Gastroenterology Flashcards
What are some medical causes of abdominal pain ?
Constipation
UTI
Coeliac disease
Inflammatory bowel disease
IBS
Mesenteric adenitis
Abdominal migraine
Pyelonephritis
Infantile colic
DKA
What are some additional causes of abdominal pain in adolescent girls ?
Dysmenorrhoea
Mittelschmerz
Ectopic pregnancy
Pelvic inflammatory disease
Ovarian torsion
Pregnancy
What are some surgical causes of abdominal pain ?
Appendicitis
Intussusception
Bowel obstruction
Testicular torsion
What are some red flags for serious abdominal pain ?
Persistent or bilious vomiting
Severe chronic diarrhoea
Fever
Rectal bleeding
Weight loss or faltering growth
Dysphagia
Nighttime pain
Abdominal tenderness
What are some initial investigations and results that should be performed when someone has abdominal pain ?
Anaemia - IBD or coeliac disease
Raised inflammatory markers - IBD
Raised anti-TTG or anti-EMA antibodies - coeliac disease
Raised faecal calprotectin - IBD
Positive urine dipstick - UTI
What is involved in the management of abdominal pain ? ( careful explanation and reassurance )
Distracting the child from the pain
Advice about sleep, regular meals, healthy balanced diet, staying hydrated, exercise and reducing stress
Probiotic supplements
Avoid NSAIDs
Address psychosocial triggers and exacerbating factors
What is abdominal migraines ?
Presents with episodes of central abdominal pain lasting more than 1 hour.
Children are more likely to suffer
What are some signs or symptoms associated with abdominal migraine ?
Nausea and vomiting
Anorexia
Pallor
Headache
Photophobia
Aura
What can be used to treat an acute attack of abdominal migraines ?
Low stimulus environment
Paracetamol
Ibuprofen
Sumatriptan
What are some preventative medications for abdominal migraines ?
Pizotifen
Propranolol
Cyproheptadine
Flunarazine
What is pizotifen ?
The main migraine preventative medication
It needs to be withdrawn slowly when stopping as it is associated with withdrawal symptoms such as depression, anxiety, poor sleep and tremor.
How does constipation present ?
Less than 3 stools a week
Hard stools that are difficult to pass
Rabbit dropping stools
Straining and painful passages of stools
Abdominal pain
Rectal bleeding associated with hard stools
Faecal impaction causing overflow soiling
What is encopresis ?
The term for faecal incontinence
Not considered pathological until 4 years of age
Sign of chronic constipation where the rectum becomes stretched and looses sensation.
Other than constipation what are some rarer causes of encopresis ?
Spina bifida
Hirschsprung’s disease
Cerebral palsy
Learning disability
Psychosocial stress
Abuse
What are some lifestyle factors that can contribute to the development of constipation ?
Habitually not opening the bowels
Low fibre diet
Poor fluid intake and dehydration
Sedentary lifestyle
Psychosocial problems - difficult home or school environment
What is desensitisation of the rectum ?
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. This leads to faecal impaction and desensitisation.
What are some secondary causes of constipation ?
Hirschsprung’s disease
Cystic fibrosis
Hypothyroidism
Spinal cord lesions
Sexual abuse
Intestinal obstruction
Anal stenosis
Cow’s milk intolerance
What are some red flags of constipation ?
Not passing meconium within 48 hours of birth
Neurological signs or symptoms particularly in the lower limbs
Vomiting
Ribbon stool - anal stenosis
Abnormal anus
Abnormal lower back or buttocks
Failure to thrive
Bloating
What are some complications of constipation ?
Pain
Reduced sensation
Anal fissures
Haemorrhoids
Overflow and soiling
Psychosocial morbidity
What is the management of functional constipation ?
Recommend a high fibre diet and good hydration
Start laxatives - Movicol
Dis impaction regimen - high dose of laxatives
Encourage and praise visiting the toilet
Laxatives should not be continued long term and slowly weaned off as the child develops a normal, regular bowel habit.
What is GORD ?
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.
How does problematic GORD present ?
Chronic cough
Hoarse cry
Distress, crying or unsettled after feeding
Reluctance to feed
Pneumonia
Poor weight gain
How may older children present with GORD ?
Heartburn
Acid regurgitation
Retro sternal or epigastric pain
Bloating
Nocturnal cough
What are some causes of vomiting ?
Overfeeding
GORD
Pyloric stenosis
Gastritis or gastroenteritis
Appendicitis
Infections such as UTI, tonsillitis or meningitis
Intestinal obstruction
Bulimia
What are some features of a serious underlying problem associated with GORD symptoms ?
