Gastroenterology Flashcards
red flags for constipation in a child?
-symptoms appearing from birth or during 1st few wks of life- may indicate Hirschsprung’s disease (congenital aganglionic megacolon).
-delay in passing meconium for more than 48 hours after birth, in a full-term baby-may indicate Hirschsprung’s disease or CF.
-abdo distension with vomiting-may indicate Hirschsprung’s disease or intestinal obstruction.
-FH of Hirschsprung’s disease.
-ribbon stool pattern-may indicate anal stenosis (more likely to present in a child younger than 1 yr of age).
-leg wkness or motor delay-may indicate a neurological or SC abnormality.
examination may reveal unexplained lower limb deformity or abnormal neuromuscular signs, including abnormal reflexes.
-abnormal anus appearance (including fistulae,bruising,fissures,tight or patulous (widely patent) anus,anteriorly placed anus (anal ectopia),lichen sclerosis, or an absent anal wink (a reflex contraction of the external anal sphincter when the skin around the anus is stroked, may indicate spinal or neurological pathology), bruising or multiple fissures-?sexual abuse.
-abnormalities in LS and gluteal regions (such as asymmetry of the gluteal muscles, evidence of sacral agenesis, scoliosis, discoloured skin, naevi, hairy patch, sinus or central pit)-?spina bifida occulta.
child should be r/f urgently to appropriate specialist.
what are amber flags in presentation of constipation in children?
child needs r/f for specialist assessment but can be treated in primary care whilst waiting assessment:
- evidence of faltering growth, developmental delay, or concerns about wellbeing that may indicate systemic condition-should arrange testing for possible coeliac disease, hypothyroidism, CF and electrolyte disturbance if appropriate.
- constipation triggered by intro. of cows milk
- concern of possible child maltreatment-follow local safeguarding procedure.
diagnostic concern if constipation and failure to thrive/growth failure symptoms?
hypothyroidism
coeliac disease
CF-usually diarrhoea and failure to thrive in infants
hirschsprung disease
why is knowing whether a baby is breast or bottle fed import with regards to constipation presentation?
in determining whether stool pattern normal for child, as breast fed infants may not pass stools for several days and be entirely healthy.
management of patients with overflow soiling due to long standing constipation?
- must explain to child and parents that soiling is involuntary and recovery can be achieved with treatment to recover normal rectal size and sensation that has been disturbed with rectum overdistension.
- initial aim=evacuate rectum completely-disimpaction regimen with Movicol laxative-stool softener, escalating dose regimen over 1-2wks, or until impaction resolution, stimulant laxative may also be needed if this is unsuccessful. if can’t tolerate movicol may use osmotic laxative.
- follow with maintenance tment e.g. movicol, which is gradually reduced over mnths.
- ensure sufficient fluid and fibre in diet, and encourage child to sit on toilet post meals to utilise physiological gastrocolic reflex.
- explore child’s concerns and motivation to change, provide encouragement e.g. star chart, for regular defecation in the toilet.
- some cases may require psychiatric r/f.
presentation of Hirschsprung disease?
neonate: failure to pass meconium within 1st 24hrs of life-*alternative differential is meconium ileus due to CF, or small bowel obstruction from another cause resulting in subsequent delayed or absent passage of meconium.
later, abdo distension-tympanic on percussion and bile stained vomiting
rarely neonatal meconium plug syndrome or appendicitis
later childhood: chronic constipation-resistant to usual tments and enemas, usually without soiling, assoc. with abdo distension and possible growth failure as disease causes early satiety and abdo discomfort and distention due to constipation causing poor nutrition and weight gain. DRE-empty rectum, but may cause forceful faecal material expulsion on exam. completion.
note constipation presenting after 1mnth of age unlikely hirschsprung’s
infants occasionally may present with severe, life threatening hirschsprung enterocolitis during 1st few wks of life, sometimes due to C.diff infection-abdo pain, fever, foul smelling and poss. bloody diarrhoea with vomiting.
how is hirschsprung disease diagnosed?
suction rectal BIOPSY or transanal wedge resection biopsy-absence of ganglion cells, along with presence of large acetylcholinesterase-+ve nerve trunks.
suction biopsy 2-2.5cm above dentate line on poster. wall to reduce perforation risk.
unreliable for diagnosis but anorectal manometry-failure of internal sphincter relaxation in response to balloon inflation or barium studies can be useful for giving idea to surgeon of length of aganglionic segment.
double contrast barium enema-proximal dilated colonic segment with transition zone and narrowed distal colonic segment.
mangement of hirschsprung disease?
- acute problems-intestinal obstruction-IV rehydration, bowel decompression-NGT and DRE or normal saline enemas OD/BD.
- broad spec Abx-metronidazole and aggressive fluid rehydration if enterocolitis. bowel irrigation to evacuate rectosigmoid contents, overcoming distal obstruction.
-surgical definitive management: usually initial colostomy followed by anastamosing normally innervated bowel to anus.
