Gastroenterology Flashcards
What foods should be avoided if weaning <6m?
Wheat
Fish
Eggs
Food high in: salt/sugar/honey (risk of botulism)
What is mild Failure to Thrive classed as? + severe?
Mild = cross 2 centile lines Severe = cross 3 centile lines
List some non-organic (env/psych) causes of Failure to Thrive (5)
What % of cases are due to non-organic causes?
Feeding probs/lack of food Low socioeconomic status/maternal education Abuse Poor bond with child Maternal depression
> 95% due to non-organic causes
List some organic causes of Failure to Thrive (6)
Impaired suck/swallow (cleft) Impaired retention (vom, severe GORD)
Malabsorption (Coeliac, CF, CMP, NEC, Short gut, Cholestatic liver disease)
Chronic illness (Crohn’s, CF Chronic renal failure, liver disease)
Failure to utilise nutrients (IUGR, Premature, Down’s Infection, metabolic disorders)
High requirements (thyrotoxicosis, congenital heart, malignancy, chronic infection)
What things should be asked about in Failure to Thrive (5)
Detailed Hx + food diary Social Hx probs Feeding probs Symptoms (Vom, Diarrhoea) Illness
What Ix can be done in Failure to Thrive (7)
FBC Urinalysis + culture U&E + creatinine LFTs + TFTs Coeliac screen Sweat test Prealbumin (nutritional marker)
When is hosp admission in failure to thrive indicated? (3)
<6m
Severe FTT
Requiring active refeeding
What is the outcome like for FTT with non-organic cause?
Non-organic / continued underrating → lasting deficit
If due to developmental impairment → short term
When might acute constipation be caused by?
How is it managed?
e.g. febrile illness
Self-limiting / mild laxatives + extra fluid
What is a complication of long term constipation?
Rectum can over distend → lose feeling to defacate → involuntary soiling
What are some common causes of constipation? (6)
Dehyration
Reduced fluid intake
Anal fissure → pain
In older, related to:
Toilet training
Unpleasant toilets
Stress
What are the red flag symptoms for constipation?
Failure to pass meconium in 1st 24hrs Abdo distension Failure to Thrive Bruising/Fissures (abuse) Abnormal lower limb neurology (lumbosacral pathology) Sacral dimple (spina bifida occulta)
How is constipation managed if faeces are not palpable?
+ if palpable?
→ Balanced diet + fluids + mild laxatives
→ Mild laxatives (movicol)
If spontaneous stools: maintain balanced diet + fluids
If not → stimulant laxatives (senna) ± osmotic laxative (lactulose)
Still unsuccessful: enema (± sedation)/ manual evacuation
What types of milk are recommended + for how long?
Breast/formula recorded for 12m (wean after 6m)
+ pasteurised cow’s milk may be given after 12m
What may specialised formulas be used for? (5)
Cow's milk protein (CMP) allergy/intol Lactose intol CF Neonatal cholestatic liver disease After intestinal resection
Why should soya milk not be used in <6m?
High aluminium content + phytoestrogens
What are the different types of hydrolysed formula milks + when are they used?
Partially hydrolysed (longer peptide chains):
Used for CMP prophylaxis (reduces risk allergy where FH)
Not suitable when have allergy (adverse reaction)
Extensively hydrolysed: for those with CMP allergy (amino acid formula - not v tasty)
What are the features of CMP enteropathy (12)
Cutaneous:
Urticaria
Atopic + contact dermatitis
Angioedema
GI: N+D+V Constipation Colic + colitis Transient enteropathies
Resp/ENT: Asthma/wheeze Otitis media Rhinoconjunctivitis Laryngeal oedema Anaphylaxis
Describe the symptom latency (which Sx + when) of CMP enteropathy
Immediate → rash + resp probs
Hrs → GI
24hrs → cough/wheeze
What Ix can be done into CMP allergy? (3)
Hx - FH atopy common
Skin prick test for CMP
IgE (specific for CMP) blood test
How is CMP allergy managed?
If breast fed:
Eliminate CMP + eggs from mum’s diet + req Ca supplements
If formula-fed: change to amino acid formula
What types of food allergies are common in infants?
