Gastroenterology Flashcards
What is gastro-oesophageal reflux disease?
Symptoms or complications resulting from reflux of gastric contents into the oesophagus or beyond
Why might GORD symptoms be worse at night?
Because of vagal stimulation causing upper oesophageal relaxation
What condition can predispose to GORD?
Hiatus hernia
What cancer can GORD predisposed to and why is this?
Oesophageal cancer either Adenocarcinoma or squamous cell
because the gastric contents of the damages the mucosal epithelial cells and causes oesophagitis
What are risk factors of GORD?
Family history of heartburn
obesity
increased age
hiatus hernia
What are the symptoms of GORD?
name the red flag symptoms of GORD?
Heartburn tightness in chest regurgitation asthma -like symptoms with cough burping
dysphasia
bloating
early satiety
what is the initial investigation of GORD?
A PPI trial of eight weeks and then check for improvement
Following a PPI trial there is no improvement in the patient’s GORD symptoms, what is the next line investigation?
when else would you want to order this investigation for GORD?
OGD endoscopy
if there are any red flag symptoms
What sign may you see on endoscopy that is a precursor to oesophageal cancer?
Barrett’s oesophagus showing cellular metaplasia
What is the management plan with GORD?
Continue PPI (up to x2 doses a day)or have surgery if that is possible
if there is a nocturnal component ranitidine H2 agonist can be used
what is oesophageal cancer?
Mucosal lesions originating in the epithelial cells lining the oesophagus either adenocarcinoma or squamous cell carcinoma
What other two main causes of oesophageal cancer?
Gastro-oesophageal reflux disease and Barrett’s oesophagus
high BMI with an unclear mechanism
What are the risk factors associated with oesophageal cancer?
GORD High BMI male Tobacco use excess alcohol use family history diet low in fibre
What is the main presentation of oesophageal cancer?
Dysphasia it is usually a late presentation with two thirds of the oesophagus occluded
painful swallow and weight loss
What investigation is required to diagnose oesophageal cancer?
what other investigations useful?
OGD with biopsy
and metabolic profile since cancers are usually advanced
What other cancers can cause dysphasia?
Mediastinal cancers :
lung
lymphatic inc. non-Hodgkin’s lymphoma
thymoma
What is oesophageal achalasia?
A disorder of unknown aetiology characterised by aspirations and insufficient lower oesophageal sphincter relaxation due to loss of neurons in the oesophageal myenteric plexus - aucherbach plexus
What is the presentation of oesophageal achalasia?
Aspirations when eating
dysphasia
changing posture when swallowing to help
retro sternal pain and pressure with regurgitation
a gradual weight loss - rapid weight loss indicates malignancy and is a red flag
heartburn is not usually present!
What investigations would you use for oesophageal achalasia?
Upper GI endoscopy + barium swallow
oesophageal manometry
What would you see on an upper GI endoscopy for oesophageal achalasia?
Retained saliva with frothy appearance
What would barium swallow show for oesophageal achalasia?
Delayed swallow with a tapered dilated appearance
What is the management of oesophageal achalasia?
Surgical or pharmacological with Botox and possibly gastrostomy
pharmacological therapy = isorbatide denigrate or CCB (nifiedepine)
What is systemic scleroderma?
Systemic scleroderma is a multisystem autoimmune disease characterised by functional and structural abnormalities of small blood vessels fibrosis of the skin and internal organs as well as the production of autoantibodies
Describe the pathophysiology of systemic scleroderma?
Has a strong genetic component and immunological components (ANA positive in 90%)
immune system activation leading to endothelial cell activation and damage of the endothelium
fibroblasts because increased collagen deposition
activated T cells promote disease by making for pro fibrotic cytokines and down regulating the inhibitory cytokines
What is the presentation of systemic scleroderma in the hands and feet?
Hand and feet swelling
skin thickening
functional loss
What is the presentation of systemic scleroderma in the GI tract?
