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Paediatrics > Gastroenterology > Flashcards

Gastroenterology Flashcards

1
Q

Causes of prolonged neonatal jaundice

A 
Unconjugated: 
Breast milk jaundice
Infection
Haemolytic anaemia
Hypothyroidism
High GI obstruction
Critter-Najjar Syndrome

Conjugated:
Biliary atresia
Neonatal hepatitis syndrome - CF, inborn errors of metabolism, congenital infection
Intrahepatic biliary hypoplasia

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2
Q

Why is it important to investigate prolonged neonatal jaundice

A

To distinguish bw conjugated and unconjugated

Because conjugated means liver disease - need early detection and treatment to prevent permanent liver damage

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3
Q

What is biliary atresia

A

Progressive, idiopathic fibrosis and obliteration of extra and intrahepatic biliary tree

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4
Q

Clinical features of biliary atresia

A

Prolonged neonatal jaundice
Pale stools
Faltering growth
Hepatomegaly - late stage w significant progression
Splenomegaly - portal hypertension in late stage

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5
Q

Investigations for biliary atresia

A 
Raised conjugated bilirubin 
Normal LFTs
Liver uss
ERCP
Liver biopsy
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6
Q

Management of biliary atresia

A

Surgical intervention as soon as possible - earlier the intervention, better the outcome due to permanent liver damage
Hepatoportoenterostomy - loop of jejunum anastamosed to porta hepatis to bypass fibrosed biliary tree
Liver transplantation - Most common indication for liver transplantation

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7
Q

Normal frequency of defecation in neonates, infants, >1yo?

A

4/day in 1st week of life
2/day up to 1 year
1/day after 1 year

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8
Q

Definition of constipation

A

Infrequent passage of stools leading to 1 or more of: painful defecation, overflow incontinence, rectal fecal impaction, active defecation avoidance behaviour

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9
Q

Red flag clinical features of constipation

A

Failure to pass meconium within 24 hrs of life
Faltering growth/growth failure
Gross abdominal distension
Abnormal lower limb neurology or deformity
Sacral dimple, naevus/hairy patch/central pit over spine
Absent/ectopic anus
Perianal bruising of fissures
Perianal fistulae, abscess, fissures

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10
Q

Causes of constipation

A 
Functional - majority
Hirschsprung disease
Anorectal anomaly
Anal sexual abuse 
Hypothyroidism, coeliac 
Lumbosacral pathology
Spina bifida occulta
Crohn’s disease
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11
Q

Pathophysiology of constipation

A

Combination of painful defecation and sufficient rectal capacity to withhold stools

  1. Hard stools produced - low fibre diet, low hydration, excessive colonic transit time allowing water reabsorption
  2. Pain on passing stool and Learned sphincter contraction
  3. Increasing delays bw defecation, enlargement of stool volume in rectum
  4. Increase in size of rectum
  5. Increase in pain and fear
  6. Overflow incontinence - rectum becomes overdistended, loss of feeling the need to defecate, involuntary soiling occifsndue to contractions of full rectum inhibit internal sphincter, leading to overflow with passage of softer stool around retained hard stool
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12
Q

General Management of constipation

A

Coeliac screen and TFTs

Dietary modification - fluid intake, fibre intake

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13
Q

Management of constipation with no impaction

A

Dietary modification
1. Macrogol laxative: polyethylene glycol + electrolytes (movicol) Low dose regimen
2. Stimulant laxative: senna
Maintenance: minimum 6month laxative therapy - PEG

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14
Q

Management of constipation with impaction

A

Education:
soiling is involuntary, recovery of normal rectal size and sensation achieved but takes long time, long term use of laxatives is safe
Dietary modification no benefit, fibre not helpful
Behavioural modification: star chart for motivation p
Disimpaction:
1. Polyethylene glycol 3350 + electrolytes disimpaction regimen
2. + stimulant laxative: senna, sodium pocosulphate
Maintenance:
osmotic laxative at least 6 moths until regular bowel movements achieved

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15
Q

What is disimpaction regimen

A
  1. Movicol given in escalating dose over 1-2 weeks or until impaction resolves
  2. Stimulant laxative If unsuccessful
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16
Q

What is the maintenance treatment for constipation

A

Polyethylene glycol for at least 6 months
To ensure regular pain free defecation
Dose reduced in response to improvement in stool consistency and frequency

17
Q

Management of relapse of constipation

A

Disimpaction regimen:
Early aggressive and prolonged use of laxatives
Ensure passage of large soft stool once a day

