Gastroenterology Flashcards
Definition of Failure to Thrive (FTT) and nutrition
FTT - suboptimal wght gain in infants and toddles AKA faltering growth/weight
Nutrition - intake of food, considered in relation to the body’s dietary needs.
NICE guidelines on infant feeding (abridged)
Breast feeding
- Ensure good attachement and positioning
- Look for baby and mum indicators of successfull feeding e.g. audible swallow + breast feel empty
- Know how to pump and store milk
- Know signs to look out for related to breast feeding issues e.g. nipple pain
Bottle feeding
- Ensure mum knows associated risks
- Ensure mum knows how to give and make formula
- Get advice from independant source not advertising
General advice
- Good indicators for child health: colour, temp, regular UO, regular stools
- Babies should: initiate feeds, suck well and settle between feeds
- They should not be excessively irritable, tense, sleepy or floppy
- Vital signs: 30-60 RR, 100-160 HR, 37 deg in normal room
Where to find advice on breast feeding
Midwife
NICE postnatal care (bit hard for gen pop)
NHS breast feeding page
Types of formula and their indications
All based on varying levels of modified cows milk
Whole protein - Standard formula
Semi-hydrolysed - Based on modified cows milk and 100% whey protein. Marketed as easier to digest. In studies no difference found.
Hydrolysed - Supposed to be for cows milk allergies.
(NICE) considers that there is insufficient evidence to suggest that infant formulas based on partially or extensively hydrolysed cows’ milk protein can help prevent allergies (National Institute for Health and Clinical Excellence, 2008)
this is a very extensive document: http://www.firststepsnutrition.org/pdfs/draft_specialised_milks_mar_2013.pdf
Key Hx taking points in FTT or faltering growth
- Dietary Hx, incl food diary of several days
- Feeding, exactly what happens during meal times
- Child well with lots of energy?
- Other Sx: diarrhoea, vomiting, cough, lethargy
- Prematurity?
- IUGR?
- Other significant medical issues
- FHx of growth +/- illnesses
- Development normal?
- Psychosocial problems at home?
Differentials for failure to thrive/faltering growth
Inadequate intake
Non-organic/Environmental
- Inadequate food available e.g not enough of what they having, poor breast technique, lack of interest in feeding, not enough money
- Psychosocial deprivation: e.g. maternal depression
- Neglect of child abuse: deliberate underfeeding
Organic (only 5% of FTT)
- Impaired suck/swallow e.g. neuro issues
- Chronic illness anorexia: crohns
Inadequate retention
- Vomiting/GORD
Malabsorption
- Coeliac, Cystic fibrosis, allergy
Failure to utilise nutrients
- Downs, metabolic disorders
Increased requirement
- Thyrotoxicosis, malignancy, chronic infection (HIV)
Importance of nutrition scoring
Nutrition scores can do all sorts of things.
The one mentioned is MUST which tells you according to your wght now and 6 months ago and your health status what changes to make to your nutrition. http://www.bapen.org.uk/screening-and-must/must-calculator
There are loads of different ones for children,
- STRONGKIDS best for quick assessment of all aged children
- PYMS or STAMP are a bit longer but will detect all children with malnourishment and provide advice
Presenting features of kwashiorkor (protein malnutrtion)
- Generalised odema
- Sever wasting
- Due to odema wght might not be too bad
- Flaky paint skin w/ hyperkeratosis (thick skin) + desquamation
- Distention
- Hepatomegaly
- Angular stomatitis
- Sparse depigmented hair
- Diarrhoea
- Hypothermia
- Bradycardia
- Hypotension
S&S of overfeeding
- Gaining too much wgt
- >7 heavy wet nappies a day
- Frequent sloppy foul smelling motions
- Flatulence
- Belching
- Milk regurg
- Irritability
- Sleep disturbance
Approximate recommended intake for 0-3 mnts, 3-6 months and 6-12 months
0-3: 115 kcal/kg/day = 185 mls of breast milk/kg/day
3-6: 115 kcal/kg/day = 185 mls of breast milk/formula /kg/day
SOLID FOOD INTRODUCED AT 6 MONTHS
6-12: 95kcal/kg/day = Two meals a day, each 2-4 tablespoons
Hx of constipation and how differentiate from Hirschprungs
Def of constipation- Infrequent dry hardened faeces often w/ straining and pain. May wax and wane + be accompanied overflow soiling
Age - Hirschprungs usually presents in first 48 hours of life. More unlikely the older you get
Failure to pass meconium - Classic Hirschprungs, may have been delayed so ask
Bilious vomiting (green) - This will be a later Sx in Hirschprungs defo not constipation.
