Gastroenterology Flashcards
What does blood in the stool of a vomiting child indicate?
Intussusception, gastroenteritis - salmonella or campylobacter
What does bile stained vomit indicate in the vomiting child?
Intestinal obstruction
What does haematemesis indicate in the vomiting child?
Oesophagitis, peptic ulceration, oral/nasal bleeding
What does projective vomiting in the first few weeks of life indicate?
Pyloric stenosis
What does vomiting at the end of paraoxysmal coughing indicate?
Whooping cough
What does abdominal tenderness or abdominal pain on movement in the vomiting child indicate?
Surgical abdomen
What does abdominal distension in the vomiting child indicate?
Intestinal obstruction, including strangulated inguinal hernia
What does hepatosplenomegaly in the vomiting child indicate?
Chronic liver disease
What does severe dehydration or shock in the vomiting child indicate?
Severe gastroenteritis, systemic infection (UTI, meningitis), DKA
What does a bulging fontanelle or seizures in a vomiting child indicate?
Raised intracranial pressure
What does failure to thrive in a vomiting child indicate?
Gastro-oesophageal reflux, coeliac disease and other chronic gastrointestinal conditions
What is posseting?
The non-forceful return of small amounts of milk which often accompany the return of swallowed air (‘wind’).
What is regurgitation?
The non-forceful return of larger (than posseting), losses of milk. Regurgitation may indicate the presence of more significant gastro-oesophageal reflux
When would serious disorders need to be excluded with vomiting?
If vomiting is bilious or prolonged, or if the child is systemically unwell or failing to thrive. In infants, vomiting may be associated with infection outside the GI tract, especially a UTI or CNS infection.
When is vomiting not bile-stained in intestinal obstruction?
When the obstruction is proximal to the ampulla of Vater.
What is gastro-oesophageal reflux?
The involuntary passage of gastric contents into the oesophagus. It is extremely common in childhood.
What causes gastro-oesophageal reflux?
Inappropriate relaxation of the lower oesophageal sphincter as a result of functional immaturity. A predominantly fluid diet, horizontal posture and a short intra-abdominal oesophagus all contribute
When should symptomatic reflux resolve spontaneously?
By 12 months of age
What are some complications of gastro-oesophageal reflux?
Failure to thrive
Oesophagitis (haematemesis, discomfort on feeding or heartburn, iron deficiency anaemia)
Recurrent pulmonary aspiration (recurrent pneumonia, cough or wheeze, apnoea in preterm infants)
Dystonic neck posturing
Apparent life threatening events
In which children in severe reflex more common?
Cerebral palsy or other neurodevelopmental disorders
Preterm infants
Following surgery for oesophageal atresia or diaphragmatic hernia
How would you manage gastro-oesophageal reflux?
Parental reassurance, adding inert thickening agents to feeds and positioning in a 30 degree head-up prone position after feeds. Occasionally, ranitidine or omeprazole or domperidone
What is pyloric stenosis?
Hypertrophy of the pyloric muscle causing gastric outlet obstruction.
When does pyloric stenosis present?
Between 2 and 7 weeks of age, irrespective of gestation
Is pyloric stenosis more common in boys or girls?
Boys: 4:1
What are the clinical features of pyloric stenosis?
Vomiting, which increases in frequency and forcefulness over time, ultimately becoming projectile
Hunger after vomiting until dehydration leads to loss of interest in feeding
Weight loss if presentation is delayed
What investigation is used to diagnose pyloric stenosis?
A test feed: baby is given a milk feed, gastric peristalsis may be seen as a wave moving from left to right across the abdomen. If the stomach is overdistended with air, it will need to be emptied by a nasogastric tube to allow palpation. US is helpful is diagnosis isn’t clear
How do you manage pyloric stenosis?
Correct any fluid and electrolyte disturbance with IV fluids. Pyloromyotomy will be performed. The child can be fed within 6 hrs and discharged within 2 days
What electrolyte disturbances are associated with pyloric stenosis?