Heartburn
reflux
bloating
faecal incontinence
What is the presentation of systemic scleroderma in the respiratory system?
dysnopea
dry crackles at bases of lungs
What is the presentation of systemic scleroderma in the vascular system?
Raynaud’s disease
pits and ulcers at the tips of fingers from ischaemia
What investigations are required in oesophageal scleroderma?
Serum antibodies:
ANA - most common 90%
anti-SCL
anti- rna polymerase
U+E (renal involvement) urine microscopy (to check the renal crisis, proteinuria)
ESR and CRP are usually normal
pulmonary function tests (interstitial lung disease)
chest x-ray (interstitial lung disease)
ECG (arrhythmias which show cardiac involvement)
echocardiogram (yearly test for pulmonary hypertension)
barium swallow ( decreased peristalsis)
What is the management of oesophageal scleroderma?
Manage any heartburn symptoms with PPI
increased motility using erythromycin or domperidone (pro kinetics)
What is a common complication of oesophageal scleroderma?
what is the treatment?
Bacterial overgrowth is causing diarrhoea and weight loss
treat with cephalexin and metronidazole
What is classed as a peptic ulcer
A breakdown in the mucosal lining of the stomach and duodenum reaching the submucosa
an ulcer is classed at 5 mm anything smaller or more shallow is considered an erosion
What are the protective factors of the stomach for peptic ulcer disease?
Prostaglandins
mucus
HCO3
mucosal blood flow
What are the damaging factors of stomach for peptic ulcer disease?
Gastric acid
Patsy
H. pylori
NSAIDs
What are the symptoms of peptic ulcer disease?
Upper epigastric pain exacerbated by eating (gastric) or 2 to 3 hours after eating (duodenal)
then maybe posterior radiation of pain indicating penetration to the pancreas
epigastric tenderness
what would be your first line investigations for peptic ulcer disease?
Urea breath test or stool antigen test for H pylori
but in those >55y you may consider going straight to endoscopy
FBC - check for blood loss (microcytic anaemia)
what is the management of an active bleeding peptic ulcer?
Stop any NSAIDs
endoscopy to stop the bleeding plus PPIs
What is the management of pt with peptic ulcer which has no bleeding but is positive for H. pylori?
Triple therapy of omeprazole clarithromycin and metronidazole
what would you do if the H pylori Cannot be eradicated?
Long-term acid suppression with PPI and H2 antagonists if needed
How to manage patient which has a peptic ulcer with no bleeding and negative H. pylori?
Treat the underlying cause and give PPIs treatment usually lasts 4 to 8 weeks
what is the management of peptic ulcer if it isInduced by NSAIDs?
Misoprostol
What all gastro-oesophageal varicies?
Related collateral blood vessels that develop as a consequence of portal hypertension usually due to cirrhosis
What is the pathophysiology behind gastro-oesophageal varices?
Increased hepatic vein pressure occurs as liver function deteriorates (usually due to alcohol or hepatitis B) causing the dilation of blood vessels
what conditions can indicate a presence of gastro-oesophageal varices?
Alcoholic hepatitis
hepatitis B or C
cirrhosis
hepatic encephalopathy
What are the symptoms of gastro-oesophageal varices?
Symptoms of cirrhosis: ascites jaundice spider angiomas and caput medusa haemoptysis or haematochezia
What investigations would you do to diagnose varices?
And OGD
What investigations should you run on someone who has gastro-oesophageal varices?
full blood count (check for bleeding and thrombocytopenia indicate portal hypertension and splenomegaly)
coagulation profile (assesses function of liver but also risk a bleed)
hepatic venous pressure gradient (assesses portal hypertension)
blood type and crossmatch (in case of life-threatening bleed)
you should also attempt to find the cause of the cirrhosis of this has not been established:
serum LFTs ( AST ALT Alk Phos Billi all ++)
hepatitis B antigen – HBsAg
Hepatitis C Ig - HCV IgG
How would you treat an acute haemorrhage caused by rupture of gastro-oesophageal varices?
