Gastroenterology

Question 1

What are the red flags for constipation in paeds?

Answer 1

Not passing meconium with 48hr of birth.
Neurological symptoms.
Vomiting.
Ribbon stool (anal stenosis),
Abnormal anus,
Abnormal lower back or buttock.
Failure to thrive,
Acute severe abdominal pain and bloating.

Question 2

Presentation of coeliac’s disease in paeds?

Answer 2

Failure to thrive,
Diarrhoea,
Weight loss,
Fatigue,
Weight loss,
Anaemia,
Dermatitis herpetiformis.
Rarely - peripheral neuropathy, cerebellar ataxia or epilepsy.

Question 3

Investigations and complications of coeliacs disease?

Answer 3

Investigations - Raised anti-TTG antibodies and total immunoglobulin A levels and anti-endomysial antibodies. Endoscopy and intestinal biopsy shows crypt hypertrophy and villous atrophy.

Complications - Vitamin deficiency, anaemia, osteoporosis, ulcerative jejunitis, enteropathy-associated T-cell lymphoma. Non-Hodgkins lymphoma. Small bowel adenocarcinoma.

Question 4

Associations of coeliac’s disease?

Answer 4

Type 1 diabetes,
Thyroid disease,
Autoimmune hepatitis,
Primary biliary cirrhosis,
Primary sclerosing cholangitis,
Down’s syndrome

Question 5

Features of pyloric stenosis?

Answer 5

Stenosis of pyloric sphincter.
Presents with projectile vomiting, mass in upper abdomen which feels like a large olive (hypertrophy of pylorus). Blood gas shows hypochloric metabolic alkalosis.
Management - Diagnosis via abdominal US and treat with laparoscopic pyloromyotomy.

Question 6

Management of Crohn’s in Paeds?

Answer 6

Induce remission with steroids. If steroids alone don’t work then add immunosuppressant medication (azathioprine, mercaptopurine, methotrexate, infliximab).

Maintain remission with azathioprine or mercaptopurine

Question 7

Management of ulcerative colitis in Paeds?

Answer 7

Induce remission in mild-mod disease - first line is aminosalicylate. Second line is corticosteroids.
Induce remission in severe disease - first line is IV corticosteroids, second line is IV ciclosporin.

Maintain remission with aminosalicylate or can use azathioprine/mercaptopurine.

Question 8

explain features of biliary atresia?

Answer 8

Condition where bile duct is either narrow or absent.
High conjugated bilirubin levels which presents with persistent jaundice > 14 days (>21 days in premature babies).
Management - Kasai portoenterostomy however often needs full liver transplant

Question 9

Causes of intestinal obstruction in paeds?

Answer 9

Meconium ileus
Hirschsprung’s disease,
Oesophageal atresia,
Duodenal atresia,
Intussusception,
Imperforated anus,
Malrotation of intestines with volvulus,
Strangulated hernia

Question 10

What is Hirschsprung’s disease?

Answer 10

Congenital condition where parasympathetic ganglion cells of myenteric plexus are absent in distal bowel and rectum.
It is responsible for stimulating peristalsis.
There may be only one section of the bowel without the plexus or you may have total colonic aganglionosis.

Question 11

Presentation and management of Hirschsprung disease?

Answer 11

Presentation - Delay in passing meconium (> 24 hours),
Chronic constipation since birth,
Abdominal pain and distention,
Vomiting,
Poor weight gain and failure to thrive.
Management - abdominal xray, rectal biopsy to confirm diagnosis and then surgery to remove aganglionic section of bowel.

Question 12

Explain features of Hirschsprung associated entercolitis

Answer 12

Inflammation and obstruction of intestine.
Presents 2-4 weeks after birth with fever, abdominal distention, diarrhoea and sepsis.
Life threatening and can lead to toxic megacolon and perforation.
Rx - antibiotics, fluid resus and decompression.

Question 13

Presentation, investigations, management and complications of Intussusception

Answer 13

Presentation - Severe, colicky abdominal pain, inconsolable crying, characteristically draw knees up and turns pale, lethargic, redcurrent jelly stool (late sign), sausage shaped RUQ mass, vomiting and intestinal obstruction.

Ix - Ultrasound is Ix of choice.

Rx - Air insufflation under radiological control is first line. Surgical reduction if unsuccessful.

Complications - Obstruction, gangrenous bowel, perforation and death

Question 14

What conditions is intussusception associated with?

Answer 14

Concurrent viral illness,
HSP,
Cystic fibrosis,
Intestinal polyps,
Meckel diverticulum

Question 15

Location of liver on palpation in infants?

Answer 15

3cm below costal maegin in nipple line in infancy.
2cm at 1 year.
1cm at 5 years

Question 16

Benefits of breast feeding for baby and mum?

Answer 16

Baby - reduced gut infection, reduced respiratory infections, reduced ear infections, reduced cardiovascular disease, reduced risk of SIDS and improved cognitive ability.
Mother - Reduced breast and ovarian cancer risk, reduced risk of diabetes and postnatal depression.

Question 17

Foods to avoid before 6 months?

Answer 17

Wheat based foods (bread, rusks, breakfast cerals),
Eggs, fish, liver and shelfish,
Nuts, peanuts and peanut products.
Cow’s milk and soft, unpasteurised cheeses.

Question 18

What foods should you avoid before 1 year?

Answer 18

Honey - risk of botulism

Question 19

Describe features of infantile colic

Answer 19

Typically occurs in infants less than 3 months old. Usually resolves around 6 months of age.
Presents with bouts of excessive crying and pulling up of the legs. Often worse in evening.
Do NOT use simeticone or lactase

Question 20

What is Meckel’s diverticulum?

Answer 20

Congenital diverticulum of small intestine which is remnant of omphalomesenteric duct. Contains ectopic ileal gastric or pancreatic mucosa.
Rules of 2 - Occurs in “% of population, 2 ft from iliocaecal valve and 2 inches long.

Question 21

Presentation of Meckel’s diverticulum?

Answer 21

Abdominal pain mimicking appendicitis,
Rectal bleeding (most common cause of massive GI bleed in children)
Intestinal obstruction

Question 22

Investigations and management of meckel’s diverticulum?

Answer 22

Ix: If haemodynamically table then Meckel’s scan - 99m technetium pertechnetate. If unstable then mesenteric arteriography.
Rx: Removal if narrow neck/symptomatic