions
Sexual abuse
Intestinal obstruction
Anal stenosis
Cows milk intolerance
Constipation in children - red flags that should prompt further investigations and referral to a specialist:
Not passing meconium within 48 hours of birth (cystic fibrosis or Hirschsprung’s disease)
Neurological signs or symptoms, particularly in the lower limbs (cerebral palsy or spinal cord lesion)
Vomiting (intestinal obstruction or Hirschsprung’s disease)
Ribbon stool (anal stenosis)
Abnormal anus (anal stenosis, inflammatory bowel disease or sexual abuse)
Abnormal lower back or buttocks (spina bifida, spinal cord lesion or sacral agenesis)
Failure to thrive (coeliac disease, hypothyroidism or safeguarding)
Acute severe abdominal pain and bloating (obstruction or intussusception)
Within what time frame should a neonate pass meconium and what can failure to do so be suggestive of?
Not passing meconium within 48 hours of birth (cystic fibrosis or Hirschsprung’s disease)
Complications of constipation in children?
Pain
Reduced sensation
Anal fissures
Haemorrhoids
Overflow and soiling
Psychosocial morbidity
Management of constipation in children?
A diagnosis of idiopathic constipation can be made without investigations, provided red flags are considered. It is 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.
NICE clinical knowledge summaries recommend:
- Correct any reversible contributing factors, recommend a high fibre diet and good hydration
- Start laxatives (movicol is first line)
- Faecal impaction may require a disimpaction regimen with high doses of laxatives at first
- Encourage and praise visiting the toilet. This could involve scheduling visits, a bowel diary and star charts.
Laxatives should be continued long term and slowly weaned off as the child develops a normal, regular bowel habit.
First line laxative in paediatrics?
Movicol
When and why is GORD normal in children?
Gastro-oesophageal reflux is where contents from the stomach reflux through the lower oesophageal sphincter into the oesophagus, throat and mouth.
In babies there is immaturity of the lower oesophageal sphincter, allowing stomach contents to easily reflux into the oesophagus.
It is normal for a baby to reflux feeds, and provided there is normal growth and the baby is otherwise well this is not a problem, however it can be upsetting for parents.
By what age do 90% of infants stop having reflux feeds?
1 year
Presentation of GORD in children
It is normal for babies to have some reflux after larger feeds. It becomes more troublesome when this causes them to become distressed. Signs of problematic reflux include:
Chronic cough
Hoarse cry
Distress, crying or unsettled after feeding
Reluctance to feed
Pneumonia
Poor weight gain
Children over one year may experience similar symptoms to adults:
Heartburn
Acid regurgitation
Retrosternal or epigastric pain
Bloating
Nocturnal cough
Possible causes of vomiting in children
Overfeeding
Gastro-oesophageal reflux
Pyloric stenosis (projective vomiting)
Gastritis or gastroenteritis
Appendicitis
Infections such as UTI, tonsillitis or meningitis
Intestinal obstruction
Bulimia
What red flag features of vomiting may be suggestive of pyloric stenosis?
Not keeping down any feed
Projectile or forceful vomiting
What red flag features of vomiting may be suggestive of intestinal obstruction?
Not keeping down any feed
Projectile or forceful vomiting
Bile stained vomiting
Abdominal distention
What red flag features of vomiting may be suggestive of peptic ulcer, oesophagitis or varicies?
Haematemesis or melaena
Why are reduced consciousness, bulging fontanelle or neurological signs are considered red flags when a child presents with vomtiing?
Meningitis
Raised ICP
When a child presents with vomiting alongside respiratory symptoms what may be of concern?
Potential aspiration or infection
Why are signs of infection red flag features in a presentation of vomiting?
Consider:
Pneumonia
UTI
Tonsilitis
Otitis
Meningitis
When a child presents with vomiting, what might make you suspect a cows milk allergy?
Rash, angiodema and any other signs of allergey
Red flags in a presentation of vomiting
Not keeping down any feed (pyloric stenosis or intestinal obstruction)
Projectile or forceful vomiting (pyloric stenosis or intestinal obstruction)
Bile stained vomit (intestinal obstruction)
Haematemesis or melaena (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)
Apnoeas are a concerning feature and may indicate serious underlying pathology and need urgent assessment
Management of mild/simple GORD in children?