?transanal approach or Swenson’s procedure-full thickness excision of rectum and remaining aganglionic bowel. normal ganglionic bowel is then pulled through.
surgical complications: specific immediate, early-anastamosis leakage, persisting constipation, soiling and incontinence, and late-intestinal obstruction poss. due to adhesions, resected segment stricture.
what is hirschsprung disease?
aganglionic large bowel with absence of parasympathetic ganglion cells from myenteric and submucosal plexuses extending proximally from rectum, producing a narrow, contracted segment as unable to relax.
5X more common in boys
diseases associated with hirschsprung disease?
Down’s syndrome-prognosis less favourable, permanent colostomy may be recommended
MEN-MEN2A and MEN2B
gastric diverticulum
intestinal atresia
Waardenburg’s syndrome-congenital deafness, partial albinism
what accounts for most mortality assoc. with hirschsprung disease?
enterocolitis-can progress to sepsis, transmural intestinal necrosis and perforation if not treated early.
what is failure to thrive?
failure of weight gain in particular, but espec. if long standing, may also include lack of linear growth.
if head circumference significantly affected then this suggests and intrauterine onset
must demonstrate inadequate weight gain on centile chart-mild failure to thrive if weight falls across 2 centile lines, 3=severe.
most have weight below 2nd centile. below 0.4 should always trigger evaluation.
how does pattern of height, weight and head circumference curves on percentile charts relative to each other help with determining cause of failure to thrive?
if all percentiles equally affected, might be intrauterine TORCH infections-toxoplasma, other-syphilis, rubella, CMV, HSV and VSV, or chromosomal abnormalities.
height most affected-?endocrinopathies and skeletal dysplasias
weight most affected-?malnutrition-height less so, and head circumference relatively normal.
what should skin be examined for in failure to thrive patient?
dermatitis herpetiformis-symmetrical distribution of VERY itchy papules (prurigo) and vesicles on normal or erythematous skin, so often presents as erosions and crusting due to immediate scratching, found on elbows, knees, scalp, shoulders and buttocks. ? underlying coeliac disease.
erythema nodosum-IBD
pyoderma gangrenosum-IBD
ichthyosis-sign of malnutrition, shwachman-diamond syndrome-AR congenital disorder with exocrine pancreatic insufficiency.
features to look out for on hand examination of failure to thrive pt?
nails: clubbing-CF, chronic liver disease, cyanotic congenital heart disease, IBD. leukonychia.
hand structure-dysmorphic syndromes
radial and femoral pulses-coarctation of aorta, CHD.
moving to brachial area-BP for aorta coarctation and renal disease, hypotension-Na+ low, dehydration.
features of TORCH congenital infection o/e of baby with failure to thrive?
low weight, height and head circumference on percentile charts
eyes-cataract, chorioretinitis
abdomen-hepatosplenomegaly
head and neck features to look out for in o/e of infant with failure to thrive?
nutrition related signs e.g. conjunctival pallor-anemia
dysmorphic features, macrocephaly, scars, shunts
eyes-cataract, chorioretinitis, retinitis pigmentosa (abetalipoproteinaemia, shwachman’s syndrome), papilloedema (hydrocephalus, IC tumour), EO movements (neurol. disease)
mouth-thrush (cell-mediated immunity defects), cleft palate (?DiGeorge syndrome-deletion on chromosome 22), observe method of feeding.
examples of chest deformities that may be seen in failure to thrive infant?
harrison’s sulcus-horizontal groove along lower border of thorax corresponding to costal insertion of diaphragm, ?chronic lung disease e.g. CF.
sternal deformity-pectus excavatum and carinatum-syndromes
what cause of failure to thrive may be indicated by buttock excoriations o/e of pt?
carbohydrate intolerance
look also for reducing substances in urine
how would you consider investigating a child with failure to thrive?**
admit child to hospital if undernutrition seems possible and see if child can gain weight with adequate calories.
if they don’t, investigate for malabsorption or any chronic disease*
investigations to consider: FBC-anaemia-may be Fe deficiency, neutropenia, lymphopenia-immune deficiency
CRP
serum ferritin-Fe deficiency
Igs
anti-TTG and anti-EMA-coeliac
serum creatinine, Us and Es, acid base, Ca2+, PO43-metabolic disorders, renal failure, renal tubular acidosis, william syndrome
LFTs-liver disease, malabsorption, metabolic disorder
TFTs
urine microscopy, culture and dip-UTI, renal disease
stool microscopy, culture and faecal elastase-intestinal infection, parasites, pancreatic insufficiency e.g. CF
karyotype in girls-Turner
CXR and sweat test-CF
organic causes of failure to thrive due to inadequate intake?
impaired suck/swallow: oro-motor dysfunction, neurological disorder e.g. cerebral palsy
chronic disease leading to anorexia: Crohns, chronic renal failure, CF, liver disease.
effects of CF on the liver?
liver cirrhosis and portal HTN-due to plugging of liver bile ducts with dehydrated bile
cholelithiasis
inorganic causes of failure to thrive due to inadequate intake?