Failure to thrive - Simple constipation should not present with this something else is going on. Not Hrisch specific
Frequency of bowels - In Hirsch you get profound constipation i.e. nothing passes for weeks. Infants should go 4 times a day in 1st week of life, this falls to 2 per day by 1st year. Breast fed infants may not go for days and this can be normal. By 4 years they should be like adults normal is 3 stools per day to wk.
Management of simple constipation
Balanced diet + fluid + exercise
Is the patient impacted? (breakthrough diarrhoea, distention, palpable mass)
- Yes - Commence disimpaction treatment then continue to maintenance
- Escalation dose Movicol
- Add stimulant laxative if not effective in 2 wks (Senna)
- Substitute stimulant laxative +/- lactulose if movicol not tolerated
- Warn carer that disimpaction may Sx of soiling + abdo pain
- No - Commence maintenance treatment
- Movicol adjusted to Sx response
- Substitute stimulant if movicol not tolerated
- Continue on therapy several wks after bowel return to normal
- Dec dose slowly
Differentiating constipation overflow from functional encopresis
Functional Encopresis - repeated involuntary fecal soiling in the underpants that is not caused by organic defect or illness.
Presence of constipation +/- pain - If the child has prior to the episode had painful constipation they may be hanging on the avoid the pain.
Skid marks - Children may start presenting with skid marks if they have overflow
Social issues - Children with functional encopresis are much more likely to have emotional/behavioural/social issues
Parent attitude - If a parent has a negative attitude about the problem likely functional encopresis
Ask about the situation surrounding the toilet - Is there a lot of negative emotion around it? Is there a lot of intereference? Probs functional encopresis
Urgency? - There usually isn’t any in overflow, not sure about functional enc, but seems like there should be
Treatment of functional encopresis
Medical
- Laxatives
Diet and fluid intake
- 5 a day
- Wholemeal bread and pasta
- Lots of water
- Exercise
Healthy toilet habits
- Regular routine
- Timed sits after meals
Aetiology, presenting Sx, diagnosis, management and complications of Hirschprungs
Aetiology
Abscence of ganglionic cells from myenteric and submucosal plexus = narrow contracted segment of bowel
Triggering event unclear risk factors: family member w/ hirschprungs, male gender, having another inhereted condition
Sx
- Failure to pass meconium/profound constipation
- Abdo distention
- Bilious vomiting
- Failure to thrive in older children
- Hirschprungs enterocolitis
- Severe, life-threatening
- Diarrhoea
- Vomiting
- Loss of appetite
- Abdo cramping and pain
- Fever
- Other congenital disease e.g. down’s or heart
Diagnosis
- Digital rectal exam leads to release of bowels and flatulence = temporary easing of Sx
- Suction rectal biopsy
Management
- Surgical
- Initial colostomy (creation of stoma)
- Re connect non diseased bowel to anus
Complications
- Perforation
- Hirschprungs enterocolitis
Gastroenteritis: clinical features, management and assessment of hydration
Clinical features
- DnV
- Abdo pain
- Pyrexia
- Travel abroad is very suggestive
- Recent contact w/ someone w/ similar issues also suggestive
Applies to under 5’s
Assessing hydration (red flags)
- Urine output (wet nappies)
- Appears unwell/deteriorating
- Lethargy
- Altered responsiveness
- Pale mottled skin
- Dec skin turgour
- Sunken eyes
- Dry mucous membranes
- Tachycardia
- Tachyopnoea
- Weak peripheral pulses
- Prolonged CAP
- If you have a baseline weight that helps with fluid resus
Management
- Treat dehydration
- See attached flow chart
- Only give antibiotics if septicaemia or confirmed bacterial infection
GORD: definition, pathophysiology, management and complication
Definition
Involuntary passage of gastric contents into oesophagus
Pathophysiology
Inappropriate relaxation of the lower oesophageal spincter as a result of functional immaturity. Fluid diet, lying horizontally, short intra-abdominal oesophagus also contribute.
