Gastroenterology Flashcards
Why are infants more prone to GORD
Immature involuntary relaxation of the lower oesophageal sphincter
lying on back
Liquid diet
What are the clinical signs of GORD
distress post feeding
vomiting and posseting
poor weight gain
What are the complications of GORD
due to regurgitation and sequelae: poor weight gain nausea, vomiting due to oesophagitis and sequelae: chest/ epigastric pain irritability/ feeding problems anaemia/ haematemesis dysphagia/ peptic stricture causing obstruction Respiratory symptoms: aspiration pneumonia (recurrent or chronic) bronchospasm/ wheezing (intractable asthma) apnoea/ cyanotic episodes/ ALTEs cough/ stridor/ hoarseness/ hiccoughs Neurobehavioural: Infant “spells” (including seizure-like events) Sandifer’s syndrome`
What investigations could you do for GORD
Mainly clinical diagnosis
24 hour oesophageal pH monitoring
barium studies
endoscopy
How would you treat GORD
reassure that 95% will go by the age of 18 months prescribe thickners (gaviscon and thick and easy) for feeds, H2 antagonists/PPIs prokinetic drugs like domperidone surgery may be required - Nissen fundoplication
What is pyloric stenosis
thickening of the pyloric muscle causing gastric outlet obstruction. presents between 2-7 weeks
What are the clinical features of pyloric stenosis
Non bilious 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 is the classic metabolic sign of pyloric stenosis
Hypochloraemic hypokalaemic metabolic alkalosis. This is due to loss of acidic gastric acid contents and the kidneys retaining hydrogen ions at the expense of potassium
How would you diagnose pyloric stenosis
Test feed with milk - look for gastric peristalsis, look for pyloric mass that looks like an olive in RUQ.
abdominal USS if in doubt.
Check U&Es for hypercholraemic metabolic alkalosis
how do you treat pyloric stenosis
correct fluid balance and electrolyte disturbance.
Ramstedt pyloromyotomy surgical procedure
What are the causes of gastroenteritis
rotavirus - most common
noravirus
astrovirus
Shigella e.coli campylobacter jejuni cholera - vibro cholerae typhoid - salmonella typhi
What are non infective cause of diarrhorea
pyloric stenosis intussusception acute appendicitis necrotising enterocolitis short gut syndrome hirschsprung disease diabetic ketoacidosis
clinical signs of gastroenteritis
Sudden change to loose watery stool and vomiting.
other members of family may have had similar
dehydration
bloody stool
usually preceeded by a viral illness
abdominal pain
fever indicates bacterial cause
What investigations would you perform for gastroenteritis
U&Es, plasma urea, glucose, electrolytes
stool culture if stool is bloody or child is septic or immunocompromised.
How would you manage gastroenteritis
Oral rehydration therapy/ fluids
antibiotics if bacterial
NO LOPERAMIDE
What is constipation
less than 1 stool a day in infants
and less than 3 stools a day in school children
Causes of constipation
hirschsprungs disease hypothyroidism coeliac disease spina bifida abnormal anorectal anatomy sexual abuse toilet training stress diet perianal crohns disease hypercalcaemia dehydration
clinical features of constipation
pain distended abdomen overflow diarrhoea pr bleeding anorexia fear of toilet straining loss of the feeling the need to defecate - often before overflow diarrhoea
Management of constipation
- diet and habit change
- Macrogol laxative (type of osmotic laxative) - e.g. movicol (polyethene glycol)
- stimulant laxative - senna +/- lactulose
- enema or manual evacutation
polyethene glycol for maintenance
What is appendicitis
inflammation from the appendix usually following obstruction (faecolith)
How to Dx appendicitis
abdominal USS
FBC and CRP
X ray
pregnancy test
Treatment of appendicitis
appendectomy
IV antibiotics
How would you treat an inguinal hernia
opioid analgesia and gentle compression - then referral to surgery
BUT if nonreducible then emergency referral to surgery due to risk of strangulation
How would you manage a crohns flare in children
Remission is induced with nutritional therapy, when
the normal diet is replaced by whole protein modular
feeds (polymeric diet) for 6–8 weeks. This is effective
in 75% of cases. Systemic steroids are required if
ineffective.