Not keeping down any feed - pyloric stenosis or intestinal obstruction
Projectile or forceful vomiting
Bile stained vomit
Haematemesis or melaena - peptic ulcer, oesophagitis or varices
Abdominal distension
Reduced consciousness, bulging fontanelle
Resp symptoms
Blood in the stools
Signs of infection
What is the management of simple GORD ?
Small frequent meals
Burping regularly to help milk settle
Not over feeding
Keep the baby upright after feeding
What is the management of problematic GORD ?
Gaviscon mixed with feeds
Thickened milk or formula
PPI
Rarely - surgical fundoplication
What is Torticollis ?
Forceful contraction of the neck muscles causing twisting of the neck
What is Dystonia ?
Abnormal muscle contractions causing twisting movements, arching of the back or unusual postures
What are the key features of sandifer’s syndrome ?
Torticollis
Dystonia
What is sandifer’s syndrome ?
A rare condition causing brief episodes of abnormal movements associated with GORD in infants. The infants are usually neurologically normal.
What are some differentials of sandifer’s syndrome ?
Infantile spasms
Seizures
What causes pyloric stenosis ?
The pyloric sphincter is a ring of smooth muscle that forms the canal between the stomach and the duodenum. Hypertrophy and therefore narrowing of the pylorus is called pyloric stenosis.
How does pyloric stenosis cause projectile vomiting ?
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 the mouth.
How does pyloric stenosis present ?
Presents in the first few weeks of life
Thin, pale and failing to thrive
Projectile vomiting
Firm, round mass can be felt in the upper abdomen
what does the blood gas analysis show in pyloric stenosis ?
Hypochloric metabolic alkalosis as the baby is vomiting the hydrochloric acid from the stomach.
What is the management of pyloric stenosis ?
Laparoscopic pyloromyotomy
How is a diagnosis of pyloric stenosis made ?
Abdominal USS to visualise the thickened pylorus
What is a laparoscopic pyloromyotomy ?
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.
What is acute gastritis ?
Inflammation of the stomach and presents with nausea and vomiting
What is enteritis ?
Inflammation of the intestines and presents with diarrhoea
What is gastroenteritis ?
Inflammation all the way from the stomach to the intestines and presents with nausea, vomiting and diarrhoea.
What should happen on the wards with a patient with gastroenteritis ?
Isolate the patient as it can easily spread to other patients
Keep hydrated as dehydration is a main concern
What is steatorrhoea ?
Greasy stools with excessive fat content. This suggests a problem with digesting fats such as pancreatic insufficiency.
What are some key conditions to think about in patients with loose stools ?
Gastroenteritis
IBD
Lactose intolerance
Coeliac disease
CF
IBS
What are the common viral causes of gastroenteritis ?
Rotavirus
Norovirus
Adenovirus - less common
What is campylobacter jejuni on gram stain ?
Gram negative - curved or spiral shape
How is campylobacter spread ?
Raw or improperly cooked poultry
Untreated water
Unpasteurised milk
What is the timeline of a campylobacter infection ?
Incubation is usually 2 - 5 days
Symptoms resolve after 3 - 6 days
What are the symptoms of campylobacter infection ?
Abdominal cramps
Diarrhoea often with blood
Vomiting
Fever
What is the management of campylobacter infection ?
Azithromycin or ciprofloxacin
How is shigella spread ?
By faeces contaminating drinking water, swimming pools and food.
What is the timeline of shigella ?
Incubation period is 1 - 2 days
Symptoms usually resolve within 1 week without treatment
What are some symptoms of a shiga infection ?
Bloody diarrhoea
Abdominal cramps
Fever
What can a shiga infection cause ?
Haemolytic uraemic syndrome due to the production of shiga toxins
What is the management of shigella ?
Azithromycin or ciprofloxacin
How is salmonella spread ?
Spread by eating raw eggs or poultry or food contaminated with the infected faeces of small animals.
What is the timeline of a salmonella infection ?
Incubation is 12 hours to 3 days
Symptoms usually resolve within a week
What are some symptoms of salmonella ?
Watery diarrhoea associated with blood or mucus
Abdominal pain
Vomiting
What does bacillus cereus show on gram stain ?
Gram positive rod
How is bacillus cereus spread ?
Spread through inadequately cooked food - typically on fried rice
How does bacillus cereus cause watery diarrhoea ?
