Gastroenterology Flashcards
What are some key clinical features of constipation?
- Hard stool, difficulty passing, strain and painful abdominal pain
- Rabbit dropping stools
- Retentive posturing
- Overflow soiling
- Rectal bleeding associated with hard stools
- Loss of sensation of necessity to open bowels
What is encopresis?
Faecal incontinence
Encopresis is not pathological until the age of 4, what are the rare causes of it?
Abuse, stress, learning disability, cerebral palsy, spina bifida.
What can be observed in encopresis?
Soiling of loose and smelly stools with hard stool remaining in the rectum.
What characterizes rectum desensitization?
Don’t open bowels when they need to and ignore sensation of a full rectum leading to retention, steadily increasing rectum stretch and further desensitization.
What lifestyle factors may contribute to constipation?
- Low fiber diet
- Poor fluid intake and dehydration
- Sedentary lifestyle
- Psychological problems - home or at school
- Don’t open bowels when required
What secondary pathological problems may contribute to a child’s constipation?
- Hypothyroid
- Spinal cord lesions
- Intestinal obstruction
- Cystic fibrosis
- Hirschsprung’s disease
Consider complications of paediatric constipation; what might they be?
- Pain
- Reduced sensation
- Hemorrhoids
- Anal fissure
- Overflow and soiling
- Psychological morbidity
What are 7 red flags to consider should a paediatric patient be constipation?
- Not passing meconium w/in 48 hrs of birth
- Neurological - lower limb
- Vomiting
- Ribbon stools
- Abnormal anus, lower back buttocks
- Failure to thrive
- Severe abdominal pain and bloating - obstruction or intussusception
Should a baby not pass meconium w/in 48 hrs of birth what are you thinking?
Hirschsprung’s disease or cystic fibrosis
What is the 1st line laxative prescribed for constipation?
Movicol (need to ween as bowel habits regulate)
What are 7 red flags to consider should a paediatric patient be constipation?
- Not passing meconium w/in 48 hrs of birth
- Neurological - lower limb
- Vomiting
- Ribbon stools
- Abnormal anus, lower back buttocks
- Failure to thrive
- Severe abdominal pain and bloating - obstruction or intussusception
What causes GORD in babies?
Immaturity of the lower oesophageal sphincter causing the stomach contents to easily reflux into the oesophagus.
A child is projectile/forceful vomiting their food, what would you consider this as a red flag for?
Pyloric stenosis
Intestinal obstruction
If a patient is unable to keep their food down, what would you consider?
Pyloric stenosis
Intestinal obstruction
A child has bile-stained vomit, what would you consider this as a red flag for?
Obstruction
A child presents with haematemesis or melaena, what would you consider this as a red flag for?
Ulcer
Oesophagitis
Varices
A child presents with abdominal distension, what would you consider this as a red flag for?
Intestine obstruction
A child presents with respiratory symptoms what may be causing these respiratory symptoms and they are red flags for?
Aspiration
Infection
A patient presents with blood in their stools, what is this a red flag for?
Infection
Cow milk protein allergy
A child presents with the red flags which would suggest an infection - what potential diagnoses can be made?
Pneumonia
UTI
Tonsillitis
Meningitis
A child presents with rash, angioedema and urticaria, what is a potential diagnosis?
Cow milk protein allergy
What are management options for a child with Sx of GORD?
Small, frequent meals, burp regularly
Don’t overfeed
Keep baby upright post feed
If GORD is problematic and conservative management is not successful what are management options?
Gaviscon, thicken their milk/formula, ranitidine, omeprazole
A child presents with reduced consciousness, bulging fontanelle and neuro signs, what are these red flags for?
Meningitis
Raised ICP
What may be offered in very severe cases of GORD?
Surgical fundoplication
What are the complications of Sandifer’s Syndrome?
Infantile spasms and seizures
What characterizes Sandifer’s Syndrome?
Brief abnormal movements associated with GORD in infants - features include torticollis and dystonia (back arching and unusual postures)
What is the difference between acute gastritis, enteritis and gastroenteritis?
