Gastroenterology Flashcards
Blood in vomit
Oesophagitis, peptic ulceration, oral/nasal bleeding
Projectile vomiting in first few weeks of life
Pyloric stenosis
Vomiting at the end of paroxysmal coughing
Whooping cough
Abdominal distension
Intestinal obstruction, including strangulated inguinal hernia
Blood in stool
Intussusception or gastroenteritis
Failure to thrive
GORD, coeliac disease and other chronic GIT conditions
What is posseting?
Is the return of small amounts of milk with the return of swallowed air - occurs in nearly all babies from time to time
What sort of infections can be associated with vomiting in infants
Gastroenteritis but also with UTI and CNS infections
When does GORD usually resolve by?
Usually resolves spontaneously by 12 months of age - due to maturation of lower oesophageal sphincter, assumption of upright posture and more solids in diet (liquid diet, lying down and immature sphincter are reasons for GORD)
Complications of GORD
Failure to thrive
Oesophagitis
Recurrent pulmonary aspiration
Dystonic neck posturing (sandifer syndrome)
Management of uncomplicated GORD
Adding inert thickening agents to feeds and positioning in head up 30degree position after feeding
Management of more severe GORD
Acid suppression with h2 receptor antagonists (ranitidine) or proton pump inhibitors (omeprazole)
Surgery if don’t respond to medication or have oesophageal stricture
What is pyloric stenosis
Hypertrophy of pyloric muscle causing gastric outlet obstruction
Presents between 2-7 weeks of age
Which infants is pyloric stenosis more common in
More common in boys 4:1
Particularly in first borns and may have a family history especially on maternal side
Type of vomiting in pyloric stenosis
Increases in frequency and forcefulness over time until it becomes projectile
Hunger after vomiting until dehydration causes loss of interest in eating
Diagnosis of pyloric stenosis
Feed test - gastric peralstasis wave moving across abdomen and pyloric mass (like olive) usually palpable in RUQ - ultrasound can be helpful
Management of pyloric stenosis
IV fluids to correct any fluid and electrolyte imbalance
Treatment by pyloromyotomy - Ramsteadt - division of muscle - quick recovery
Green vomit in child
Obstruction
What is colic?
Paroxysmal, inconsolable crying or screaming often accompanied by drawing up of the knees and passage of flatus several times a day - particularly in the evening
Incidence and period of colic
Occurs in first few weeks of life and resolved by 4 months of life and occurs in up to 40% of babies
Benign condition but can be worrying for parents
What can severe and persistent colic be due to?
Milk protein allergy or GORD
Causes of acute abdomen pain? x8
Appendicitis , hernia, hip joints and testes need to be checked
Lower lobe pneumonia
Primary peritonitis with nephrotic syndrome or liver disease
DKA
UTI and acute pyelonephritis
In what age is acute appendicitis uncommon in?
Uncommon in children under 3 years
Symptoms of acute appendicitis? x3
Anorexia
Vomiting (usually only a few times)
Abdominal pain, initially central and colicky and then localising to RIF
Signs in acute appendicitis?
Flushed face with oral fetor
Low grade fever
Abdominal pain aggravated by movement
Persistent tenderness with guarding in RIF
Why does diagnosis of acute appendicitis need to be made quickly in preschool children?
Perforation may be rapid - omentum is less developed
What might be identified in urine of acute appendicitis
White blood cells or organisms as inflamed appendix may be adjacent to ureter or bladder
What is intusseception?
Invagination of proximal bowel into a distal segment - most commonly the ileum passes into the caecum through the ileocaecal valve
At what age does intusseception commonly occur?
May occur at any age but peak age is between 3 months and 2 years
Most serious complication of intusseception
Constriction of mesentery therefore venous obstruction and engorgement, bleeding from mucosa, fluid loss and bowel necrosis
Presentation of intusseception
Paroxysmal, severe colicky pain and pallor - pale during pain - especially around mouth. May refuse feeds, may vomit
Sausage shaped mass palpable in abdomen
Abdominal distension and shock
Type of stool in intusseception
Characteristic red currant jelly stool comprising blood stained mucus - tends to occur later in illness
May be first seen on PR
Management of intusseception
Rectal air infusion normally enough (once child has been fluid resuscitated)
Ultrasound good to confirm diagnosis and see effect of treatment
Surgery if air infusion doesn’t work
Cause of volvulus in infant
Malrotation of small bowel in fetal life, mesentery not fixed properly and predisposed to volvulus - causes obstruction
When does malrotation usually present
First 1-3 days of life from Ladd bands obstructing
What is abdominal migraine?
Migraine associated with abdominal pain - midline abdominal pain with vomiting and facial pallor
Usually family history of migraine
Possible causes of recurrent abdominal pain x2
Irritable bowel syndrome
Gastritis - including being caused by h.pylori (urea breath test)
Most common virus causing gastroenteritis in children
Rotavirus - now a successful vaccine been introduced
What sort of gastroenteritis is caused by E. coli and cholera?
Profuse, rapidly dehydrating diarrhoea
Which surgical disorders can mimic gastroenteritis x5
Pyloric stenosis, intusseception, appendicitis, necrotising enterocolitis, Hirschsprung disease
What systemic infections can mimic gastroenteritis
Septicaemia and meningitis
Which local infections can mimic pyloric stenosis
Respiratory tract infection, otitis media, hep A, UTI
Most serious complication of gastroenteritis
Dehydration leading to shock
Signs of dehydration
Weight loss (5-10% is clinical dehydration) Depressed fontanelle Pale or mottled skin Reduced urine output Cold extremities Pli cutanee Prolonged cap refill time Dry mucous membranes Sunken and tearless eyes Tachycardia and weak peripheral pulses Hypotension
What is hyponatraemic dehydration?
