Gastroenterology Flashcards
Features of colic?
2 weeks - 4 months old
Bouts of excessive crying and pulling-up of legs, often worse in evenings.
Passage of excessive flatus several times a day.
Occurs in up to 20% of infants.
Diagnosis and treatment of colic?
Exclusion - GORD, cow’s milk protein allergy, incarcerated hernia, intussusception, otitis media, UTI.
No treatment needed.
Definition of constipation?
Delay or difficulty in passing stools for more than 2 weeks.
How often do infants usually open bowels?
<6 months - 3 times a day
Decreases to once a day after 3 years.
Causes of constipation?
Functional non-organic constipation Idiopathic Medication - eg opiates May follow acute febrile illness Psychological Organic - Hirschprung disease, coeliac disease, food allergies, bowel obstruction, CF, cerebral palsy, spina bifida, spinal cord injury, hypothyroidism, hypercalcaemia, learning disabilities.
Red flags for constipation?
Starts in first few weeks of life
Delayed meconium passage (>48 hours)
Abdominal distention (and bilious vomiting)
Faltering growth - coeliac disease, hypothyroidism
Delayed walking or lower limb neurology
Child protection concerns.
Diagnosis criteria for constipation in child <1 year of age
2 or more of following:
Fewer than 3 complete stools per week (type 3 or 4). Hard large stool, Rabbit droppings (type 1)
Distress on passing stool
Bleeding associated with hard stool
Straining
Previous episodes of constipation. Previous or current anal fissure.
Diagnosis criteria for constipation in child >1 year of age
2 or more of following:
Fewer than 3 complete stools per week (type 3 or 4). Overflow soiling - loose, smelly.
Poor appetite that improves with passage of stool.
Maxing and waning of abdominal pain with passage of stool
Evidence of retentive posturing - typically straight legged, tiptoed, back arching posture.
Straining
Anal pain
Previous episodes of constipation.
Painful bowel movement and bleeding with hard stools.
Management of constipation?
Treat underlying cause
Do coeliac screen and TFTs.
Adequate fluid intake and encourage good toileting habits.
First line - Movicol Paediatric Plain (osmotic laxative)
Second line - add stimulant laxative eg Senna if Movicol doesn’t work after 2 weeks.
If movicol not tolerated, use lactulose.
Reduce dose gradually over months once regular bowel habits are established.
Psychological support.
Praising behaviour and toileting routine.
Long-term complications of constipation?
Scquired megarectum (reduced sensation of full rectum)
Anal fissures
Overflow incontinence
Behavioural problems - fear of defection, embarrassment of overflow
Causes of gastroenteritis?
Viral - rotavirus (most common), adenovirus, provirus, atrovirus.
Bacterial - staph, enterotoxic E. coli, cholera, enteroinvasive E. coli, enterohaemorrhagic E. coli, shigella, campylobacter jejune, salmonella enteritidis.
Protozoal - giardia lamblia, cryptosporidium.
Features of gastroenteritis?
Acute onset diarrhoea and vomiting
Abdominal pain and distension
Mild pyrexia
Invasive bacterial infection - fever, unwell, blood and mucoid stool
May have dehydration
Acidosis, hypokalaemia, hypocalcaemia, hypogylcaemia.
Investigations of gastroenteritis?
Stool culture if:
Stool is bloody or child septic or immunocompromised.
child has recently been abroad.
Diarrhoea not improved by day 7.
Uncertain about diagnosis of gastroenteritis.
FBC, haematocrit, U&Es, creatinine, glucose.
Management of gastroenteritis?
Usually self-limiting - 14 days.
No signs of dehydration - continue normal fluid intake, breast feeding and other milk feeds. Discourage fruit juices and carbonated drinks.
If clinical dehydration signs -
50ml/kg ORS over 4 hours, in addition to maintenance fluids of ORS.
Continue breastfeeding.
If evidence of shock - 20ml/kg normal saline bolus, then IV rehydration with normal saline adding 100ml/kg maintenance requirements.
Complications of gastroenteritis?
Hypernatraemic dehydration -
Due to high insensible losses of water
Shift of water into extracellular space from intracellular compartment.
Depression of fontanelle, reduced tissue elasticity, sunken eyes.
Cerebral shrinkage with rigid skull - jittery movements, increased muscle tone with hyperreflexia, altered consciousness, seizures, multiple small haemorrhages.
Hyponatraemic dehydration -
Drink large quantities of water
Shift of water from extracellular to intracellular areas
Increases brain volume - seizures.
Definition of failure to thrive?
Failure to gain adequate weight/growth during infancy at a normal rate for age.
Fall in one or more weight centile spaces, or weight below 2nd percentile of weight for age.
What happens to weight changes in first few days of life?
Weight loss after birth is normal, and most babies return to their birth weight by week 3.
Non-organic causes of failure to thrive?
Undernutrition
Child abuse
Organic causes of failure to thrive?
Inadequate calorie intake - vomiting, reflex, cleft palate, breast feeding poorly, bottle feeds too dilute, exclusion diets.
Inadequate calorie absorption - coeliac, giardia, food intolerance, short gut syndrome, pancreatic disease
Excessive calorie loss - vomiting, pyloric stenosis, protein-losing enteropathy.
Increased calorie requirements - chronic illness, thyrotoxicosis, malignancy
Failure of utilisation of absorbed calories - chromosomal abnormalities, prenatal growth failure, HPA-axis tumour, metabolic abnormalities.
Investigations of failure to thrive?
History - height of parents and siblings, pregnancy history, social history, birth history, dietary history.
Dietary assessment - age of weaning, milk feeding history, range and types of foods now taken, mealtime routines and eating and feeding behaviours, 3-day food diary.
