Gastroenterology Flashcards
What is colic? Describe the different symptoms of colic
What age of children does it usually occur in?
What commonly is a differential?
What is essential in it’s treatment?
Continual crying in a baby - inconsolable/difficult to comfort. Crying is often high pitched/screeching
More common in the afternoon or evening (but not always)
Baby may bend knees up towards chest and tighten fists
Passage of excessive flatus
Usually occurs in babies aged up to 3 or max 6 months of age
Commonly a differential is gastrointestinal problems
Essential in treatment is support of parents as is can often be very frustrating and worrying for parents. It may precipitate non-accidental injury in infants already at risk
What is the definition of constipation?
Infrequent passage of dry, hardened faeces often accompanied by straining or pain and bleeding associated with hard stools
What other symptoms may be associated with constipation in children?
Abdominal pain
Usually, what is the reason for the development of constipation (think of lifestyle rather than diagnosis)
Decreased fluid intake Dehydration Anal fissure (causes pain so they don't want to go) Problems with toilet training Anxieties over using unfamiliar toilet
How does Hirschsprung’s disease present? What time frame?
Usually presents as failure to pass meconium in first 24 hours of life
Presentation:
- Constipation
- Abdominal distention
- Bile-stained vomiting
Can present later in life with growth failure
What is a complication of long standing constipation? Why?
Distention of the rectum leading to loss of sensation which leads to involuntary soiling
This occurs because the rectum becomes over distended, leading to decreased sensation of the need to defecate.
Involuntary soiling subsequently occurs because contractions of the full rectum inhibit the internal sphincter, leading to overflow
This may present on a AXR as severe faecal loading
What is the treatment for faecal impaction in children?
Disimpaction regime:
Stool softeners (commonly movicol paeds plan) for 1-2 weeks or until the impaction resolves FOLLOWED BY... maintenance treatment to ensure ongoing, regular pain free defecation (target is 1 large soft stool/day). The medication should be continued at the maintenance dose for several weeks after regular bowl habit it established, then the dose reduced gradually
If movicol paediatric plain doesn’t lead to disimpaction after 2 weeks a stimulant laxative should be given
How is involuntary soiling in children treated?
Involuntary soiling is commonly due to faecal loading in the rectum. You carry out disimpaction regime followed by regular laxatives. Encouragement by family and health professionals is essential as relapse is common and psychological support is sometimes required
Which test is diagnostic of Hirschsprung’s disease?
Rectal biopsy is the diagnostic test (tissue is diagnosed under the microscope for the absence of ganglionic cells).
This may also be combined with a barium enema or anorectal manometry
What is the most common causative organism of gastroenteritis in the UK?
Rotavirus
What are some bacterial causes of gastroenteritis?
How may each present?
How common is bacterial gastroenteritis in the UK?
Campylobacter - SEVERE abdominal pain
Shigella - blood, pus, fever, tenesmus
Chloera and E.coli - quickly dehydrating diarrhoea
What protozoal organisms can cause gastroenteritis?
Giardia
Cryptosporidium
Clinically assessing dehydration in children is difficult - what is the most accurate measure?
Change in weight
This can, however, be difficult f the child has not recently been weighed or if you are unsure whether they were wearing clothes when they were weighed
What signs may be seen on examination of a patient with clinical dehydration?
What percentage of body weight are the likely to have lost?
Eyes - sunken, Tachycardia, Tachypnoea, decreased urine output, irritable, dry mucous membranes, looks ill or deteriorating, reduced skin turgor
5-10%
What signs may be seen on examination of a patient with shock?
What percentage of body weight are they likely to have lost?
Hypotension, tachycardia, tachypnoea, decreased cap refill, cold peripheries, pale in colour or mottled rash, decreased urine output, sunken eyes, may be unconscious, looks ill or deteriorating, reduced skin turgot
Usually >10%
Explain how hyponatraemic dehydration may arise.
What are the complications of hyponatraemic dehydration?
In what circumstances does it most commonly occur?
If a child is drinking a lot of water then they net loss of sodium is more than the loss of water. This leads to a shift of water from extracellular to intracellular compartments. This can cause the brain to swell (cerebral oedema) and can lead to seizures.
It occurs more commonly in underdeveloped countries where children are more likely to be malnourished
What is hypernatraemic dehydration?
When does it arise?
What are the complications?
How may it present?
–
When is a stool culture indicated in the investigation of gastroenteritis?
If there are signs of sepsis If the patient has blood or mucus in their stool If diarrhoea has not improved by day 7 If they are questioning the diagnosis If the child is immunocompromised If there has been recent foreign travel
When are antibiotics indicated in gastroenteritis?
- If there is suspected or confirmed sepsis
- Extra-intestinal spread of bacterial infection
- Salmonella gastroenteritis if aged under 6 months
- Malnourished/immunocompromised children
- Specific bacterial or protozoal infections
If antibiotics are started a blood culture should be taken first
What is the mainstay of management of gastroenteritis?
Prevention or correction of dehydration
This may be done via oral rehydration solution and encouraging fluid intake or in the cases where patients are continually vomiting/deteriorating/in shock IV fluids
What is the most likely cause is a child presents with projective vomiting in the first few weeks of life?
Pyloric stenosis
What is gastro-oesophageal reflux?
What is it caused by in infants?
What other factors contribute to GOR in infants?
Involuntary passage of stomach contents into the oesophagus
In infants it is caused by an functional immaturity of the lower sphincter combined with that fact that infants spend a lot of time horizontally, mainly have liquid diet and also have a short intra-abdominal length.
By what age does most GOR resolve by?
What is this thought to be due to?
Usually resolves by the age of 12 months
This is thought to be due to maturation of the lower sphincter, increased solid diet and more time sitting up
When is gastro-oesophageal reflux termed gastro-oesophageal reflux disease?
When there are complications e.g:
Faltering growth (failure to thrive) due to severe vomiting
Oesophagitis (which may present as haematemesis)Recurrent pulmonary aspiration resulting in recurrent pneumonia, cough or wheeze or apnoea in preterm infants
Dystonic neck posturing (Sandifer syndrome)
Life threatening events
Which children is gastro-oesophageal reflux DISEASE more common in?
- Children with cerebral palsy or other neuro-developmental disorders
- Preterm infants (especially those with bronchopulmonary dysplasia)
- Following surgery for oesophageal atresia or diaphragmatic hernia
When may investigations be indicated for GOR?
What investigations?
If the child is suffering from complications
Investigations include:
- 24 hour pH monitoring
- 24 hour impedence monitoring
- Endoscopy with oesophageal biopsies (to look for oesophagitis)
How is uncomplicated GOR managed?
Adding thickening agents to foods and changing feeds to more frequent, smaller feeds
General advise e.g advise regarding position during feeds - 30 degree head-up
Ensure infant is not being overfed (as per their weight)
Trial of alginate therapy (gavison). (Alginates should not be used at the same time as thickening agents)