Normally with dehydration sodium and water loss is equal - but if fluid loss is replaced with water then sodium is less than water and causes shift of water from extra cellular to intracellular - increase brain volume causes convulsions
Also more shock
What is not useful in gastroenteritis
Anti diarrhoeal drugs because they prolong excretion of bacteria and are ineffective
Management of gastroenteritis without clinical dehydration ( >5% of body weight)
Prevent dehydration with good fluid intake and oral rehydration solution
Management of gastroenteritis if clinical dehydration but without shock
Oral rehydration solution
Continue normal fluid intake aka breastfeeding and give fluid deficit replacement over 4 hours (50ml/kg)
If dehydration continues consider IV fluids with 0.9% sodium chloride solution with 5% glucose - 50ml/kg if not shocked
Management of gastroenteritis if dehydrated and shocked
Fluid infusion
100ml/kg (10% of body weight)
0.9% sodium chloride solution with glucose
What should be avoided in dehydration with gastroenteritis
Fruit juices and carbonated drinks
What can sometimes occur after recovery from gastroenteritis
Temporary lactose intolerance with watery diarrhoea on returning to normal diet
Presentation of malabsorption x3
Abnormal stools (smelly and can't flush down toilet) Failure to thrive Nutrient deficiencies
Presentation of coeliac disease
Classical presentation is profound malabsorption syndrome at 8-24 months when wheat/gluten products are introduced - failure to thrive, abdominal distension, wasting of buttocks and abnormal stools
But now children present later in childhood - nonspecific gastrointestinal symptoms and anaemia (iron/folate deficiency) and growth failure
Tests for coeliac disease
IgA tissue transglutaminase antibodies and endomysial antibodies
Small intestine biopsy showing villus changes
What is toddler diarrhoea?
Non specific diarrhoea of varying consistency in preschool children
Thrive well
Probably due to maturational delay in bowel
Usually grow out by age 5
Diet needs a good amount of fat, not too much juice/squash and a normal about of fibre in diet
Crohn and UC from normal notes
Yup
Presentation of Crohn and UC in children
Crohn just generally unwell and failure to thrive but without gastrointestinal symptoms - can mimic anorexia nervosa
UC - rectal bleeding, diarrhoea and colicky pain - may also get failure to thrive but not as much as with crohns
What can long standing constipation in children cause
Can cause distension of rectum and then overflow involuntary soiling - need disimpaction regime with stool softeners etc and rectum will go back to normal after this
Must be followed by maintenance treatment
Fluid and fibre can help
General constipation in children
Children stool patterns vary as much as adults therefore parents reporting “constipation” is often not a problem
What is Hirschsprung disease?
Absence of ganglion cells from the myenteric and submucosal plexuses of part of large bowel causes a narrow constricted segment - extends from rectum, usually just affecting recto sigmoid colon - but can stretch further - causes obstruction and failure to pass meconium in first 24 hours of life
Signs of Hirschsprung
Abdominal distension and bile stained vomit
Failure to pass meconium
Rectal examination may reveal narrow segment
And removal of finger may lead to gush of liquid stool and flatus
How does Hirschsprung present in later childhood
Profound chronic constipation, abdominal distension and growth failure - usually without soiling
Diagnosis of Hirschsprung disease
Suction rectal biopsy - showing absence of ganglion cells, presence of large acetylcholinesterase positive nerve trunks
Management of Hirschsprung disease
Surgical - usually initial colostomy followed by anastomosing normal innervated bowel to anus
How make diagnosis of appendicitis
USS may help - but regular clinical review every few hours is best as appendicitis is a progressive condition
USS shows thickened, non-compressible appendix with increased blood flow
Management of appendicitis
If guarding already (perforation) then IV antibiotics and fluid resus before appendicetomy
If there is a mass palpable and no signs of peritonitis then can do IV antibiotics and conservative management - perform appendicetomy later on
Diagnosis of intussusception
Xray will show distended small bowel and absence of gas in the distal colon or rectum
Abdominal US may help confirm diagnosis and check response to treatment
Complication and urgent management of intussusception
Shock - therefore fluid resus is needed - due to pooling of fluid in the gut which may lead to hypovolaemic shock
Treatment of Crohns x3
Steroids and diet modification to induce remission
Immunosuppressants (azathioprine, mercaptopurine or methotrexate) to maintain remission
Anti-TNF (infliximab and adalimumab) if these fail
How does UC in children differ from it in adults?
90% have pancolitis as opposed to adults where it is normally confined to distal colon
Treatment of UC
Mild - aminosalicylates (balsalazide and mesalazine), more aggressive = systemic steroids for acute exacerbations and immunomodulatory therapy (azathioprine) to maintain remission
Leading cause of death in premature infants (bowel stuff)
Necrotising enterocolitis
Symptoms of necrotising enterocolitis (early and more advanced)
Early - feeding intolerance, abdominal distension and bloody stools
Quickly progress to abdominal discolouration, perforation and peritonitis
X ray signs in necrotising enterocolitis
Dilated bowel loops, bowel wall oedema, pneumatosis intestinalis (intramural gas) portal venous gas, air inside and outside bowel wall (Rigler sign), air outlining the falciform ligament (football sign)
Management of necrotising enterocolitis
IV fluids, TPN and IV antibiotics for 10-14 days to rest bowel