Assess weight, height and head circumference.
General examination and developmental assessment.
Risk factors for GOR?
Preterm infants - especially if chronic lung disease
Cerebral palsy
Congenital oesophageal abnormalities
Causes of GOR?
Due to incompetence or inappropriately relaxed lower oseophageal sphincter
Features of GOR?
Vomiting or regurgitation following feeds
Some infants may have abdominal pain after feeds, worse on lying down.
Abdominal discomfort may lead to food refusal, poor sleeping, irritability, crying
Typically develops before 8 weeks and resolves at around 12-18 months.
Investigations of GOR?
Clinical diagnosis
Only needed if no response to treatment or in ?GORD
24 hours oesophageal pH monitoring in older children
Barium studies
Endoscopy
CXR, urine MC&S, iron studies, faecal occult blood.
Management of GOR?
Reassurance
Position head up at 30 degrees during feed
Infants sleep on backs
Trial of smaller and more frequent meals (child might be overfed)
Trial of thickened formula (rice starch, cornstarch etc)
Trial of alginate therapy eg Gaviscon - do not use alongside thickening agents.
Trial of PPI or H2RA if 1 or more of following:
- unexplained feeding difficulties eg refusing feeds, gagging or choking.
- Distressed behaviour
- Faltering growth
Prokinetic agents eg metoclopramide
Last resort - Nissan fundoplication
Complications of GOR?
Bronchospasm, apnoea, wheeze Recurrent aspiration pneumonia Oesophagitis Faltering growth Distress Frequent otitis media In older children - dental erosion may occur.
Causes of jaundice in childhood?
Infection - hepatitis A, EBV, malaria
Liver disease is rare in children but manifests as jaundice and hepatomegaly
Gallstones - post-hepatic jaundice
Wilson disease (copper build up in liver from food sources)
Liver injury due to drugs (sodium valproate, halothane, paracetamol/iron overdose
Jaundice with pallor suggests haemolysis (sickle cell, HUS, G6PD def.)
Investigations of jaundice in childhood?
Physical examination
Blood - FBC, TFTs, LFTs, U&Es, blood film
Urinalysis
Direct antiglobulin test (Coombs test for haemoylsis)
Cause of coeliac disease?
Damage to mucosa of proximal small intestine -> atrophy of villi and loss of surface area for absorption.
Risk factors for coeliac disease?
FH Caucasian Associated with other autoimmune disease (T1DM, thyroid disease) Downs syndrome Turners syndrome
Features of coeliac disease?
Faltering growth Steatorrhoea Abdominal distention Diarrhoea Iron or folate deficiency anaemia Fatigue Amenorrhoea Short stature Oral ulcers Dermatitis herpetiformis
Investigations of coeliac disease?
First line - IgA anti-endomysial IgA tissue transglutaminase (TTG), total IgA levels.
Gold standard - jejunal biopsy - see total or subtotal villous atrophy.
Management and complications of coeliac disease?
Avoid gluten
Increased risk of small bowel malignancy (especially lymphoma)
Osteoporosis.
What is Encopresis and soiling?
Voluntary or involuntary passage of stool beyond normal age for toilet training.
Normal bowel continence usually achieved by around 2-3 years (girls achieve it first).
Causes of encopresis and soiling?
Faecal retention with overflow incontience (most common)
Hirschsprung disease
Hypothyroidism
Megarectum
Neurological damage - cerebral palsy, learning difficulties
Psychological - neglect, stressors.
Diagnosis of encopresis and soiling?
Abdo and neuro exam
Plain AXR - foecal retention
TFTs, serum calcium, bicarb
Consider rectal biopsy (Hirschsprung’s disease)
Management of encopresis and soiling?
Treat underlying cause
Relieve any faecal impaction with laxatives
Set up regular toilet routine for child
Star charts
Dietary changes - increased fibre and hydration
Psychological management
Extra-intestinal features of IBD?
Poor growth, delayed puberty
Skin - erythema nodosum, pyoderma gangrenosum
Haemolytic - anaemia, increased risk of thrombosis
Skeletal - osteoporosis, arthritis, spondylitis
Eyes - anterior uveitis, episcleritis
Liver - fatty liver, cirrhosis, gall stones
Hands - clubbing
Intestinal causes of general malabsorption?
Coeliac disease, crohn’s disease, giardiasis, short gut syndrome.
Pancreatic causes of general malabsorption?
Chronic pancreatitis
Cystic fibrosis
Biliary causes of generalised malabsorption?
Biliary atresia
What is mesenteric adenitis? Features? Management?
Inflammation of mesenteric lymph nodes
Mimics appendicitis, but with no peritonitis or guarding on examination.
Often follows recent viral infection (URTI or gastroenteritis)
Self-limiting so requires no treatment - can give analgesia.
What is toddler diarrhoea? Management?
Chronic diarrhoea in otherwise healthy child.
Stools vary in consistency, often containing undigested food.
Resolves spontaneously by 3 years old.
Reassurance and dietary changes - increase fat, reduce fibre, reduce juice.
How to reduce risk of baby getting Hep B in Hep B positive mothers?
Hepatitis B vaccine at birth
Hepatitis B IG infusion
Then hep B vaccination again at 1 and 12 months of age.
Tested for HBsAb at 1 year to see if they have contracted hepatitis B.
Management of Hep C in children born to Hep C positive mothers?
Test babies to hepatitis C positive mothers at 18 months of age.
Breastfeeding is safe.
Treatment often not needed because child clears virus spontaneously, and does not usually cause any issues.
Yearly follow up with infectious disease for LFTs and hepatitis C viral load.
Treatment is with pegylated interferon and rivavirin.