Hyponatraemia, hypokalaemia and hypochloraemic alkalosis
What is colic?
A term used to describe a common symptom complex which occurs during the first few months of life. Paroxysmal, inconsolable crying or screaming often accompanied by drawing up of the knees and passage of excessive flatus takes place several time a day, particularly in the evening.
When does colic tend to occur?
It typically occurs in the first few weeks of life and resolves by 4 months of age.
What is a differential diagnosis of colic?
If severe and persistent, it may be due to a cow’s milk protein allergy or gastro-oesophageal reflux and an empirical 2-week trail of a whey hydrolysate formula followed by a trial of anti-reflux meds may be considered
Where may lower lobe pneumonia get referred pain?
The abdomen
What are the clinical features of acute appendicitis?
Symptoms - anorexia, vomiting (not much), abdominal pain (central and colicky then right iliac fossa)
Signs - flushed face with oral fetor, low grade fever, abdominal pain aggravated by movement (coughing, jumping), persistent tenderness with guarding at McBurney’s point
How is acute appendicitis different in preschool children?
Perforation may be rapid
Faecoliths are more common and can be seen on abdo X-ray
Is appendicitis progressive?
Yes, so repeated observation and clinical review every few hours are key
What are the surgical causes of acute abdominal pain?
Acute appendicitis Intestinal obstruction Inguinal hernia Peritonitis Inflamed Meckel diverticulum Pancreatitis Trauma
What are the medical causes of acute abdominal pain?
Gastroenteritis Urinary tract: UTI, acute pyelonephritis, hydronephritis, renal calculus Henoch-schonlein purpura DKA Sickle cell disease Hepatitis IBS Constipation Psychological
What are some extra-abdominal causes of acute abdominal pain?
Upper respiratory tract infection
Lowe lobe pneumonia
Torsion of the testis
Hip and spine
What is complicated appendicitis?
It includes the presence of an appendix mass, an abscess or perforation
How do you manage appendicitis?
If there are no signs of generalised peritonitis, culd give IV antibiotics, if more serious fluid resuscitation and IV antibiotics are given prior to a laparotomy.
What is non-specific abdominal pain?
Abdominal pain which resolves in 24-48h. The pain is less severe than in appendicitis, it is often accompanied by an upper respiratory tract infection
What is intussusception?
The invagination of proximal bowel into a distal segment.
What parts of the bowel are most commonly in intussusception?
Ileum passing into the caecum through the ileocecal valve.
When does intussusception most commonly occur?
Although it may occur at any age, the peak age of presentation is between 3 months and 2 years.
What are the complications of intussusception?
The most serious complication is stretching and constriction of the mesentery resulting in venous obstruction, causing engorgement and bleeding from the bowel mucosa, fluid loss and subsequently bowel perforation, peritonitis and gut necrosis.
How does intussusception usually present?
Paroxysmal, severe colicky pain and pallor, drawing up legs during painful episodes, becoming more lethargic after every episode.
May refuse feeds, may vomit, which may become bile-stained
A sausage shaped mass often palpable
Passage of characteristic redcurrant jelly stool comprising blood-stained mucus
Abdominal distention and shock
What would you see on X-ray of intussusception?
Distended small bowel and absence of gas in the distal colon or rectum. Sometimes the outline of the intussusception itself can be visualised. Abdo US is also helpful.
What is the management of intussusception?
If no signs of peritonitis, reduction of the intussusception by rectal air insufflation is usually attempted by a radiologist. If this fails (25%) operative reduction is required
What is a Meckel diverticulum?
Around 2% of individuals have an ileal remnant of the Vitello-intestinal duct, a Meckel diverticulum, which contains ectopic gastric mucosa or pancreatic tissue.
How do Meckel diverticulum’s present?
Most are asymptomatic, but they may present with severe rectal bleeding, which is classically neither bright red nor true melaena
How do you investigate Meckel diverticulum?