Management
Non-medical
- Parental reassurance that it should get better by 12 months age due to maturity
- Sit head up 30 degrees after feed
- Consider cows milk protein allergy
Medical
- Add thickening agents to food (can be given for mild the rest are for more severe)
- H2 antagonist (ranitidine)
- PPI
- Drugs to improve gastric emptying do not have a lot of evidence but may be used domperidone
Surgical (only in complicated, refractory GORDor oesophageal stricture)
- Nissen fundoplication
Complications
- SIDS (sudden infant death syndrome
- Aspiration
- Barrett’s oesophagus
Bilirubin cycle
Don’t need to know but helpful when looking at jaundice
There is also a good diagram in the paeds book pg 169
Aetiology and pathogenesis of unconjugated jaundice
Can be physiological jaundice aka non-pathogenic (but still potentially dangerous) or pathogenic i.e. something is physically wrong. This jaundice present yellow rathen than green which in conjugated jaundice
Physiological
Aetiology
- There is a lot of RBC break down at birth due to high Hb conc
- Red cell life span in infant is 70 days (shorter than adults 120 days)
- Heptatic bilirubin metabolism is less efficient in the first days of life
- All these lead to high levels of unconjugated bilirubin in the blood = jaundice
Pathogenic
Aetiology/Causes
- Increased lysis of RBC (increased haemoglobin release)
- Rh/ABO incompatobility
- Decreased uptake and conjugation of bilirubin
- Pyloric stenosis
- Increased enterohepatic reabsorption
- Breast feeding jaundice i.e. dehyfdration from lack of feeding
Pathogenesis for both
- This physiological jaundice may still be an issue as unconjugated bilirubin can cross BBB ==> kernicterus
- Kernicterus: encephalopathy from deposits of unconjugated bilirubin. Usually occurs when there is more unconj bilirubil than albumin to take it safely to the liver. Initially presents with lethargy and poor feeding -> increased mm tone -> seizures -> coma. Complication include choreoathetiod CP, learning difficulties, sensorineural deafness
Aetiology and pathogenesis of conjugated jaundice
Conjugated (pathological) jaundice caused by cholestasis. So the bilirubin has been conjugated in the liver but it building up giving the jaundice more or a green appearance
Aetiology/Causes
- Hepatocellular damage
- Hepatitis
- Biliary tree abnormalities
- Biliary atresia
Pathophysiology
Conjugated bilirubin isn’t toxic treat the cause
NICE guidelines for investigating and managing jaundice
Assessment is attached
Management
- Phototherapy
- Exchange transfusion
Likely causes of jaundice and age of baby
Attached
Importance of stool colour in child with jaundice
If pale and chalky this indicates that bilirubin is not getting to the gut in order to colour the poo. So it gives you a clue as to what is causing the jaundice. If they are jaundice with normal poo that probs means there is too much RBC break down, whereas if the poo is white it may indicate biliary atresia.
S&S and investigations of biliary atresia
Hx
- Normal birthweight
- FTT
- Mild jaundice
- After meconium stools are pale and chalky
Ex
- Splenohepatomegaly
Investigations
- LFTs not always helpful
- Fasting abdo USS may help
- Radioisotope scan to see livere uptake and lack of passing into biliary tree
- Liver biopsy may help b/c difficult to distinguish from hepatitis
- Diagnosed at laprotomy by operative chiolangiography
Aetiology and presenting features of viral hepatitis
Aetiology
- Hep A - faecal oral
- Hep B - bodily fluid e.g. blood and semen, important cause of chronic liver disease world wide
- Hep C - blood borne in CUTS
- Hep D - co-infection with hep B necesarry. It is a dysfunctional virus - you get a D for being a virus
- Hep E - Faecal oral
Presenting features
- Nausea
- Vomiting
- Abdo pain
- Lethargy
- Jaundice
- Hepatomegaly +/- splenomegaly
- Abdo tenderness on palpation
Diagnosis and management of coeliac disease
Diagnosis
- Total immunoglobulin A (IgA)
- IgA Tissue transglutaminase antibody (tTG)
- Small intestine biopsy
- (BUTTOCK WASTING BUZZ WORD FOR COELIAC)
Management
- GF diet
- Deitician referral
Hx w/ focus on food intolerance
GI symptoms? Food allergies usually do something to the GI tract. In first few weeks of life may present with blood in stool.
Rash?
Angiodema?
Have you noticed that it is preciptated by any food? What did they last eat? What did they eat in the last few hours
Abdo pain/colic?
Have they got any other allergies/hayfever/asthma/eczema/atopy?
What’s the difference between type 1 and type 2 hypersensitivity, in the context of food allergy
Type 1
- IgE mediated
- Example - immediate cows milk allergy/allergic rhinoconjunctivus/anaphalaxis
- Occurs 10-15 minutes after ingesting food
- Sx include angiodema to anaphalxis
Type 2
- Non-IgE mediated IgG or IgM
- Example cows milk allergy that occurs hours after ingestion
- Occurs hours after ingestion and usually involves GI tract diarrhoea, vomiting etc.