18
Q

Define Hirschsprung disease

A

congenital condition characterised by partial or complete colonic functional obstruction associated with Absence of ganglion cells from myenteric and submucosal plexuses

19
Q

Location of Hirschsprung disease

A

At rectum and extends proximally
Rectosigmoid - 75%
Entire colon - 10%

20
Q

Pathophysiology of Hirschsprung disease

A

Absence of ganglion cells and presence of hypertrophic nerves and increase in acetylcholinesterase
Uncoordinated contraction of affected bowel leads to spasms and tonic contraction
Partial or total functional colonic obstruction

22
Q

Clinical features of Hirschsprung disease

A

Neonate:
failure to pass meconium first 24 hrs, distension, bilious vomiting
Explosive passage of liquid stools on PR exam
Hirschsprung enterocolitis

Childhood:
profound chronic constipation, distension, growth failure

23
Q

Investigations for Hirschsprung disease

A

AXR - colonic distension

Contrast enema - non-distended aganglionic portion, distended proximal Bowel

24
Q

Diagnosis of Hirschsprung disease

A

Suction rectal biopsy - absence of ganglion cells + presence of large acetylcholinesterase-positive nerve trunks

26
Q

Management of Hirschsprung disease

A

Initial colostomy and anastamosis of normally innervated bowel to anus

27
Q

Causes of vomiting in infants

A 
GORD 
Feeding problems - overfeeding 
Infection: gastroenteritis, respiratory, otitis media, whooping cough, urinary tract, meningitis
Intestinal obstruction: pyloric stenosis, atresia, intussusception, malrotation, volvulus, hernia, Hirschsprungs 
Food allergy and intolerance
Eosinophillic oesophagitis 
Inborn errors of metabolism
Congenital adrenal hyperplasia 
Renal failure
28
Q

Causes of vomiting in preschool children

A

Infection: gastroenteritis, Resp/otitis media, urinary tract, meningitis, whooping cough
Bowel obstruction: intussusception, malrotation, hernia, volvulus, foreign body
GI: appendicitis, coeliac disease, inborn errors of metabolism
RICP
GU: renal failure, testicular torsion

29
Q

Causes of vomiting in school children

A

Infection: gastroenteritis, Resp, pyelonephritis, sepsis, meningitis
GI: peptic ulceration w H pylori infection, appendicitis, coeliac
GU: pregnancy, testicular torsion, renal failure
Metabolic: alcohol, drugs, DKA
RICP
Migraine
Anorexia nervosa, bulimia

30
Q

Red flags of vomiting in children

A 
Bilious vomiting - obstruction 
Projectile vomiting at 2-8 weeks - pyloric stenosis 
Haematemesis 
Vomiting at end of paroxysmal coughing - whooping cough 
Abdominal pain - surgical abdomen 
Abdominal distension - obstruction 
Hepatosplenomegaly 
Bulging fontanelle, seizures - RICP 
Severe dehydration, shock - infection 
Faltering growth - GORD, coeliac
31
Q

What is posseting and regurgitation?

A

Posseting - non-forceful, small amounts of return of milk that accompanies return of swallowed air
Regurgitation - non-forceful return of milk, that is larger and more frequent

32
Q

Why is GORD common in infancy?

A

Functional immaturity of lower oesophageal sphincter
Predominantly fluid diet
Mainly in horizontal posture
Short intra-abdominal length of oesophagus

33
Q

Prognosis of GORD

A

benign - Mostly Resolves spontaneously by 12 months

Some develop complications and need treatment

34
Q

What are complications for GORD?

A 
Faltering growth 
Oesophagitis 
Recurrent aspiration - pneumonia 
Dystonic neck posturing - Sandifer Syndrome: GORD w spastic torticollis and dystonic body movements 
Apparent life-threatening events
35
Q

What is torticollis

A

Abnormal, asymmetrical neck posturing due to neck dystonia

36
Q

Clinical features of GORD

A

Regurgitation
Vomiting in absence of other symptoms
Faltering growth - Poor weight gain
Oesophagitis - Haematemesis, discomfort on feeding, iron deficiency anaemia
Aspiration - pneumonia, cough, wheeze, apnoea

37
Q

Management of GORD

A
  1. Parental reassurance, small frequent feeds
  2. Feed thickeners: carobel, gaviscon
  3. PPI/H2: Omeprazole, Ranitidine - severe w complications
  4. Enteral tube feeding - faltering growth w failed medical mx
  5. Nissen fundoplication - failed medical w aspiration or life threatening events

Paediatrics (15 decks)

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