Whilst growing on food it produces a toxin called cereulide. This toxin causes abdominal cramping and vomiting within 5 hours of ingestion.
When it arrives in the intestines it produces different toxins that cause a watery diarrhoea.
How does staph aureus cause diarrhoea ?
It produces enterotoxins when growing on food such as eggs, dairy and meat. When eaten these toxins it causes small intestinal inflammation. This causes diarrhoea, perfuse vomiting, abdo cramps and fever
What is the timeline of staph aureus infection ?
Symptoms start within hours of digestion and settle within 12-24 hours
What is the timeline of a staph aureus infection ?
Symptoms start within hours of ingestion and settle within 12-2 hours
How does giardia spread ?
It is a microscopic parasite.
Living in the small intestines of mammals
Releases cysts in the stools of infected mammals.
These cysts can contaminate food or water and are eaten infecting a new host.
This is faecal - oral transmission
How is a diagnosis of giardia made ?
Stool microscopy
What is the management of giardiasis ?
Metronidazole
What are the principles of gastroenteritis management ?
Good hygiene
Rigorous infection control
Stay off school until 48 hours after symptoms have resolved.
Test with microscopy, culture and sensitivities
Fluid challenge
Rehydration - dioralyte
Antidiarrhoeal medication - loperamide
Antiemetic medication - Metoclopramide
What are some post gastroenteritis complications ?
Lactose intolerance
IBS
Reactive arthritis
Guillain-Barré syndrome
What is coeliac disease ?
An autoimmune condition where exposure to gluten causes an immune reaction that creates inflammation in the small intestine. It usually develops in childhood but can start at any age.
What is the pathophysiology of coeliac disease ?
Autoantibodies are created in response to exposure to gluten. These autoantibodies target the epithelial cells of the intestine and lead to inflammation.
There are 2 autoantibodies - anti-TTG and anti-endomysial.
Inflammation affects the small bowel particularly the jejunum. It causes atrophy of the intestinal villi. These help absorb nutrients and inflammation can lead to malabsorption and disease related symptoms.
How does coeliac disease present ?
Asymptomatic
Failure to thrive
Diarrhoea
Weight loss
Mouth ulcers
Anaemia
Dermatitis herpetiformis
How is coeliac disease diagnosed ?
Investigations must be carried out on a gluten free diet
Check total immunoglobulin A levels to exclude IgA deficiency
Raised anti-TTG and anti-endomysial
Endoscopy
What are some conditions 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
Non-Hodgkin lymphoma
What is the treatment for coeliac disease ?
A lifelong gluten free diet is essentially curative
What are some features of Crohn’s disease ?
No blood or mucus
Entire GI tract
Skip lesions
Terminal ileum most affected
Transmural inflammation
Smoking is a risk factor
Weight loss
Strictures and fistulas
What are some features of UC ?
Continuous inflammation
Limited to colon and rectum
Only superficial mucosa affected
Smoking is protective
Excrete blood and mucus
How does IBD present ?
Children and teenagers
Perfuse diarrhoea
Abdominal pain
Bleeding
Weight loss
Anaemia
What are some extra-intestinal manifestations of IBD ?
Finger clubbing
Erythema nodosum
Pyoderma gangrenosum
Episleritis and iritis
Inflammatory arthritis
Primary sclerosing Cholangitis
What investigations are performed when suspecting IBD ?
FBC
TFT
U&E’s
LFT
CRP
Faecal calprotectin
Endoscopy - OGD and colonoscopy
Imaging - USS, CT, MRI
What is the management of inducing remission of Crohn’s ?
Steroids - oral prednisolone and IV hydrocortisone
What is the management of maintaining remission of Crohn’s ?
Azathioprine
Mercaptopurine
Alternative - methotrexate
What is the management of inducing remission of UC ?
Mild to moderate - aminosalicylate such as mesalazine
Severe - iv corticosteroids ( hydrocortisone )
What is the management of maintaining remission of UC ?
Aminosalicylate - mesalazine
Azathioprine
Mercaptopurine
What surgical treatment can be used to treat UC ?
Panproctocolectomy - removal of the colon and rectum
The patient is then left with a permanent ileostomy or ileo-anal anastomosis ( j-pouch )
What is biliary atresia ?
A congenital condition where a section of the bile duct is either narrowed or absent. This results in cholestasis where the bile cannot be transported from the liver to the bowel.
How does biliary atresia present ?
Presents shortly after birth with significant jaundice due to high conjugated bilirubin levels.
Persistent jaundice
What is the management of biliary atresia ?