+ in older children
Infants: milk, eggs, peanuts
Older: peanuts, tree nuts, fish/shellfish
How may IgE mediated + non-IgE mediated food allergies present differently?
IgE mediated (T1HS): allergy symps
Urticaria / Facial swelling / Anaphylaxis
10-15mins after ingestion
Non-IgE mediated (T2HS): = intolerance
GI symps (N+D+V + abdo pain + FTT) / Colic / Eczema
Sometimes present w. bloody stools in 1st wks life
Hrs after ingestion
How are food allergies/intolerances Dx?
Skin prick test
Specific IgE blood tests
Poss need intestinal biopsy to support Dx
Gold standrd: oral food challenge (double blind placebo)
How are food allergies/intolerances managed?
Avoid allergen food completely
Plan/training in case of incident
For mild (no cardioresp Sx) → oral antihistamines For severe → epipen
What is functional encoperesis / how does it occur?
What are the RFs (4)
Retain stools to prevent pain
→ lose more water in colon → more painful
→ colon distension → loss of defacate sensation
→ rectal sphincter distends → stools force way out
No toilet training
Toilet phobia
Manipulative soiling
IBS
List some support sources for child soiling/encoporesis (4)
GP
Many referred to paed gastroenterologists
Psychological / parental help
Online info / Encoporesis support groups
What is soiling/encopresis defined as?
Child >4 (previously toilet trained) soiling self w/wo constipation/overflow
What is the incidence/prevalence of gastroenteritis in children in UK? + commonest causative pathogen?
10% of <5s
Rotavirus
How does gastroenteritis generally present?
What are the main RFs (ask in Hx) (3)
Sudden stool change → loose/watery
OR
Onset of vomiting
Recent contact with acute D+V
Exposure to known source
Recent travel abroad
What symptoms may make you think of an alternative Dx to gastroenteritis (8)
Temp >38 ( in <3m) or >39 (in >3m) SOB/Tachypnoea Severe abdo pain Abdo distension /rebound tenderness Blood/mucus in stools Bilious vomiting Meningism signs (stiff neck/ fontanelle/ purpuric rash) Altered consciousness
What situations are Ix done in gastroenteritis?
Stool sample
- if blood/mucus
- if immunocompromised
- if suspect sepsis
Microbiology:
- recent travel
- diarrhoea not improved in 7d
What is mesenteric adenitis? What is it caused by?
Inflamed lymph glands in abdo
Common cause of abdo pain in <16s
Usually viral - self-resolves
What are the features of mesenteric adenitis? (4)
Abdo pain - central/RIF
Nausea + diarrhoea
Fever + malaise
Preceding sore throat/ coryzal symptoms
What are the DDx of mesenteric adenitis (2) + poss Ix (4)
Ectopic preg
Appendicitis
Bloods (CRP/ESR)
Preg
Poss PR
Occasionally laparotomy
What is the incidence + age onset of colic?
40% babies
Occurs in 1st weeks of live + resolves by 4m
What are the features of colic?
Paroxysmal
Inconsolable crying
Excessive flatulence (esp in evenings)
Often accompanied with drawing up the knees
What may severe / persistent colic be due to? (2)
→ May be due to CMP allergy / reflux
How is infantile colic managed? (3)
Support + reassurance
Gripe water recommended (unproven benefit)
If suspect CMP: 2wk trial of hydrolysed formula
→ Then trial anti-reflux Tx
How much of food intake is used in growth in infants/children?
at 4m → 30% intake for growth
at 1yr → 5%
What are some S+S of overfeeding (3)
Increased GI reflux
Obesity
Lactose overload (cramps, gas, crying, watery stools)
List some of the features of clinical dehydration (14) + of which of these indicate shock (5/13)
Tachycardia
Tachypnoea
Hypotension (indicates shock) Weak periph pulses (shock) Cold peripheries (shock) Pale/mottled skin (shock) Prolonged CRT (shock)
Reduced skin turgor
Dry mucous membs
Sunken eyes
Sunken fontanelle
Reduced urine output
Sudden wt loss
Altered responsiveness (loss consciousness = shock)
What are the RFs for dehydration in (7)
<1yr (esp <6m) Low birth weight infants 6+ diarrhoeas in 24hrs 3+ vomits in 24hrs Signs malnutrition Stopped breastfeeding during illness Unable to have fluids before presentation
What factors would make you suspect hypernatraemia (3)
Jittery / convulsions
Increased tone / hyperreflexia
Drowsiness/coma
What management measures should be taken (4) if assessed for dehydration + confirm NOT dehydrated
Continue breast
Encourage fluid intake
Discourage fruit juices/ carbonated
Use ORS
How is clinical dehydration (not shock) initially managed?
