Gastroenterology Flashcards
How might a small bowel obstruction present in a neonate?
Persistant vomiting (will be bile stained unless site is above ampulla of vater) Abdominal Distension becoming increasingly prominent Meconium passage may be delayed or absent
Why might the timing of presentation differ in a small bowel obstruction?
Higher lesions present soon after birth, but a lower lesion may not present for several days.
List some of the causes of small intestine obstruction in neonates
Atresia or Stenosis of duodenum, jejenum or ileum
Malrotation with volvulus
Meconium Ileus
Meconium Plug
What investigation would you do in a neonate with suspected small bowel obstruction?
Abdominal XR
What is the management of small bowel obstruction in neonates?
Atresia and Malrotation are treated surgically
Meconium ileus treated with gastrograffin enema first
Meconium plugs often pass spontaneously
List some of the causes of large bowel obstruction in neonates
Hirschsprung Disease
Rectal Atresia
What is Hirschsprungs Disease and how does it present?
Absence of the myenteric nerve plexus in the rectum, which may extend along the colon
Baby initially will not pass meconium in the first 48hrs of life and the abdomen begins to distend.
What is rectal atresia?
Absence of the anus at the normal site, lesions are high or low depending on whether the bowel ends above or below the levator ani muscle.
Management is surgical
Describe soiling.
In long standing constipation the rectum becomes over distended, leads to a loss of feeling the need to defecate
Involuntary soiling may occur as contractions of the full rectum inhibit the internal anal sphincter, leading to overflow
List some of the functional disorders associated with chronic abdominal pain in children
Functional Dyspepsia
IBS
Abdominal Migraine
List some of the red flags that might make you think of an organic cause in a child presenting with recurrent abdominal pain?
diarrhoea, weight loss/weight faltering, blood in stools
vomiting, jaundice, bilious vomiting, abdominal distension, unexplained fever, Family Hx of IBD
List some of the common viruses causing gastroenteritis.
Rotavirus
Adenovirus
Norovirus
What questions are important to ask in a diarrhoea history?
Any contacts with people who have D&V
Recent travel abroad
Recent course of antibiotics
Food out of the ordinary
BLOOD? Indicates it might be a bacterial cause
List some of the clinical signs of dehydration in children.
Dry Mucous Membranes Reduced Skin Turgor Prolonged Capillary Refill Time Reduced Urine output Sunken Eyes Sunken Anterior Fontanelle Rapid Pulse Body weight loss If severe - Drowsy
What is different about UC in adults and children?
In adults the colitis is usually confined to the distal colon, in children 90% have pan-colitis
How might Crohns disease present in children compared to adults?
In children - often lethargy and failure to thrive/weight loss is the main presenting feature. Only 25% get abdo pain and diarrhoea.
How does Ulcerative Colitis tend to present in children?
Typically with rectal bleeding, diarrhoea and colicky pain
When does coeliac disease classically present in children?
Usually between 8 and 24 months of age after the introduction of wheat containing weaning foods.
How might a child with coeliac disease present?
Failure to thrive, abdominal distension, wasting of buttocks, abnormal stools and general irritability
What happens to the small intestine in coeliac disease.
Gluten provokes damaging immunological response
Villi become progressively shorter and then absent, leaving a flat mucosa
What is the gold standard for diagnosing coeliac disease?
Biopsy of small intestine
One while on gluten diet and one following resolution of symptoms following gluten withdrawal.
Why is gastro-oeophgeal reflux so common in infancy?
Inappropriate relaxation of LOS due to functional immaturity
Predominantly fluid diet
Mainly horizontal posture
Short intraabdominal legnth of oeophagus
When do gastro-oesophageal reflux symtpoms tend to resolve?
Nearly all spontaneously resolve by 12 months due to maturation of LOS, upright posture and more solids in diet.
Lost some of the complications that may occur as a result of gastro-oesophgeal reflux in infancy.
Failure to thrive (rare)
Oesophagitis - haematemesis, heartburn - anaemia
Recurrent pulmonary aspiration - can cause recurrent pneumonia, cough or wheeze, apnoea
What might be done to manage gastro-oesphgeal reflux of infancy?
Food thickeners and upright position after eating
Medication - H2 receptor agonists or PPIs if has not resolved by 1 year
Surgery - in those unresponsive to other things (Nissen Fundiplication)
What is pyloric stenosis and when does it present?
Hypertrophy of the pyloric muscle causes gastric outlet obstruction
Presents between 2-7 weeks of age
How would a baby with pyloric stenosis present?
Vomiting - increasing in frequency and forcefulness over time - ultimately becoming projectile
Hunger after vomiting until dehydration leads to loss in feeding
Weight loss if presentation is delayed
How do we diagnose pyloric stenosis?
Pyloric mass - feels like an olive, usually palpable in RUQ
+ visible peristalsis
May be confirmed by ultrasound
How is pyloric stenosis managed?
Correct fluid and electrolyte balance
Surgery
What are the two ways cows milk protein intolerance can present?
IgE MEDIATED
Occurs 10-15 minutes, usually after milk first ingested, if mild reaction may see uritcaria and facial swelling or if severe can have anapylaxis
NON IgE MEDIATED
Usually presents with diarrhoea and vomiting and failure to thrive. Colic or eczema may also be present.
How might Tortion of Testes present?
There is typically sudden, severe pain in one testis.
There may be lower abdominal pain and, in any boy presenting with abdominal pain, the testes should be checked
May be nausea and vomiting
May be history of previous self limiting episodes
What is the management of testicular torsion?
Must be relieved surgically within 6-12 hours of the onset of symptoms for their to be a good chance of testicular viability
If torsion is confirmed the collateral testes must be fixated because there may be anatomical predisposition to torsion
If unsure SURGICAL EXPLORATION IS MANDATORY to rule out torsion
What is the classical presentation of appendicitis?
Abdominal pain - initially vague and central, then localizing and severe in the RIF
Nausea and Vomiting
Anorexia
How do we diagnose acute appendicitis?
It is a CLINICAL DIAGNOSIS based on symptoms
If unsure can do bloods (WCC may be raised, alongside acute inflammatory markers)
Ultrasound may help to confirm diagnosis, although appendix not always visualized
CT is most sensitive and is being used more frequently.
What is mesenteric adenitis?
Less severe, non-specific abdominal pain
Often accompanied by an URTI with cervical lymphadenopathy
When can the diagnosis of mesenteric adenitis be made?
Can only definitively be made in those children where large mesenteric nodes are seen at laparotomy/laparoscopically and whose appendix is normal.
Describe what happens in intussusception?
Telescoping of proximal bowel into a distal segment
Most commonly involves the ileum passing into the cecum through the ileocecal valve.
When does intussusception typically present?
Betwen 3 months and 2 years, although may occur at any age
It is the commonest cause of intestinal obstruction in infants after the neonatal period
How might an infant with intussusception typically present?
Paroxysmal severe colicky pain - during episodes of pain child becomes pale and draws up legs
Becomes increasingly lethargic as time goes on
May refuse feeds and may vomit which might be bile stained.
Passing of characteristic redcurrant jelly stool - comprising blood stained mucus - occurs late.
Eventually may have abdominal distension and shock
What condition is redcurrant jelly stool classically associated with?
Intussusception
What might you feel in the abdomen of a child with intussusception?
A sausage shaped mass
How do we manage intussusception?
Unless signs of peritonism - reduction is attempted by the radiologist with rectal air insufflation - 75% success rate
The remaining 25% require operative reduction
What does dehydration look like on U&Es
Increased urea, small increase in creatinine