A technetium scan will demonstrate increased uptake by ectopic gastric mucosa in 70% of cases
How would you treat Meckel diverticulum?
Surgical resection
What is malrotation?
During rotation of the small bowel in fetal life, if the mesentery is not fixed at the duodenojejunal flexure or in the ileocaecal region, its base is shorter than normal, and is predisposed to volvulus. Ladd bans may cross the duodenum, contributing to bowel obstruction
How does malrotation present?
Obstruction with bilious vomiting in the first few days of life but can be seen at a later age.
How would you investigate/manage malrotation?
Any child with dark green vomiting needs an urgent upper gastrointestinal contrast study to assess intestinal rotation, unless signs of vascular compromise are present, when an urgent laparotomy is needed.
What does surgery do to treat malrotation?
The malrotation is not ‘corrected’, but the mesentery broadened. The appendix is generally removed to avoid diagnostic confusion in the event the child subsequently has symptoms suggestive of appendicitis
What is recurrent abdominal pain?
Pain sufficient to interrupt normal activities and lasts for at least 3 months. The pain is characteristically periumbilical and the children are otherwise entirely well.
What are some causes of recurrent abdominal pain?
It can be a manifestation of stress, maybe leading to a vicious cycle of anxiety with escalating pain leading to family distress and demands for increasingly invasive investigations.
How do you manage recurrent abdominal pain?
Look for and treat causes, reassure parents and child
What are the symptoms of IBS?
Abdominal pain, often worse before or relieved by defecation Explosive, loose or mucousy stools Bloating Feeling of incomplete defecation Constipation
What are some symptoms and signs that suggest organic disease in recurrent abdominal pain?
Epigastric pain at night, haematemesis (duodenal ulcer)
Diarrhoea, weight loss, growth failure, blood in stools (IBD)
Vomiting (pancreatitis)
Jaundice (liver disease)
Dysuria, secondary enuresis (UTI)
Bilious vomiting and abdo distention (malrotation)
What is the infection that causes most gastroenteritis’?
Rotavirus, particularly in the winter and early spring
What are some symptoms that may indicate Shigella and some Salmonella?
A dysenteric type of infection, with blood and pus in the stool, pain and tetanus. Shigella may be accompanied by a high fever.
What are some differential diagnoses for gastroenteritis?
Systemic infection: septicaemia, meningitis
Local infections: respiratory tract infection, otitis media, hep A, UTI
Surgical disorders: pyloric stenosis, intussusception, acute appendicitis, NEC, Hirschsprung disease
Metabolic disorder: DKA
Renal disorder: haemolytic uraemic syndrome
Other: coeliac disease, cow’s milk protein intolerance, adrenal insufficiency
What are the clinical features of gastroenteritis?
Sudden change to loose or watery stools often accompanied by vomiting. There may be contact with a person with diarrhoea and/or vomiting or recent travel abroad.
What is the most serious complication of gastroenteritis?
Dehydration leading to shock
Which children are at increase risk of dehydration?
Those under 6 months born at low birthweight
Passed >6 diarrhoeal stools in the past 24h
Vomited three or more times in the previous 24h
Unable to tolerate extra fluids
Malnutrition
Why are infants at increased risk of dehydration?
Increased SA:volume ratio so greater insensible losses, higher basal fluid requirements and immature renal tubular reabsorption
What are the clinical features of shock from dehydration in an infant?
Decreased LOC Sunken fontanelle Dry mucous membranes Eyes sunken and tearless Tachypnoea Prolonged cap refil Tachycardia, weak peripheral pulses Pale or mottled skin Reduced tissue turgor Hypotension Sudden weight loss Reduced urine output Cold extremities
What is isonatraemic dehydration?
The losses of sodium and water are proportional and plasma sodium remains within the normal range
What is hyponatraemic dehydration?
When children with diarrhoea drink large quantities of water or other hypotonic solutions, so there is a greater loss of sodium than water, leading to a fall in plasma sodium
What are the consequences of hyponatraemic dehydration?