Fluid deficit replacement (50ml/kg) over 4hrs
Continue breast
Use ORS small/often
If poor intake use ORS+ other fluids
If vomiting: consider NG
How is severe dehydration/shock initially managed?
0.9% saline ± 5% dextrose:
Fluid deficit replacement:
100ml/kg if initially shocked
50ml/kg if later shocked)
Maintenance fluids:
100ml/kg/day for first 10kg
50ml/kg/day for next 10kg
20ml/kg/day for remainder kg (or 4:2:1 per hour)
Continue breast if poss
Monitor U&Es / creatinine / glucose
What is the management after rehydration (following dehydration/shock) (4)
Full strength milk / Reintroduce usual solids
Avoid fruit juices/carbonated
Advise parents on good hygiene
No return to school until 48hrs after last episode
What drugs are NOT routinely given in dehydration?
Abx
Anti-diarrhoeals
In what cases of dehydration would Abx be given? (3)
Suspect sepsis
Immunocompromised
Bacterial infection (salmonella/ C.diff)
What is post-gastroenteritis syndrome
+ how is it managed?
Introducing normal diet after
→ watery diarrhoea + temporary lactose intolerance
Confirmed with +ve ‘Clinitest’ result (presence of non-absorbed sugar in stools)
Use ORS 24hrs / continue reintro normal diet
Why is GORD so common in infants?
Functional immaturity of lower oesophageal sphincter
Fluid diet
Horizontal posture
Short intra-abdo length of oesophagus
What are the features of GORD? (4)
Recurrent regurgitation / vomiting
Post-feed
Regurgitate 1/3rd-1/2 of food
Putting wt on normally + otherwise well
CLINICAL DX OF REFLUX
When are Ix indicated for GORD? (3)
What Ix may this include? (4)
Atypical Hx
Failed Tx response
Complications:
Aspiration / ALTEs / FTT / Dystonic neck / Oesophagitis
24hr pH oesophageal monitoring
24hr impedance monitoring (freq/food-related onset)
Endoscopy + biopsy
Contrast studies
How is reflux managed in uncomplicated cases? (4)
in more severe cases?
if failure to respond to treatment?
Parental reassurance
Adding inert thickeners to feeds
30degree head-up position after feeds
Feeding smaller amounts more often
In signif: H2R antag (ranitidine) / Domperidone / PPI
If failure to respond Tx: consider DDx CMP allergy
When/what surgical management can be done in reflux?
If complications/ unresponsive to intense medical Tx / oesophageal strictures
Nissen fundoplication (abdo/laparoscopic)
What are the complications that can occur from reflux? (7)
FTT (from severe vomiting)
Oesophagitis (haematemesis/ Fe defc anaemia/ heartburn/ feeding discomfort)
Dystonic neck posture
Aspiration (pneumonia/ cough/wheeze/ apnoea)
ALTEs
SIDS (rare)
Barrett’s oesophagus (rare)
Describe the conjugation process of bilirubin
Hb + haem prot breakdown → unconj bilirubin // albumin
Normally conj in liver + excreted in bile (dark urine/stools)
XS conj → albumin saturated → unconj crosses BBB
→ Basal ganglia damage (kernicterus)
In infants, what might alter bilirubin resorption in the gut?
Reduced milk intake → increased bilirubin resorption
List some causes of jaundice from unconj bilirubin (6)
Breast milk jaundice Haemolytic anaemia Hypothyroidism Infection High GI obstrn Crigler-Najjar syndrome (bilirubin metab disorder)
List some causes of jaundice from conj bilirubin (3)
Bile duct obstrn (choledochal cyst)
Intrahepatic biliary hypoplasia (atresia)
Neonatal hepatitis syndrome:
(CF / a1-antitrypsin defc / congenital inf / inborn error)
What % of newborns get physiological jaundice?