Surgery - kasai portoenterostomy
How is a Kasai portoenterostomy performed ?
Involves attaching a section of the small intestine to the opening of the liver where the bile duct normally attaches.
Often patients require a full liver transplant to resolve
What is intestinal obstruction ?
Where a physical obstruction prevents the flow of faeces through the intestines. This blockage will lead to a back pressure through the GI system causing vomiting.
What are the causes of intestinal obstruction ?
Meconium ileus
Hirschsprung’s disease
Oesophageal atresia
Duodenal atresia
Intussusception
Volvulus
How does intestinal obstruction present ?
Persistent vomiting - may be bilious
Abdominal pain and distension
Failure to pass stools or wind
Abnormal bowel sounds - high pitched and tinkling
How is intestinal obstruction diagnosed ?
Abdominal x-ray showing dilated loops of bowel proximal to the obstruction and collapsed loops of bowel distal to the obstruction
There will also be absence of air in the rectum.
What is the management of intestinal obstruction ?
Paediatric surgical unit
Nil by mouth and insert a nasogastric tube to help drain the stomach and stop vomiting.
Require IV fluids
What is Hirschsprung’s disease ?
A congenital condition where nerve cells of the myenteric plexus are absent in the distal bowel and rectum.
How does the myenteric plexus work ?
Forms the enteric nervous system - its the brain of the gut.
This nerve plexus runs all the way along the bowel in the bowel wall. It is responsible for stimulating peristalsis of the large bowel.
What is the pathophysiology of Hirschsprung’s disease ?
The absence of parasympathetic ganglion cells.
During foetal development these cells start higher in the GI tract and gradually migrate down to the distal colon and rectum.
Hirschsprung’s disease 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 parasympathetic ganglion cells.
What conditions can be associated with Hirschsprung’s disease ?
Down’s syndrome
Neurofibromatosis
How does Hirschsprung’s disease present ?
Delay in passing meconium
Chronic constipation
Abdominal pain and distension
Vomiting
Poor weight gain
Failure to thrive
What is Hirschsprung-associated enterocolitis ?
Inflammation and obstruction of the intestine.
Typically presents within 2-4 weeks of birth with fever, abdominal distention, diarrhoea and features of sepsis.
What can Hirschsprung-associated enterocolitis lead to ?
Toxic mega colon and perforation
How is Hirschsprung-associated enterocolitis managed ?
Urgent antibiotics
Fluid resuscitation
Decompression of the obstructed bowel
How is Hirschsprung’s disease diagnosed ?
Abdominal X-ray
Rectal biopsy
How is Hirschsprung’s disease managed ?
Fluid resus
Antibiotics IV
Definitive management - surgical removal of the aganglionic section of bowel.
What is intussusception ?
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. There is obstruction of the passage of faeces though the bowel.
What are some associated conditions of intussusception ?
Concurrent viral illness
Henoch-Schonlein purpura
Cystic fibrosis
Intestinal polyps
Merkel diverticulum
How does intussusception present ?
Severe, colicky abdominal pain
Pale, lethargic and unwell child
Recurrent jelly stool
RUQ mass - sausage shaped
Vomiting
Intestinal obstruction
How is intussusception diagnosed ?
USS or contrast enema
What is the management of intussusception ?
Therapeutic enemas
Surgical reduction
What are some complications of intussusception ?
Obstruction
Gangrenous bowel
Perforation
Death
What is appendicitis ?
Inflammation of the appendix - small thin tube sprouting from the caecum.
Inflammation is usually due to infection and this can quickly proceed to gangrene and rupture.
what can a ruptured appendix cause ?
Peritonitis due to release of faecal count and infective material into the abdomen.
How does appendicitis present ?
Starts as central abdominal pain that moves to the right iliac fossa.
On palpation there is tenderness over McBurney’s point.
Loss of appetite
Nausea and vomiting
Rovsing’s sign
Guarding
Rebound tenderness
How is appendicitis diagnosed ?
Clinical presentation and raised inflammatory markers
CT scan
USS is used in females to exclude ovarian or gynaecological pathology
What are some key differentials for appendicitis ?
Ectopic pregnancy
Ovarian cysts
Meckel’s diverticulum
Mesenteric adenitis
What is the management of appendicitis ?
Removal of the inflamed appendix - appendicectomy
Laparoscopic surgery
What are some complications of appendicectomy ?
Bleeding , infection, pain and scars
Damage to bowel, bladder or other organs
Removal of a normal appendix
Anaesthetic risks
VTE