Supportive therapy ABCDE
and vasoactive drugs (vasopressin or another pressin)
endoscopic therapy
consider using BBlocker propranolol as adjunct
What procedure should be performed in anyone who has an acute haemorrhage caused by gastro-oesophageal varices and is high risk of getting it again?
Trans-jugular intrahepatic Porto systemic shunt aka tips
How would you treat large varices which are not bleeding?
Binding and ligation with a non-selective beta-blocker
how would you treat small varices which are not bleeding?
Beta-blocker and endoscopic surveillance
How would you treat someone who has portal hypertension but has not yet developed varicies?
Endoscopic surveillance and vasoactive drugs
how would you treat someone Who has cirrhosis but has not yet developed varices or portal hypertension?
Endoscopic surveillance
What is a Mallory Weiss tear?
A tear or laceration in the oesophagus caused by a sudden increase in the pressure gradient
it is usually spontaneous and self-limiting
What is the most common location for a Mallory Weiss tear?
Near the gastro-oesophageal junction
What are the risk factors for Mallory Weiss tear?
Conditions predisposing to vomiting retching straining including from coughing chronic cough hiatal hernia endoscopy alcohol with excessive vomiting
what investigations are required in a Mallory Weiss tear?
Full blood counts
OGD
if severe crossmatch and save
plus…
urea and creatinine – monitoring severity please
a T assessing for liver disease
PT/INR consider anticoagulation
chest x-ray normal in an uncomplicated Mallory Weiss tear
How would you manage a Mallory Weiss tear?
ABCDE management
when giving fluids make sure bilateral IV
if severe intubate and give phytomenadione IV aka Vit K
endoscopic clip placement +/- adrenaline - always before 24h even if not severe
plus…
pantoprazole and promethazine (antiemetic)and erythromycin (contracts stomach) pre surgery
What is gastritis?
The histological presence of gastric mucosal inflammation
What is gastropathy?
Lesions characterised by minimal or no inflammation
What are the causes of gastritis?
H. pylori (causes acute or chronic non-erosive gastritis)
erosive (NSAIDs or alcohol induced)
stress induced (in the critically ill on mechanical ventilation> 48 hours or coagulopathy)
autoimmune
phlegomonus (S. aureus, strep, e coli)
What are symptoms of gastritis?
Dyspepsia
epigastric discomfort
nausea and vomiting
loss of appetite
lack of red flags
What is the management of gastritis caused by H. pylori?
Triple therapy of lansoprazole clarithromycin and metronidazole
What is the management of gastritis caused by erosive causes?
Discontinue exposure use PPI or H2 antagonist
What could you give to someone who is at risk of gastritis?
Ranitidine
misoprostol
What type of cancer is stomach cancer?
adenocarcinoma
What are some risk factors for developing stomach cancer?
NHS anaemia H. pylori 50 to 70 years family history smoking
What are symptoms of stomach cancer?
Epigastric pain – an early symptom lymphadenopathy – see virchows node nausea dysphagia lower GI bleeding and Melina
What investigations are necessary for stomach cancer?
Endoscopy and biopsy
What is the management of stomach cancer?
Pre-and post op chemotherapy or radiotherapy
surgery
consider immunotherapy
What is viral gastroenteritis?
Acute inflammation of the lining of the stomach and intestines caused by an enteropathic virus
What viruses cause gastroenteritis?
norovirus
rotavirus
cytomegalovirus – significant in immunocompromised groups
What risk factors are associated with viral gastroenteritis?
Exposure to contaminants or close contact with someone infected
living in close quarters such as care homes
Poor hygiene
extremities age – causes more severe dehydration
comorbidities
immunocompromised groups
when would you need to investigate viral gastroenteritis?