Why does it occur
> 50%
Shorter RBC lifespan + RBC breakdown
Liver bilirubin metabolism less efficient in 1st few days life
What are the features of physiological jaundice of the newborn? (4)
Jaundiced sclera/gums/skin
Dark urine + pale stools (= unconj; water soluble)
Hepatomegaly
Poor wt gain
What Ix can be done for jaundice?
If visible jaundice → transcutaneous bilirubinometer
(unless <24hrs old / <35/40) → if over 250 → test serum
Measure/6hrs whilst on Tx until sub-threshold/stable
What are the features of kernicterus? (4)
Lethargy / irritability
Poor feeding
Increased muscle tone
Arched back
What are the complications of kernicterus? (3)
Choreoathetoid (dyskinetic) cerebral palsy
Learning difficulties
Sensorineural deafness
List the possible causes for neonatal jaundice if <24hrs (5)
if 2d-2wks (4)
if >2wks (>3wks preterm) (4)
<24hrs: Haemolytic disorders (Rh, ABO, spherocytosis, G6PD) Congenital infection IUGR Hepatosplenomegaly ITP
2d-2wks: Physiological jaundice of newborn Breast milk jaundice Infection Dehydration
>2-3wks: Breast milk jaundice Infection Congenital hypothyroidism Biliary atresia (conj)
How is neonatal jaundice managed if bilirubin not extremely high?
+ if dangerously high
Single phototherapy (w. breaks/feeds/hydration) → If falls then stop // If not then continuous (no interrupt) → If falls then single
Exchange transfusion with donor blood (2x circ vol)
Check levels /2hrs
→ then continuous phototherapy
What is the incidence of biliary atresia?
What may it progress too if no surgical intervention?
1 in 14,000
can → chronic liver failure + death
What are the features of biliary atresia?
FTT (normal birth wt)
Jaundice (conj - dark urine/pale stools (post-meconium))
Hepatosplenomegaly (portal HT → spleno)
Bruising
What Ix may be done into biliary atresia? (4)
LFTs useless
Fasting abdo USS
Radioisotope scan w. TIBIDA (shows liver uptake/ no excr)
Liver biopsy (NB overlap features w. neonatal hepatitis)
Dx by laparotomy
What is the surgical treatment for biliary atresia?
Use jejunum loop + join onto porta hepatis
What is Coeliac disease?
What is its incidence in Europe?
Gluten → damaging immune response in proximal SI mucosa
1 in 3000
What is the classical presentation of Coeliac disease? (6)
8-24m Failure to thrive Abdo distension Buttock wasting Abnormal stools Irritability
How may Coeliac disease present in older children? (5)
Failure to Thrive / unexpected wt loss Prolonged fatigue Persistent/unexplained GI symps (D+V) Recurrent abdo pain Unexplained Fe defc anaemia
How is Coeliac disease investigated?
If on gluten diet AND S/s or Associated conditions
→ serological tests
If been off gluten, must have 1+ gluten meal /day/6wks
→ Serological tests
IgA -ve → check IgA defc / exclude DDx / poss biopsy
IgA +ve → intestinal biopsy (Dx)
How is Coeliac disease managed?
Gluten free diet for life
UNLESS <2y/o → gluten challenge later in life
Which tissue/site of the bowel is affected in Crohn’s
Transmurual IBD
Commonly affecting distal ileum/ prox colon
Inflamm/thickening → strictures + fistulae
How may Crohn’s disease present in children?
What are the possible presenting features (7)
Older children
Lethargy + malaise (not necessarily with GI symps)
Abdo pain Diarrhoea Fever Growth failure Wt loss Delayed puberty
What are the extra-systemic manifestations of Crohn’s? (FACE U POO)
Fe defc anaemia Arthralgia Clubbing Erythema nodosum Uveitis Perianal skin tags Oral lesions Osteoporosis
How is Crohn’s Dx?
Endoscopy/biopsy - non-caseating granulomata
AXR - small bowel irregs/fissures/narrowing
Describe the management of Crohn’s (5)
Nutritionally (whole prot feeds every 6-8wks)
→ effective in 75%
Ineffective → systemic steroids
+ immunosuppressants (prevent relapse)
Steroids ineffective → MABS
Longterm enteral supplement (overnight NG/gastrostomy)
→ to correct growth failure
Surgery: if severe localised unresponsive / complications
Which tissue of the bowel is affected in UC?