budesonide azathioprine then biologics long term enteral nutrition surgery
Definition of failure to thrive
failure to gain adequate weight or achieve adequate growth during infancy or early childhood’
• Fall across 2 centiles on growth chart
What is marasmus
Undernutrition plus discrepancy between height and weight (more than 3 SD below the median). Caused by lack of all nutrition. standard deviations below the median, Oedema is
not present. Skinfold thickness and mid-arm circumference are markedly reduced, and affected children are often withdrawn and apathetic.
corresponding to <70% weight for height, and a
wasted, wizened appearance.
What is kwashiorkor
Another manifestation of severe protein malnutrition, not necessarily lack of overall nutrition.
There is generalised oedema as well as severe wasting.
Because of the oedema, the weight may not be as severely reduced. In addition, there may be:
• a ‘flaky-paint’ skin rash with hyperkeratosis
(thickened skin) and desquamation
• a distended abdomen and enlarged liver (usually
due to fatty infiltration)
• angular stomatitis
• hair which is sparse and depigmented
• diarrhoea, hypothermia, bradycardia and hypotension
What is hirschsprungs disease
Absence of ganglion cells in the myenteric and submucosal plexuses in part of the large bowel
Risk factors for hirschsprung disease
downs syndrome
meconium ileus
male
family history
Clinical features of hirschsprung disease
usually intestinal obstruction in
the newborn period following delay in passing
meconium. In later childhood – profound
chronic constipation, abdominal distension and
growth failure
Diagnosis and management of hirschsprung disease
barium enema and Xray showing contracted narrow section of bowel
Suction rectal biopsy
treatment - colostomy then anastomosing normally innervated bowel
What is intersussception
telescoping of the bowel
How does intussusception present
paroxysmal, colicky pain, legs drawn up
with pallor, sausage shaped abdominal mass, redcurrant jelly
stool
How is intussusception diagnosed
abdominal USS Abdominal x ray
How is intussusception treated
Reduction is attempted by rectal air insufflation
unless peritonitis is present
• Surgery is required if reduction with air is
unsuccessful or for peritonitis.
What is meckel diverticulum
An ileal remnant of
the vitello-intestinal duct, a Meckel diverticulum,
which contains ectopic gastric mucosa or pancreatic
tissue.
How does meckel diverticulum present
Generally asymptomatic, but may present with
bleeding (which may be life-threatening),
intussusception, volvulus or diverticulitis.
How do you diagnose meckel diverticulum
A technetium scan will demonstrate increased uptake by
ectopic gastric mucosa in 70% of cases
How do you treat meckel diverticulum
surgical resection
What is infant colic
Paroxysmal, inconsolable crying or screaming
often accompanied by drawing up of the knees and passage of excessive flatus takes place several times a
day, particularly in the evening. Occurs <4 months
How is infant colic managed
The condition is benign but it is very frustrating and worrying for parents and may precipitate non-accidental injury in infants already at risk.
Support and reassurance should be given.
If severe and persistent, it may be due to a cow’s milk protein allergy or gastro-oesophageal reflux and an empirical 2-week trial of a whey hydrolysate formula followed by a trial of anti-reflux treatment may be considered.
What is the most appropriate way to confirm a diagnosis of pyloric stenosis
test feed. NG tube and aspiration to empty the stomach, small feed of dioralyte, examiners fingers placed just below the liver edge. palpable olive mass = stenosed pylorus
What would indicate cows milk intolerance
abdominal pain
chronic vomiting
eczema
flatulence, bloody stool, diarrhoea/constipation
What investigations are needed for cows milk intolerance
skin prick or specific IgE antibody testing
How is cows milk intolerance managed
cows milk elimination diet, hypoallogenic infant formula, mother to avoid cows milk