Acute gastritis - stomach inflammation presenting with N/V
Enteritis - intestinal inflammation presenting with diarrhoea
Gastroenteritis - stomach to intestine inflammation presenting with N/V/diarrhoea
What are viral causes of gastroenteritis?
Rotavirus, norovirus (adenovirus rare)
Name bacterial causes of gastroenteritis?
- Escherichia coli
- Cambylobacter jejuni
- Shigella
- Salmonella
- Bacillus cereus
- S. aureus toxin
- Giardiasis
How is E.coli spread?
Infected faeces, unwashed salad, contaminated water
What is the pathophysiology of E.coli (how does it cause the symptoms)?
Produces Siga toxin causing abdominal cramps, bloody diarrhoea, vomiting.
Which syndrome can E.coli causing gastroenteritis lead to?
Destroys blood cells and leads to haemolytic uraemic syndrome (HUS)
Why should antibiotics be avoided when treating gastroenteritis caused by E.coli?
Increase the risk of haemolytic uraemic syndrome (HUS)
What is the shape of campylobacter jejuni?
Gram negative curved or spiral shape
How is C.jejuni spread?
Raw, improper cooked poultry, untreated water, unpasteurized milk
What are the symptoms of gastroenteritis caused by c.jejuni?
Fever, diarrhoea and vomiting and abdominal cramp
How is gastroenteritis caused by C.jejuni treated?
Azithromycin and ciprofloxacin
How is shigella spread?
Faeces
What are the symptoms of shigella caused by?
Bloody diarrhoea, abdominal cramps, fever
What is the pathophysiological mechanism of Shigella causing gastroenteritis?
Shiga toxin causes HUS
What antibiotics will treat Shigella?
Azithromycin, ciprofloxacin
How is salmonella spread?
Raw eggs, poultry, food contaminated with infected faeces.
What are the symptoms of gastroenteritis caused by salmonella?
Watery diarrhoea with mucus/blood, abdominal pain, vomiting
What is the shape of bacillus cereus and how is it spread?
Gram +ve rod, fried rice left out at room temperature
What are the Sx and their progression of bacillus cereus infection?
Abdominal cramp
Vomiting (5hr)
Diarrhoea (8hr)
Sx resolution after 24 hours
The enterotoxins in s. aureus will cause gastroenteritis, what is there source and where will they cause infection?
On food; eggs, dairy, meat
Small intestine inflamed causing D/V, abdominal cramp, fever.
How is giardiasis lamblia spread?
Cysts in stool contaminate food, water and are eaten thus infecting a new host (faecal-oral transmission)
What are the Sx of giardiasis?
Chronic diarrhoea
How is giardiasis diagnosed?
Stool microscopy
What is the treatment of choice for giardiasis?
Metronidazole
Which medication is not recommended in E.coli 0157 infection and Shigella or blood diarrhoea/high fever?
Metoclopramide
What is the main aim and what can help a patient if this is not so straightforward in a gastroenteritis patient?
Stay hydrated
Dioralyte can be prescribed to help if tolerated
What is the aetiology of intussusception?
Infant 6 months to 2 years (>boys)
What is intussusception?
Bowel invaginated/telescopes into itself, folding inwards.
–> Thickens overall bowel size and narrows lumen at the folded area so palpable mass in abdomen
–> Faces passage obstructed
What is the clinical presentation of intussusception?
RUQ palpable mass
Intestinal obstruction, vomiting
Severe, colicky abdominal pain
Pale, lethargic, unwell child
Redcurrant jelly stool
What is the characteristic stool of intussusception?
Redcurrant jelly stool
How is intussusception diagnosed?
Ultrasound scan, contrast enema
What is the management of intussusception?
Therapeutic enema, surgical reduction/resection (bowel gangrenous or perforated)
What is pyloric stenosis?
Hypertrophy of the pyloric sphincter causing pyloric narrowing and therefore preventing food passing into the stomach.
Why does projectile vomiting result from pyloric stenosis?
Increasingly powerful peristaltic stomach contractions as food is attempted to be forced into the duodenum eject food out oesophagus
–> eventually projectile vomiting
What is the typical presentation of a baby suffering pyloric stenosis?
Thin, pale and failing to thrive suffering projectile vomiting
What is present on blood gas analysis in a baby suffering pyloric stenosis?