Colon mucosa
What are the features of UC (4)
Rectal bleeding
Diarrhoea
Colicky pain
Growth failure (not as bad as Crohn’s)
What are the extra-systemic manifestations of UC (MADAME UC)
Mouth ulcers Ank spon DVT Arthralgia (sero -ve) M: erytheMa nodusuM Episcleritis
Uveitis
Clubbing
How is UC Dx?
Endoscopy/Biopsy
AND
Exclusion of gastroenteritis
How is UC in children different to adults?
Adults usually confined to distal rectum
Children: 90% have pancolitis
Describe the management of UC (5)
Aminosalicylates (for mild) → remission/maintenance
Extensive/exac → systemic steroids + immunosupps
Confined to rectum/sigmoid → topical steroids
Fulminant = emergency (risk toxic mega/ bad chronic)
→ IV steroids/fluids
→ colectomy/ileostomy + ileorectal pouch
Bowel cancer screening 10yrs post-Dx
Describe the features of functional/recurrent abdo pain (4)
Characteristically periumbilical
Child otherwise well
Interrupts normal activities
Lasts >3m
List the usual causes of functional/recurrent abdo pain (4)
IBS**
Abdo migraine
Functional dyspepsia
Stress/anxiety related
What must the Ex/basic Ix include in a child presenting with functional/recurrent abdo pain (4)
Assess growth
Abdo palpation (exclude gall stones / PUJ obstrn)
Inspect perineum (anal fissures)
Urine MC+S (UTI DDx)
How is functional/recurrent abdo pain discussed with the parents?
Reassure parents (10% school aged children)
Explain that aim to find any serious cause without unnecessary Ix
Explain diff b/wn serious/dangerous
(serious = signify time out of school, not dangerous)
What causes IBS?
Altered GI motility + abnormal sensation
Often post-GI infection / FH
Also psychosocial factors (stress + anxiety)
What are the symptoms of IBS (ABCEF)
Abdo pain: worse before/relieved by defacating Bloating Constipation (b/wn normal/loose) Explosive/loose/mucousy stools Feeling of incomplete defacation
What are some causes of gastritis / peptic ulcer in children? (3)
H.Pylori (usually silent/asymp infection in children)
Infection
Pernicious anaemia
Bile reflux
List the symptoms of gastritis in children (3)
Nausea
Vomiting
Abdo pain (frequent complaints)
List the symptoms of peptic ulcers in children (3)
Gnawing/burning in epigastrium
Pain relieved by eating/antacids/milk
Bleeding → haematemesis/malaena
How is H.Pylori / gastritis / peptic ulcer managed?
Triple therapy (H.Pylori): amoxi + metro/clarithro + PPI Lifestyle factors (for older children): avoid irritant foods / alc / smoking / NSAIDs
What are the features of Toddler Diarrhoea? (4)
Vary in consistency (well formed → loose/explosive)
Often contain undigested vegetables
Paler + smellier than usual
Well + thriving
What advice can be given to parents in terms of managing Toddler Diarrhoea?
Investigations not usually necessary as v v common
Can relieve a bit by ensuring enough fat/fibre in diet
Maintain hydration
What reassuring info can be given to parents regarding Toddler Diarrhoea
Due to gut motility immaturity
NOT malabsorption
Other more serious diseases (Coeliac/ Gastroenteritis/ Lactose intol/ malabsorption) would not be well/thriving
How does Malabsorption manifest? (3)
Abnormal stools
Failure to thrive
Specific nutrient defc
List the diff types of malabsorption syndromes (8)
Coeliac
Food allergy/intolerance
Exocrine panc dysfunc
Cholestatic liver disease / Biliary atresia → fat/fat-sols
Short bowel syndrome (congenital/NEC)
Loss of terminal ileum → defective Bile/B12 absorption
Lymphatic leakage/obstrn
Small-intestinal mucosal disease (Coeliac, enzyme defects e.g. lactase post-GI, transporter defects)
How is malabsorption investigated?