- May present as FTT
Define malabsorption
Disorders affecting the digestion or absorption of nutrients manifest as: abnormal stool, FTT, specific nutrient deficiency
Hx, Ex and DD for malabsorption
Malabsorption can be caused by a wide variety of things
- GE
- Coeliac
- IBD
- CF
- Food intolerance
- Hepatic issues
- Poor diet
- Parasitic infection
Hx
- PCs
- Stool: frequency, odor, what normal looks like, consitency, blood,
- Urinary: Sx, colour
- Wght and Hgt
- Jaundice?
- Set off by certain food?
- Recent travel?
- What is their diet like?
- FHx: coeliac, allergy, CF, IBD
Ex
- Abdo
First line investigations for malabsorption
Assess nutrition
Hgt Wght
Hx + Ex and go from there
Define infantile colic and parental advice
Infantile colic: Excessive frequent crying in a baby that is otherwise well
Parental advice:
- It is not your fault, there is nothing wrong with your parenting or your baby
- It will eventually get better - colic usually resolves at 6mnths
- Looks after your own well being and ask your friends and family for help
- Hold you baby when crying
- Hold them upright during feeding
- Burp the baby after feeding
- Rock the baby gently over your shoulder
- Warm bath
- Tummy massage
- If you baby develops other sx take them to a GP
- NHS website for more information
Management of infant w/ cow’s milk protein intolerance
- Remove cows milk from diet (hydrolysed/hypoallergenic milk)
- Advice parents what to do incase of accidental ingestion (child dependent) antihistamines mild –> adrenaline severe
- Advice parents on reading food labels
Age range and clinical features of toddler’s diarrhoea
Age range: 1-5 mainly boys
Clinical features:
- Chronic non-specific diarrhoea, diarrhoea is usually smelly
- Pale and contains undigested food
- Pain is unusual
- No impact on hgt + wght
- Otherwise well
- Ex normal
Presenting features, pathology, systemic manifestation and treatment of UC
Pathology
- Confined to colon
- Mucosal/submucosal
Presenting features
- Rectal bleeding
- Diarrhoea
- Colicky pain
- Wght loss hgt failure
Systemic manifestation
- Growth restriction
- Psychological impact
- Erythema nodosum
- Arthritis
Treatment
- Aminosalicylates (balsalazide)
- Disease in rectum and sigmoid colon can be treated with topical steriods
- More aggressive disease is managed w/ systemic steriod for acute exacerbations and immunomodulatory therapy to maintain remission (azathiopine +/- corticosteriods)
- Fulminating disease requires IV fluids and steriods
- If remission is not achieved ciclosporin may be required
- Surgery such as colectomy w/ ileostomy is only for fulminating disease which may be complicated by toxic megacolon
- There is an increase incidence of colon cancer in adults w/ UC colonoscopy should be preformed 10 yrs after diagnosis
Presenting features, pathology, systemic manifestation and treatment of Crohns
Pathology
- Can affect anywhere from mouth to rectum
- Transmural
- Focal
- Sub acute
- Strictures and fistulae may form
- Usually affect ileum and proximal colon
Presenting features
- Abdo pain
- Diarrhoea
- Wgt loss
- Fever
- Lethargy
- May present as generally unwell and lethargic w/out GI sx
Systemic manifestation
- Growth restriction
- Delayed puberty
- Psychological impact
- Oral lesions
- Perianal skin tags
- Uveitis
- Arthralgia
- Erythema nodosum
Treatment
- Nutritional therapy 6-8 wks
- Replacement of diet with whole protein modular feeds
- If ineffective systemic steriods
- Immunosuppresants may be required for maintenance of remission e.g. methotrexate
- Supplemental enteral nutrition usually via NG tube overnight can be helpful to correct growth issues
- Surgery may be needed for complications e.g. obstruction, fistulae, abscesses
S&S and aetiologies of gastritis
Aetiology
- Helicobactor
S&S
- Abdo pain (epigastric) that wakes in the night
- Hx of peptic ulceration in 1st degree relative
- Nausea
Treament of gastritic duodenal ulcers
- Alcohol and smoking cessation
- PPI (omeprazole)
- If H.pylori is suggested then eradicationt therapy should be commenced
- Amoxicillin
- Metronidazole or clarithromycin
Define mesenteric adenitis and give DDs
Def: Swollen lymph glands in the mesentry
DD
- Anything that causes abdo pain
- Appendicitis
- Constipation
- IBS
- Kidney stones
- UTI
- Gallstones
- Period pain
- GE
- Stomach and duodenal ulcers