If there is severe volume depletion
What investigations would you perform for viral gastroenteritis?
Full blood count - is the white cell count elevated indicating a bacterial or parasitic infection are the signs of anaemia indicating a chronic cause such as IBD
U+E- check renal function
consider a stool sample for culture
When would you perform a stool culture for patients with viral gastroenteritis?
Blood or pus installs high fever diarrhoea lasting two weeks history of foreign travel persistent antibiotic use
What is management of viral gastroenteritis?
Dehydration is mild-to-moderate: oral rehydration salts severe: IV fluids
antiemetics may be used but antidiarrhoeal should not routinely be used
What is IBS?
A chronic condition characterised by abdominal pain and bowel dysfunction without the presence of structural abnormalities
What are risk factors for developing IBS?
Female
previous enteric infection
history of physical or sexual abuse
What symptoms does IBS carry?
Cramping abdominal pain pain in lower/middle abdomen mild/severe pain altered bowel habit relief of symptoms on defecation abdominal bloating/distension mucus-y stool
How would you diagnose IBS?
IBS would be a diagnosis of exclusion, a history of typical symptoms is suggestive of IBS
differentiate from coeliac and IBD
stool cultures will be negative
What tests differentiate IBS from coeliac disease?
Anti-endomyseal +ve in coeliac
Anti- tTG antibodies +ve in coeliac
what tests would differentiate from IBD?
Faecal calprotectin
flexible sigmoidoscopy or colonoscopies
How do you treat IBS?
Management must be symptomatic
if constipated - lactulose
if diarrhoea – loperamide (antidiarrhoeal)
pain or bloating – dicycloverine (antispasmodic)
CBT or hypnotherapy is also useful
high-fibre diets and eliminating triggers
SSRIS such as citalopram
What is Crohn’s disease?
and inflammatory bowel disease causing transmural inflammation of the GI tract which can involve any or all of the GI tract
What histopathological findings would you find for crohns disease?
Transmural inflammation
skip lesions
can be anywhere in the GI tract
where Is most common for Crohn’s disease to occur?
Terminal ileum and peri-anus
What is the presentation of Crohn’s disease?
Abdominal pain prolonged diarrhoea perianal lesions fatigue weight loss abdominal tenderness
can have some mucous blood and purse install but this is not a typical presentation
fever from inflammation or as a complication
What are perianal lesions?
Skin tags
fistula
What are the more common complications of Crohn’s disease?
Obstruction – from fibrosis
perforations and fistula – due to sinus tracts caused by inflammation
What investigation is diagnostic for Crohn’s disease?
Flexible sigmoidoscopy (colonoscopies) with biopsy and histological examination
A patient presents with symptoms of IBD disease what are the first line investigations you would do as a GP?
FBC – may find anaemia and increased white cell count
iron studies, B12, folate
comprehensive metabolic panel albumin, calcium, magnesium, phosphate all reduced
CRP, ESR
Faecal calprotectin - raised, marker of bowel inflammation
you may want to do a stool test
you may consider imaging from:
x-ray (obstruction)
CT or MRI (lesions, bowel thickening, accesses/fistulae)
How would you manage crohns ?
Budesonide (steroid) or 5 ASA therapy
Azothioprine + CS
methotrexate and folic acid
biologics and CS reduction
What is ulcerative colitis?
an inflammatory bowel disorder characterised by its involvement of the rectum and extending approximately
What are the risk factors forInflammatory bowel disease?
Ages 15 – 40 or 60 – 80
family history
white ancestry
What are the symptoms of ulcerative colitis?
Most common symptom is rectal bleeding and blood in stool
diarrhoea abdominal pain malnutrition and weight loss are more common in Crohn’s disease
What vitamin deficiencies occur in ulcerative colitis?