Small, frequent meals
Burping regularly to help milk settle
Not over-feeding
Keep the baby upright after feeding (i.e. not lying flat)
Management of problematic or severe GORD?
Gaviscon mixed with feeds
Thickened milk or formula (specific anti-reflux formulas are available)
Proton pump inhibitors (e.g., omeprazole) where other methods are inadequate
Rarely in severe cases they may need further investigation with a barium meal and endoscopy.
Surgical fundoplication can be considered in very severe cases, however this is very rarely required or performed.
What is Sandifer’s Syndrome?
This is a rare condition causing brief episodes of abnormal movements associated with gastro-oesophageal reflux in infants.
The infants are usually neurologically normal.
What are the key features of Sandifer’s syndrome?
Torticollis: forceful contraction of the neck muscles causing twisting of the neck
Dystonia: abnormal muscle contractions causing twisting movements, arching of the back or unusual postures
What is the course of Sandifer’s syndrome and why does it require specialist referal?
The condition tends to resolve as the reflux is treated or improves. Generally the outcome is good.
It is worth referring patients with these symptoms to a specialist for assessment, as the differential diagnosis includes more serious conditions such as infantile spasms (West syndrome) and seizures.
What is the pyloric spchincter?
The pyloric sphincter is a ring of smooth muscle the forms the canal between the stomach and the duodenum.
What is pyloric stenosis?
Hypertrophy (thickening) and therefore narrowing of the pylorus
How does pyloric stenosis cause projectile vomiting?
Hypertrophy (thickening) and therefore narrowing of the pylorus prevents food traveling from the stomach to the duodenum as normal.
After feeding, there is increasingly powerful peristalsis in the stomach as it tries to push food into the duodenum.
Eventually it becomes so powerful that it ejects the food into the oesophagus, out of the mouth and across the room.
When and how does pyloric stenosis present?
Typically presents in the first few weeks of life,
A hungry baby that is thin, pale and generally failing to thrive
Projectile vomiting
Pyloric stenosis - examination
If examined after feeding, often the peristalsis can be seen by observing the abdomen.
A firm, round mass can be felt in the upper abdomen that “feels like a large olive”.
This is caused by the hypertrophic muscle of the pylorus.
Blood gas analysis in pyloric stenosis
HYPOCHLORIC METABOLIC ALKALOSIS
Blood gas analysis will show a hypochloric (low chloride) metabolic alkalosis as the baby is vomiting the hydrochloric acid from the stomach.
How is pyloric stenosis diagnosed?
Diagnosis is made using an abdominal ultrasound to visualise the thickened pylorus
Definitive management of pyloric stenosis?
Laparoscopic pyloromyotomy (Ramstedt’s operation)
An incision is made in the smooth muscle of the pylorus to widen the canal allowing that food to pass from the stomach to the duodenum as normal.
Prognosis is excellent following the operation.
Acute gastritis vs enteritis vs gastroenteritis?
Acute gastritis is inflammation of the stomach and presents with nausea and vomiting.
Enteritis is inflammation of the intestines and presents with diarrhoea.
Gastroenteritis is inflammation all the way from the stomach to the intestines and presents with nausea, vomiting and diarrhoea.
Why is it important to isolate inpatients with ?gastroenteritis?
Gastroenteritis is a very common condition in children. The most common cause of gastroenteritis is viral. It is very easily spread and patients presenting with gastroenteritis often have an affected family member or contact.
It is essential to isolate the patient in any healthcare environment, such as a paediatric assessment unit or hospital ward, as they can easily spread it to other patients.
Management of gastroenteritis in children?
Dehydration is the main concern - ensure they remain hydrated whilst waiting for vomiting and diarrhoea to settle
Prevention of spread: barrier nursing and rigorous infection control if inpatient, children need to stay off school until 48 hours after the symptoms have completely resolved
Antibiotics are not generally recommended or required, however sample of the faeces can be tested with microscopy, culture and sensitivities to establish the causative organism and antibiotic sensitivities.