A shift of water from extra- to intracellular compartments. The increase in intracellular volume leads to an increase in brain volume, which may lead to convulsions, whereas the marked extracellular depletion leads to a greater degree of shock per unit of water loss.
What is hypernatraemic dehydration?
Infrequently, water loss excess the relative sodium loss and plasma sodium concentration increases.
What usually causes hypernatraemic dehydration?
It usually results from high insensible water losses (high fever or hot, dry environment) or from profuse, low sodium diarrhoea.
What are the consequences of hypernatraemic dehydration?
The extracellular fluid becomes hypertonic with respect to the intracellular fluid, which leads to a shift of water into the extracellular space from the intracellular compartment. Water is drawn out of the brain and cerebral shrinkage within a rigid skull may lead to jittery movements, increased muscle tone with hyperreflexia, altered consciousness, seizures and multiple, small cerebral haemorrhages
How would you manage gastroenteritis?
Based on rehydration
How would you rehydrate a child with hypernatremia?
Slowly, you do not want to create a shift of water into cerebral cells, as this may result in seizures and cerebral oedema
Why is there no place for medications in gastroenteritis?
They: are ineffective
may prolong the excretion of bacteria in stools
can be associated with side-effects
add unnecessarily to cost
focus attention away from oral rehydration
When are antibiotics required for gastroenteritis?
For suspected or confirmed sepsis
Extra-intestinal spread of bacterial infection
For salmonella if <6 months old
In malnourished or immunocompromised children
For specific bacterial or protozoal infections (C.diff)
What is post-gastroenteritis syndrome?
Infrequently, following an episode of gastroenteritis, the introduction of a normal diet results in a return of watery diarrhoea due to temporary lactose intolerance,
How do you diagnose temporary lactose intolerance after gastroenteritis?
A positive Clinitest result
How do disorders affecting the digestion or absorption of nutrients manifest?
Abnormal stools
Failure to thrive or poor growth in most but not all cases
Specific nutrient deficiencies, either singly or in combination
What is the ‘classic’ presentation of coeliac disease?
Failure to thrive, abdominal distention and buttock wasting, abnormal stools and general irritability at 8-24 months of age after introducing wheat.
How do you confirm diagnosis of coeliac disease?
Small intestinal biopsy performed endoscopically, showing flat mucosa. Positive serology (IgA tissue transglutaminase and endomysial antibodies)
What are some causes of nutrient malabsorption?
Cholestatic liver disease or biliary atresia Lymphatic leakage or obstruction Short bowel syndrome Loss of terminal ileal function Exocrine pancreatic dysfunction (CF) Small intestinal mucosal disease
What is toddler diarrhoea?
Stools of varying consistency, sometimes well formed, sometimes explosive and oose. The presence of undigested vegetable in the stools is common. Affected children are well and thriving and there are no precipitating dietary factors
What is the cause of toddler diarrhoea?
Maturational delay in intestinal motility which leads to intestinal hurry. Most children have grown out of it by 5 years old.
What can alleviate and exacerbate toddler diarrhoea?
Some relief of symptoms can be achieved by ensuring that the child’s diet contains adequate fat (slows gut transit) and fibre. Excessive consumption of fresh fruit juice, particularly those high in non-absorbable sorbitol, can exacerbate symptoms
How does Crohn’s disease present in children and adolescents?
Growth failure, puberty delay Classical presentation (abdo pain, diarrhoea, weight loss) General ill health (fever, lethargy, weight loss) Extra-intestinal (oral lesions or perianal skin tags, uveitis, arthralgia, erythema nodosum)
What is the histological hallmark of Crohn’s on endoscopic biopsy?
The presence of non-caseating epithelioid cell granulomata
How would you treat Crohn’s?
Remission is induced with nutritional therapy, when the normal diet is replaced by whole protein modular feeds for 6-8 weeks (effective in 75%). Systemic steroids are required if ineffective
What medications can be used in Crohn’s relapses (as it often does)?