Vitamins ACD he
beta-carotene, magnesium, zinc
What would imaging show for Crohn’s disease?
x-ray (obstruction)
CT or MRI (lesions, bowel thickening, accesses/fistulae)
What would imaging show for ulcerative colitis?
dilatoed loops with air or fluid,
free air suggests a perforation dilation of loops over 6 cm suggests toxic megacolon
What are the histopathological findings of ulcerative colitis?
Only rectal involvement with continuous and uniform diffuse erythema biopsy shows : mucosal involvement mucosal depletion absence of granulomata anal sparing
What is the management for ulcerative colitis?
mesalazine (mainstay for remission)
hydrocortisone or pred +/- tacrolimus
IV hydrocortisone (in acute flare)
In recurrent disease:
Thiopurines (azothioprine)
Biologics/TNF a inhibitor (infliximab)
colectomy
What is fulminant ulcerative colitis?
Sudden and extensive inflammation which can be life-threatening
What are symptoms of fulminant ulcerative colitis?
6+ bloody stools daily
evidence of toxicity:
- fever
- tachycardia
- anemia
- ++ESR
what is the management of fulminant ulcerative colitis?
Investigate with ultrasound and emergency colonoscopies
IV corticosteroids and IV fluids
a stable enough start infliximab and cyclosporin if not rush for a colectomy
What is toxic megacolon?
A potentially lethal complication of acute colitis with total or segmental non-obstructive chronic distension associated with systemic toxicity
What are the risk factors for toxic megacolon?
Inflammatory bowel disease infected colitis immunosuppression discontinuation of IBD medication anti-motility agents
How does toxic megacolon present?
Fever tachycardia hypotension
abdominal pain tenderness and dissension
diarrhoea
mental status changes
What investigations should you perform?
Abdominal x-ray – die rotation of over 6 cm
stool studies
full blood count (+white cell count - haemacrit)
serum electrolytes (- magnesium and potassium due to volume loss)
serum albumin (- due to volume last)
serum lactic acid if ischaemic
What is the initial management of toxic megacolon?
ABCDE
Nil by mouth IV fluid recess
broad-spectrum antibiotics
NG decompression
rancour myosin – if presumed CDF
IV hydrocortisone – history of inflammatory colitis
surgery if no improvement after 72 hours
What is mesenteric ischaemia?
An umbrella term for disorders which cause a decrease in blood flow to the GI tract
it can be acute or chronic, occlusive or non-occlusive, transient or fulminant
What are the risk factors for mesenteric ischaemia?
Old-age smoking history however quite liberal state atrial fibrillation myocardial infarction structural heart disease history of vasculitis
What is a presentation of mesenteric ischaemia?
Abdominal pain Melena – due to mucosal sloughing diarrhoea abdominal tenderness weight loss
abdominal bruit may be heard
What is a first-line diagnostic test for mesenteric ischaemia?
CT
What would a CT show for mesenteric ischaemia?
Thickening
dilatation
pneumatosis intestinalis
thumbprint sign – showing mucosal oedema or haemorrhage
which artery does mesenteric ischaemia usually affect?
Superior mesenteric artery
What is diverticular disease?
A herniation of the mucosa and submucosa through the muscular layer
it is any clinical state caused by symptoms relating to colonic diverticula
symptoms ranging from asymptomatic to severe uncomplicated
What is the most common complication of diverticular disease?
Diverticulitis
What is diverticulitis?
Inflammation of a diverticulum which may be caused by infection
What are complications of diverticular disease?
(Diverticulitis)
segmental colitis lower GI bleed abscess perforation and peritonitis fistula obstruction
What are risk factors of diverticular disease?
Low dietary fibre
anyone over the age of 50
What is the presentation of diverticular disease?
It is usually asymptomatic until there’s diverticulitis
but may have some IBS type symptoms of bloating and constipation
What are the symptoms of diverticulitis?
Lower quadrant abdominal pain
fever
guarding
leucocytosis
What are the diagnostic tests for diverticular disease?