Antibiotics should only be given in patients that are at risk of complications once the causative organism is confirmed.
Most children make a full recovery with simple supportive management, but gastroenteritis can potentially be fatal, especially in very young or vulnerable children with other health conditions.
Causes of loose stool in children?
Infection (gastroenteritis)
Inflammatory bowel disease
Lactose intolerance
Coeliac disease
Cystic fibrosis
Toddler’s diarrhoea
Irritable bowel syndrome
Medications (e.g. antibiotics)
What is steatorrhoea and what does it suggest?
Steatorrhoea means greasy stools with excessive fat content. This suggests a problem with digesting fats, such as pancreatic insufficiency (think about cystic fibrosis).
Viral causes of gastroenteritis?
Rotavirus
Norovirus
Adenovirus is a less common cause and presents with a more subacute diarrhoea.
Bacterial causes of gastroenteritis?
Escherichia coli (E. coli 0157 strain)
Campylobacter Jejuni
Shigella
Salmonella
Bacillus Cereus
Yersinia Enterocolitica
Staphylococcus Aureus Toxin
Common parasitic cause of gastroenteritis?
Giardiasis
Possible post-gastroenteritis complications?
Lactose intolerance
Irritable bowel syndrome
Reactive arthritis
Guillain–Barré syndrome
Hydration in gastroenteritis?
Attempt a fluid challenge. It involves recording a small volume of fluid given orally every 5-10 minutes to ensure they can tolerate it. If they are able to tolerate oral fluid and are adequately hydrated they can usually be managed at home.
Rehydration solutions (e.g. dioralyte) can be used if tolerated.
Dehydrated children or those that fail the fluid challenge may require IV fluids.
Antidiarrhoeal medication such as loperamide and antiemetic medication such as metoclopramide are generally not recommended in management of gastroenteritis - when in particular?
Antidiarrhoeal medications are particularly avoided in e. coli 0157 and shigella infections, and where there is bloody diarrhoea or high fever.
Why should antibiotics be avoided if E. coli gastroenteritis is considered?
The use of antibiotics increases the risk of haemolytic uraemic syndrome, therefore antibiotics should be avoided if E. coli gastroenteritis is considered.
What is Campylobacter Jejuni?
Campylobacter is a common cause of travellers diarrhoea. It is the most common bacterial cause of gastroenteritis worldwide. Campylobacter means “curved bacteria”.
It is a gram negative bacteria that has a curved or spiral shape. It is spread by:
Raw or improperly cooked poultry
Untreated water
Unpasteurised milk
Campylobacter jejuni gram stain?
Gram negative rods with gull-wing shape
Ecoli on gram stain
gram-negative bacillus
Shigella gram stain
Gram negative rod
Bacillus cereus gram stain
gram positive rod
Salmonella gram stain
rod-shaped (bacillus) Gram-negative bacteria
Yersinia Enterocolitica gram stain?
Yersinia is a gram negative bacillus.
What is Hirschspurng’s disease
Hirschsprung’s disease is a congenital condition where nerve cells of the myenteric plexus are absent in the distal bowel and rectum.
Which nervous system is formed by the myenteric plexus?
The myenteric plexus, also known as Auerbach’s plexus, forms the enteric nervous system. It is the brain of the gut.
Pathophysiology of Hirschsprung’s disease?
Absence of parasympathetic ganglion cells:
- During fetal development these cells start higher in the GI tract and gradually migrate down to the distal colon and rectum.
- Hirschsprung’s occurs when the parasympathetic ganglion cells do not travel all the way down the colon, and a section of colon at the end is left without these parasympathetic ganglion cells.
What is intussuception?
Intussusception is a condition where the bowel “invaginates” or “telescopes” into itself.
This thickens the overall size of the bowel and narrows the lumen at the folded area, leading to a palpable mass in the abdomen and obstruction to the passage of faeces through the bowel.
Imaging in NEC
The condition is usually diagnosed via abdominal X-ray, which will often demonstrate pneumatosis intestinalis; air within the intestinal wall, arising due to the ongoing intestinal ischaemia.
Gas within the portal venous system and visibly dilated intestinal loops are other commonly observed features on imaging.