Dietician review (may just be poor calorific intake) Stool sample (pH-carb/bile acids/prots/infection) Urinalysis (transporter defects) Various bloods/endoscopy/biopsy (dep on what DDx)
What are some causes/RFs of malnutrition in MEDCs/UK (7)
Chronic illness - esp at risk: Preterm Congenital heart disease IBD/Chronic GI conditions Malignancy Renal failure Cerebral palsy
Eating disorders
How is malnutrition assessed?
Food diary
Nutritional status index e.g. BMI/ tricep skin fold thickness/ mid-upper arm circumf
Biochem/immunological tests (less important)
What are the complications of malnutrition? (3)
Multi-system disorder
Impaired immunity / wound healing
Permanent delay in intellectual development
What diff types (2) of nutritional support can be given in malnutrition + when is each used?
Enteral - when digestive tract functioning
(safe + maintains gut func)
Via NG/gastrostomy - continuous feeds overnight
Parenteral - exclusively/or as adjunct
Cannula (short term)/ central venous (long-term)
Describe the MUST tool for malnutrition (5 steps)
Step 1: BMI Step 2: % unplanned wt loss Step 3: acute disease effect Step 4: add scores from steps 1-3 → gives overall risk malnutrition Step 5: use guidelines/local policy to make care plan
What are some diff measurement indexes of assessing nutritional status? (3)
Wt for ht (BMI) - acute malnutrition/wasting
Severe = 3SDs (<70%) below median
MUAC (mid-upper arm circumference)
Severe = <115mm
Ht for age - chronic malnutrition/stunting
Define + describe the 2 diff types of severe protein-energy malnutrition
Marasmus - no oedema
Severe low BMI / MUAC / skin fold thickness (wasting)
Kwashiorkor - generalised oedema/severe wasting
Wt loss not as severe due to oedema
What are the features of Kwashiorkor (9)
Flaky rash/ hyperkeratosis Dry/brittle hair Angular stomatitis Diarrhoea Abdomen distension Enlarged liver Hypotension/Bradycardia Hypothermia Low plasma albumin/Mg/K/glucose
When might you see Kwashiorkor in UK/MEDCs? (2)
When not weaned off breast until 12m (high-starch diet)
After acute inter-current infection e.g. measles/gastroenteritis
What are the features of viral hepatitis (5 common + 2 less common)
What will be seen on LFTS?
Lethargy Abdo pain / tenderness Nausea Vomiting Hepatomegaly
Jaundice (only 50%)
Splenomegaly
Transaminases v elevated + Coag normal
How is HepA transmitted?
What is the prognosis of its progression to chronic liver disease?
How Dx?
How treated/managed?
Faecal-oral
Does not progress to chronic liver disease
IgM Antibodies confirm Dx
Self-resolves + Contact prophylaxis
How is HepB transmitted
What is the prognosis of its progression to chronic liver disease?
How Dx?
How treated/managed?
Viral: perinatally/sexually/blood
> 90% become chronic carriers (+10% → cirrhosis)
Anti-HBc (acute infection) + HBsAg (ongoing/carriers)
Maternal +ve → babies need Ig Vx (5% req further dose)
How is HepB transmitted
What is the prognosis of its progression to chronic liver disease?
Viral: mainly blood (IVDUs)/ vertical (risk if HIV)
Most → chronic carriers (20-25%→ cirrhosis/carcinoma)
What are some symptoms of acute liver failure? (5)
Jaundice
Coagulopathy
Encephalopathy*
Hypoglycaemia + electrolye disturbances*
*Irritability / confusion / aggression
What is the commonest type of parasite infection in children?
What other types of parasitic infection may be seen? (2)
Worms
Giardia lambia
Cryptosporidium
How does parasitic infection of worms present?
How must it be treated
Usually asymp
Anal/vaginal itching
Esp at night
Treat whole household: hygiene/ mebendazole/piperazine
How does giardia lambia transmit?
What are the features (5)
Faecal-oral
Travellers diarrhoea >10d Nausea Abdo pain Anorexia / wt loss / FTT Dehydration
How does cryptosporidium transmit?
What are the features (3)
From animals/ infected indivs (nursery/food/water)
Low grade fever
Malaise
Sudden onset watery diarrhoea