Contrast anime shows diverticulitis abscesses
if unclear go to sigmoidoscopy
how would you Diagnose acute diverticulitis?
CT with contrast
How would you treat diverticular disease?
If asymptomatic no treatment
if symptomatic:
high fibre diet and supplements
any symptoms of bacterial infection require broad-spectrum antibiotics
How would you manage symptomatic diverticulitis?
Analgesia oral antibiotics (moved to IV if not getting better)
What is appendicitis?
An acute inflammation of the veniform form appendix most likely caused by obstruction of the lumen of the appendix
what causes the obstruction in appendicitis?
faecolith
stool
infection
lymph drainage
What are the risk factors for acute appendicitis?
There are no real risk factors however:
child/teen
low dietary fibre
smoking
What is the presentation of appendicitis?
Constant made abdominal pain that moves to the right quadrant pain worse on coughing and movement tenderness at McBurney's point rebound tenderness may be present anorexia
nausea fever decreased bowel sounds on the right side
be aware of tachycardia as it’s a sign of perforation
What does tachycardia in a patient with suspected appendicitis indicate?
Perforation
What is the diagnostic test of appendicitis?
CT
What is the management of an uncomplicated appendicitis?
Appendectomy (adjunct IV antibiotics)
antibiotic only therapy for patients who wish not to have surgery
what is the management of Appendicitis complicated by perforation or abscess?
IV antibiotics appendectomy and supportive care
drainage may be necessary if there is an abscess
What are the three main types of hernia?
Umbilical
inguinal
hiatus
what is an umbilical hernia?
A defect of the interior wall fascia occurring when the umbilical ring fails to close and the peritoneal sack protrudes
What are the risk factors for an umbilical hernia?
Low birthweight
African or African-American ethnicity
What is the presentation of an umbilical hernia?
Presents at birth with a bolt at the umbilicus
becoming larger or tense during movement or crying
stretched skin
What features would you find on examination for an umbilical hernia?
easily reducible
on examination the ring of the fascia can be felt around the defect
If an umbilical hernia presents as a tender abdominal mass what does this mean?
It’s incarcerated
What is the management of an umbilical hernia?
First attempt reduction
asymptomatic and small:
observe and offer elective outpatient surgical repair otherwise move to ASAP surgical repair
What is an inguinal hernia?
The most common type of hernia
it is a protrusion of abdominal or pelvic contents through her dilated internal inguinal ring to the external inguinal ring
What is the presentation of an inguinal hernia?
Easily visible and palpable bulge
groin discomfort or pain if the hernia is bulging
groin mass
may be confused with pathologies of the testicles
If a patient presents the tender distended abdomen with absent bowel sounds who has had a past history of groin pain what could this be?
Strangulated hernia causing an acute abdomen
What investigations are necessary for an inguinal hernia?
Usually the diagnosis is clinical if you are uncertain and ultrasound scan of the groin or CT
What is the management of a strangulated inguinal hernia?
Surgery with IV/IM cephalexin prophylaxis if open repair
What is the management of a large or symptomatic hernia
Surgery unless a patient is nonsurgical then a truss can be worn (device that compresses over inguinal canal)
What is the management of a small asymptomatic inguinal hernia?
Observation
What is a hiatus hernia?
Protrusion of intra abdominal contents through an enlarged oesophageal hiatus of the diaphragm most commonly containing a portion of stomach
What are the risk factors for a hiatus hernia?
Anyone over the age of 50
obesity
previous GI procedure
intra-abdominal pressure increases
What is the presentation of a hiatus hernia?
Heartburn
regurgitation
GORD like
How do you diagnose a hiatus hernia?
A barium swallow
endoscopy
How do you treat a hiatus hernia?
PPI and lifestyle changes
surgical repair
if there’s obstruction resus and urgent surgical repair
What is large bowel obstruction?
Mechanical interaction occurring to the flow of the intentional contents it is a surgical emergency
What can cause large bowel obstruction?
