Gastroenterology 3

Question 1

What is abdominal migraine?

Answer 1

Type of migraine where there is severe (usually central) abdominal pain in addition to headaches. There is associated vomiting and facial pallor

Question 2

How do abdominal migraines present?

Answer 2

characteristic long periods (often weeks) of no symptoms and then a shorter period (12- 48h) of non-specific abdominal pain, pallor and potentially vomiting
Can use anti-migraine meds

Question 3

What is IBS?

Answer 3

a disorder associated with altered GI motility and an abnormal sensation of intra- abdominal events
non-specific abdominal pain, often peri-umbilical, may be worse before or relieved by defaecation
• explosive, loose, or mucousy stools
• bloating
• feeling of incomplete defaecation
• constipation (often alternating with normal or loose stools)

Question 4

What is gastroenteritis?

Answer 4

Rotavirus (accounts for up to 60% of cases in under 2 years old), particularly during winter and early spring- an effective (oral) vaccine is available
Blood in the stool- bacterial infection (e.g. Campylobacter jejuni, Shigella, E.coli)
Hx: sudden change to lose or watery stools accompanied by vomiting. History of contact with a person with diarrhoea and/or vomiting or recent travel abroad

Question 5

What are conditions that can mimic gastroenteritis?

Answer 5

Systemic: Septicaemia, meningitis
Local: RTIs, otitis media, hepatitis A, UTIs
Surgical: Pyloric stenosis, intussusception, acute appendicitis, NEC, Hirschsprung disease
Metabolic: DKA
Renal: Haemolytic uremic syndrome (in E.coli E105)
Other: Coeliac disease, cow’s milk protein allergy, lactose intolerance, adrenal insufficiency

Question 6

When are children at an increased risk fo dehydration?

Answer 6

• infants, particularly those under 6 months of age or those with low birthweight
greater surface area-to-weight leading to greater insensible water losses + higher basal fluid requirements (100-120 ml/kg/24h) + immature renal tubular reabsorption + unable to obtain fluids themselves when thirsty
• if they have passed 6+ diarrhoeal stools in the previous 24h
• if they have vomited 3+ times in the previous 24h
• if they have been unable to tolerate (or not been offered) extra fluids
• if they have malnutrition

Question 7

How is hydration status assessed?

Answer 7

Most accurately via degree of weight loss, Most commonly hypernatraemia and hypolakaemia with some degree of AKI
No clinically detectable dehydration: <5% loss of body weight
Clinical dehydration: 5%-10% loss of body weight
Shock: >10% loss of body weight. MUST be identified without delay

Question 8

What is isonatraemic dehydration?

Answer 8

losses of sodium and water are proportional and plasma sodium
remains within the normal range

Question 9

What is hyponatraemic dehydration?

Answer 9

when a child drinks large quantities of water or other hypotonic solution there is greater net loss of sodium than water, leading to fall in plasma sodium, which causes shift of water from EC to IC compartments- cerebral oedema

Question 10

What is hypernatraemic dehydration?

Answer 10

Usually due to high insensible water losses (high fever or hot, dry environment) or from profuse, low-sodium diarrhoea
The EC fluid becomes hypertonic with respect to IC fluid, causing shift of water into EC space, which leads to depression of the fontanelle, increased skin turgor & sunken eyes- cerebral shrinkage

Question 11

What is the management for hypernatraemic dehydration?

Answer 11

Replace dehydration. Do not give antiemetics and antidiarrhoeals. Abx are also not routinely used and reserved for suspected or confirmed sepsis or for salmonella infections in <6 months olds.

Question 12

How does malabsorption present?

Answer 12

Abnormal stools: difficult to flush, odour
Poor weight or faltering growth
specific nutrient deficiencies, either singly or in combination: some disorders affecting small intestinal mucosa or pancreas (chronic pancreatic insufficiency) may lead to pan-malabsorption whereas others are highly specific (e.g. zinc malabsorption in acrodermatitis enteropathica)(genetic autosomal recessive disorder, characterised by periorificial dermatitis, alopecia, and diarrhea)

Question 13

What is coeliac disease?