Immunosuppressant medications (azathioprine, methotrexate). Anti-TNF agents (infliximab and adalimumab)
What are some complications of Crohn’s?
Obstruction, fistulae, abscess formation
How does ulcerative colitis present?
Rectal bleeding, diarrhoea and colicky pain. Weight loss and growth failure may occur, although this is less frequent than in Crohn’s disease. Extra intestinal complications include erythema nodosum and arthritis
How would you treat UC?
Mild disease: aminosalicylates (balsalazide and mesalazine), topical steroids
Severe: systemic steroids for acute exacerbations and immunomodulatory therapy (azathioprine) to maintain remission alone or in combination with low-dose steroids
What is a normal stool passing frequency in early life?
4 stools per day in first week
2 stools per day in first year
Breast fed infants may not pass stool for several days
By 4 years of age, similar to adults
What is constipation?
Infrequent passage of dry hardened faeces often accompanied by straining or pain. There may be abdominal pain which waxes and wanes with passage of stool or overflowing soiling
What causes of constipation should be considered in babies?
Hirschsprung disease, anorectal abnormalities, hypothyroidism and hypercalcaemia.
What does failure to pass meconium in the first 24h of life indicate?
Hirschsprung disease
What does failure to thrive/growth failure in a child with constipation indicate?
Hypothyroidism, coeliac disease
What does gross abdominal distention in a child with constipation indicate?
Hirschsprung disease or other gastrointestinal dysmotility
What does an abnormal lower limb neurology or deformity in a child with constipation indicate?
Lumbosacral pathology
What does a sacral dimple above naval cleft, over the spine - naevus, hairy patch, central pit or discoloured skin in a child with constipation indicate?
Spina bifida occulta
What does abnormal appearance/position/patency of anus in a child with constipation indicate?
Abnormal anorectal anatomy
What does perianal bruising or multiple fissures in a child with constipation indicate?
Sexual abuse
What does a perianal fissure, abscess or fistulae in a child with constipation indicate?
Perianal Crohn’s disease
What are the consequences on constipation?
In long-standing constipation, the rectum becomes overdistended, with a subsequent loss of feeling the need to defecate. Involuntary soiling may occur as contractions of the full rectum inhibit the internal sphincter, leading to overflow
How do you manage constipation?
Disimpaction with laxatives followed by maintenance treatment. The child should be encouraged to sit on the toilet after mealtimes to utilise the physiological gastrocolic reflex and improve the likelihood of success. Use a star chart to engage the child.
What is Hirschsprung disease?
The absence of ganglion cells from the myenteric and submucosal plexuses of part of the large bowel, resulting in a narrow, contracted segment.
How much of the bowel does Hirschsprung disease affect?
The abnormal bowel extends from the rectum for a variable distance proximally, ending in a normally innervated, dilated colon. In 75% of cases, the lesion is confined to the rectosigmoid, but in 10% the entire colon in involved.
How does Hirschsprung disease present?
Usually in the neonatal period with intestinal obstruction heralded by failure to pass meconium within the first 24h of life. Abdominal distension and later bile-stained vomiting develop.
What may you find on rectal examination of Hirschsprung disease?
A narrowed segment and withdrawal of the examining finger often releases a gush of liquid stool and flatus. Temporary improvement in the obstruction following the dilatation caused by the examination may lead to delay in diagnosis
If not diagnosed at first, how may Hirschsprung disease present?
Occasionally, infants present with severe, life-threatening Hirschsprung enterocolitis during the first few weeks of life, sometimes due to C.diff. In later childhood, presentation in with chronic constipation, usually profound and associated with abdominal distention but usually without soiling. Growth failure may be present.
How is Hirschsprung disease diagnosed?
By demonstrating the absence of ganglion cells, together with the presence of large, acetylcholine-positive nerve trunks on a suction rectal biopsy.
How do you treat Hirschsprung disease?
Management is surgical and usually involves an initial colostomy followed by anastomosing normally innervated bowel to the anus