inadequate food availability:
feeding problems-insufficient breast milk or poor technique, incorrect preparation of formula
insufficient or unsuitable food offered
lack of regular feeding times
infant difficult to feed-resists feeding or disinterested
intolerance over normal feeding behaviour e.g. throwing food around, leading to early meal cessation
problems with budgeting, shopping, cooking food
low SE status
PS deprivation: poor maternal-infant interaction
maternal depression
poor maternal education
neglect or child abuse:
includes factitious illness-deliberate underfeeding to generate failure to thrive
causes of failure to thrive other than inadequate food intake?
inadequate retention-severe GOR, vomiting
malabsorption-coeliac, CF, cow’s milk protein intolerance, cholestatic liver disease, short gut syndrome, post-necrotising enterocolitis (NEC)
failure to utilise nutrients-syndromes, chromosomal disorders e.g. downs, IUG, extreme prematurity, congenital infection, metabolic disorders e.g. congenital hypothyroidism, storage disorders, amino and organic acid disorders
increased requirements-thyrotoxicosis, CF, malignancy, chronic infection e.g. immune deficiency, congenital heart disease, chronic renal failure.
key components to hx of pt with failure to thrive?
detailed dietary hx, food diary over several days
feeding, what happens at mealtimes?
other symptoms-are they well with lots of energy or is there diarrhoea, vomiting, cough, lethargy
birth hx: premature or IUGR?, significant med problems?
growth of other family members and illnesses in family
?development
PS problems at home?
management of failure to thrive pt?
most non-organic causes manged in primary care with MDT approach: health visitor assess eating behaviour and provide support, paed dietician-assess food intake, SALT-feeding disorders, clinical psychologist and social services, nursery placement-relieve stress at home and assist with feeding.
admit children under 6mnths with severe failure to thrive requiring active refeeding.
most common cause of gastroenteritis in young children?
viral infection-rotavirus main cause of winter epidemics
commonest bacterial causes of gastroenteritis in children?
E coli
shigella
salmonella
campylobacter
features of bacterial gastroenteritis caused by shigella?
children 1-5yrs
febrile fits
watery, blood, mucus, pus-diarrhoea
differentials for vomiting after feeds?
normal positing-small amount of vomit in mouth-effortless, non forceful low volume, frequent spills from mouth, may be related to overfeeding-espec. bottle fed, try and reduce occurrence with winding baby during and post feeds, gentle handling, prevent upset and baby from air swallowing before feeds, propping baby after feed. common under 6 mnths, usually resolve by 1yr. can add food thickeners to milk if very troublesome and baby bottle fed
GOR-normal in baby, can be severe-GORD-requiring med., e.g. if failure to thrive, haematemesis, frequent chest infections
cows milk allergy
common causes of vomiting in infancy?
overfeeding GOR gastroenteritis anatomic obstruction: pyloric stenosis, intussusception, atresia-dudoenal, malrotation, volvulus, strangulated inguinal hernia, hirschsprung disease systemic infection-meningitis, pyelonephritis, UTI, URT/otitis media, whooping cough-?vomiting after paroxysmal coughing dietary protein intolerances-allergy* inborn errors of metabolism CAH renal failure
common causes of vomiting in childhood?
gastroenteritis systemic infection-meningitis, UTI, URT toxic ingestion or medications whooping cough appendicitis bowe obstruction-adhesions, FB-bezoar raised ICP coeliac disease renal failure inborn errors of metabolism testicular torsion
common causes of vomiting in adolescence?
gastroenteritis systemic infection-pyelonephritis, septicaemia, meningitis peptic ulceration and H pylori infection appendicitis rasied ICP coeliac disease migraine pregnancy bulimia DKA alcohol
red flag features of vomiting in a child?
bile in vomitus (green/yellow)-suggests intestinal obstruction-need paed surgical r/f, upper GI contrast study to be done
blood in vomitus-*inflammation in upper GIT, need specialist r/f, unless due to swallowed blood e.g. from epistaxis
frequent forceful (projectile) vomiting-hypertrophic pyloric stenosis in infants up to 2mnths old, needs paed surgical r/f
blood in stool-‘redcurrant jelly’ stools-intussusception
abdo distension, tenderness or palpable mass-obstruction, need paed surg r/f
chronic diarrhoea-cow’s milk protein allergy
drowsiness
refusal to feed
malnutrition
dehydration
lethargy or irritability-meningitis
late onset-after 6mnths or persisting after 1 yr, late onset maybe UTI?
what do we want to know in hx of vomiting?
what is the vomiting like?-amount, ?projectile, blood stained, bile stained, coughing
assoc. symptoms?-diarrhoea-gastroenteritis, constipation-intestinal obstruction, irritability or pain-infection, pain before or after vomiting-before ?appendicitis GOR, aspiration and apnoea-GOR
how well is child?-fever-infection, appetite, weight
baby bottle or breast fed-if bottle, how much are they taking, in excess of 200ml/kg/24hr with no weight loss likely regurgitation due to overfeeding
headache, visual aura, facial wkness, paraesthesia-?migraine in adolescents, abdo pain-gynaecological? periods-?pregnancy