Answer 13

Enteropathy in which the gliadin fraction and other related prolamines in wheat, barley and rye provoke a damaging immunological response in the proximal small intestinal mucosa. Villi become progressively shorter and then absent, leaving flat mucosa.

Question 14

How does coeliacs disease present?

Answer 14

profound malabsorptive syndrome at 8-24 months of age after the introduction of wheat-containing weaning foods
faltering growth OR delayed puberty in older children
• abdominal distension and buttock wasting
• abnormal stools
• general irritability OR tiredness in older children
• non-specific GI symptoms
• anaemia (iron and/or folate deficiency, but ­transferritin)

Question 15

When should serological testing be offered

Answer 15

o Persistent unexplained abdominal or gastrointestinal symptoms
o Faltering growth
o Prolonged fatigue
o Unexpected weight loss
o Severe or persistent mouth ulcers
o Unexplained iron, vitamin B12 or folate deficiency
o Type 1 diabetes, at diagnosis
o Autoimmune thyroid disease, at diagnosis
o Irritable bowel syndrome (only in adults)

Question 16

What are the investigations for coeliac disease?

Answer 16

Serological screening tests using anti-tTG (IgA tissue transglutaminase antibodies) and EMA (endomysial antibodies)
Consider using IgG EMA, IgG DGP or IgG tTG if IgA is deficient
Confirmation of diagnosis depends on showing intestinal mucosal changes (increased intraepithelial lymphocytes & variable degree of villous atrophy and crypt hypertrophy) on small intestinal biopsy performed endoscopically, followed by the resolution of symptoms and catch-up growth upon gluten withdrawal.
Although gluten-free diet should not be used empirically as a diagnostic test, strongly +ve serological tests in symptomatic children may reduce the need of biopsy in a small proportion of these children

Question 17

What is the management for coeliac disease?

Answer 17

Removal of all products containing wheat, rye and barley from diet results in resolution of symptoms. Dietician supervision is essential to monitor appropriate calories intake.
In children with doubtful diagnosis/response to gluten withdrawal, a gluten challenge may be required later in childhood to demonstrate continuing susceptibility of small intestine to damage by gluten.
Gluten-free diet should be adhered to for life as non-adherence risks the development of micronutrient deficiency, especially osteopenia and increases slightly the risk of bowel malignancy (especially small bowel lymphoma)

Question 18

What is the difference between food intolerance and food allergy?

Answer 18

Food intolerance = a non-IgE mediated non-immunological hypersensitivity reaction to a specific food
Food allergy = pathological IgE mediated immune response is mounted against a specific food protein.
Most commonly primary, where children usually react on first exposure, but may also be secondary, usually due to cross-reactivity between proteins present in fresh fruits/vegetables/nuts and those present in pollens

Question 19

What are the most common allergies in infants and older children?

Answer 19

Infants: Milk, egg, peanut

Older children: peanut, tree nut, fish, shellfish

Question 20

What are the clinical features of IgE mediated food allergy?

Answer 20

Onset- minutes to 2 hours
Features- urticaria to facial swelling to respiratory compromise and anaphylaxis. Diarrhoea and abdominal pain may also be present
Diagnosis- Skin-prick tests and measurement of specific IgE antibodies in blood

Question 21

What are the clinical features of Non-IgE mediated food intolerance

Answer 21

Onset- hours after ingestion
Features: Diarrhoea, vomiting, abdo pain, faltering growth. Colic or eczema. Blood in the stools in first weeks from proctitis or severe repetitive vomiting, resulting in shock
Diagnosis- Clinical history and examination. Endoscopy and intestinal biopsy. Diagnosis is supported by the presence of eosinophilic infiltrates

Question 22

What is the gold standard investigation for food allergies/intolerances when in doubt?

Answer 22

is exclusion of relevant food (under dietitian’s supervision) followed by a double-blind placebo-controlled food challenge, perform in hospital with full resus facilities available