- Hypo-chloric metabolic alkalosis
- Vomiting HCl from the stomach
How is pyloric stenosis diagnosed?
Abdominal USS to visualize thickened pylorus
What is the management for pyloric stenosis?
Laparoscopic pyloromyotomy (Ramstedt’s operation) to widen canal
What sign is present in Appendicitis?
Rovsing’s sign
Clinical features of appendicitis?
Central move to RIF abdominal pain - McBurney’s point. N/V, guarding on abdominal palpation.
What suggests appendix rupture?
Rebound tenderness, percussion tenderness.
Management for appendix ruptured?
Appendicectomy by laparoscopic surgery
What is the cow milk protein allergy?
Children <3 will have hypersensitivity to cow’s milk
What are the symptoms of cow milk protein allergy?
Bloating, wind, abdominal pain, D/V
Allergic Sx (think the classic)
Which IgE reaction will be quicker in cow milk protein allergy?
IgE - <2 hours
Non-IgE - slower over several days
How is cow milk protein allergy diagnosed?
Skin prick test
How is cow’s milk protein allergy treated?
Breast-feeding mother to avoid dairy. If formula milk then replace with special hydrolyzed formulas deigned for cow’s milk allergy
What is coeliac disease?
Autoimmune disease causing atrophy of the intestinal villi in particular the jejunum
Which genes are associated with coeliac disease?
HLA-DQ2 (90%), HLA-DQ8
How coeliac disease present?
Failure to thrive, fatigue, WL
Anaemia secondary to Fe, B12, folate deficiency
Dermatitis herpatiformis
Neuro Sx: cerebellar ataxia, peripheral neuropathy, epilepsy
What autoantibodies are present in coeliac disease?
Anti-TTG, EMA (endomysial antibodies), anti-DGP
What is seen on endoscopy and intestinal biopsy in coeliac disease?
Crypt hypertrophy and villous atrophy
What autoantibodies will be raised in coeliac disease?
Raised anti-TTG (1st choice)
Raised anti-EMA
What are the three stage subtypes of coeliac disease?
- Partial villous atrophy (Stage 3a): Your intestinal villi are still there, but are smaller.
- Subtotal villous atrophy (Stage 3b): Your intestinal villi have shrunken significantly.
- Total villous atrophy (Stage 3c): Your intestinal lining is basically flat with no intestinal villi left.
What are the 0-4 descriptions of the upper jejunal mucosal immunopathology?
0 - pre-infiltrative
1 - infiltrative
2 - infiltrative hyperplastic
3 - flat destructive
4 - atrophic hypoplastic
What is the treatment for coeliac disease?
Lifelong gluten free diet
What is coeliac disease associated with?
T1DM
Thyroid disease
AI hepatitis
Primary biliary cirrhosis
Sclerosing cholangitis
What can be a key trigger of IBS in children?
Stress
What is a common cause of toddler diarrhoea?
Underlying maturational delay in intestinal motility leading to intestinal hurry
What is Meckel diverticulum?
2% of individuals will have the ileal remnant of vitello-intestinal duct (Meckel diverticulum) containing ectopic gastric mucosa or pancreatic tissue
What is the treatment for Meckel diverticulum?
Surgical resection
How do patients with Meckel diverticulum tend to present?
Asymptomatic, intussusception, volvulus around band, diverticulitis mimicking appendicitis
What is the treatment for diaphragmatic hernia?
Large nasogastric tube then surgical repair
Which ethnicity are umbilical hernias especially common within?
Afro-Caribbean infants
How do diaphragmatic hernias tend to present?
Failure to respond to resus or respiratory distress
How does one diagnose diaphragmatic hernia?
Chest and abdominal X-Ray
What will cause inguinal hernias?
Patent processus vaginalis (on RHS commonly)
How do babies with inguinal hernias present?
Intermittent swelling in groin or scrotum on crying/straining
Irreducible lump in the groin or scrotum of the infant
Unwell with irritability and vomiting
How are inguinal hernias treated?
Opioid analgesia and sustained gentle compression then surgery
If associated with what will prompt immediate operation for inguinal hernia?
Undescended testes