Colorectal cancer
colonic Volvos
benign structure such as diverticular disease
foreign body
What are risk factors for large bowel obstruction?
older age female institutionalisation mental illness Megacolon
What is the presentation of large bowel obstruction?
Colicky abdominal pain
abdominal distension
tympanic handling
change in bowel habits no or very little faeces or flatus
rectal bleeding - indicates malignancy
abnormal bowel sounds can be increased frequency or absent in advanced disease
what does hard faeces on DRE in the context of large bowel obstruction mean?
Faecal impaction
What does an empty rectum mean in the context of a DRE in large bowel obstruction?
Proximal obstruction
Why should you perform a faecal occult blood in the context of large bowel obstruction?
To exclude barrel malignancy
what are symptoms of a Large bowel perforation?
Constant pain which is worsening
worse on movement or coughing or deep breathing
fever
abdominal rigidity – peritonitis secondary to perforation
What is a diagnostic test for a large bowl obstruction?
Plain abdominal x-ray
What is the first test you should do if you suspect perforation in large bowel obstruction
Erect chest x-ray
Apart from imaging what other tests are useful in large bowel obstruction?
Full blood count – WCC for infection anaemia in malignancy
serum electrolytes and renal function – check renal function
serum amylase – raised in intra abdominal events
you suspect abdominal perforation what investigations are indicated?
Chest X ray (USS abdominal if in unstable situation)
Septic screen
FBC, LFT and U+E
What is the management of large bowel obstruction?
ABCDE - consider blood products if theres coagulopathy catheter monitoring urinary output broad-spectrum antibiotics presurgery NG decompression! surgery
NO OPIATES
What is volvulus?
A loop of interesting twists around itself and its mesentery
causing a bowel obstruction
Where are volvulus common?
In the sigmoid or coecal
What classic sign is found on CT/x-ray for a volvulus?
a coffee or kidney bean shape
What are risk factors for a volvulus?
intestinal malrotation
enlarged colon
hirsprungs
adhesions form prev. surgery
What is a small bowl obstruction?
Mechanical disruption in the patency of the GI tract resulting in vomiting which may be pillars absolute constipation and abdominal pain
What are common causes in adults for small Bowel obstruction?
Previous surgery inguinal hernia – other hernias Crohn's disease intestinal malignancy appendicitis
what are common causes for children for small bowel Obstruction?
Appendicitis
inrucusseption
intestinal atresia
volvulus
What is the presentation of small bowel obstruction?
Failure to pass glasses or stool abdominal pain vomiting abdominal tenderness and distension if there's perforation peritonitis
there may be fever tachycardia and lethargy from inflammation and dehydration
What is the diagnostic investigation for small bowel obstruction?
CT abdominal
What is the gas distribution you would see on imaging in the bowels in a partial small-bowel obstruction?
Gas throughout the abdomen
What is the gas distribution you would see on imaging in the bowels in a complete small-bowel obstruction?
No distal gas and staggered air - fluid
What is the gas distribution you would see on imaging in the bowels in a complicated small-bowel obstruction?
Complicated by a perforation will be free air under the diagram
if complicated by ischaemia there will be thumb printing sign
What is the management of partial small-bowel obstruction?
Fluid recuss NG decompression antiemetic (ondesatron) antispasmodic (loperamide) if a more severe partial opiate analgesia
surgery if no change after 48 to 72 hours
What is the management of a complete small-bowel obstruction?
NG decompression
morphine analgesia
perioperative antibiotics
Laparotomy
if the candidate is nonsurgical then treat as a partial obstruction
what is an ileus?
The slowing of GI motility accompanied by distension in the absence of mechanical obstruction
What causes ileus?
It is something which occurs in response to physiological stress such as: surgery sepsis metabolic derangements GI diseases
What risk factors are associated with developing an ileus?
Abdominal surgery acute or systemic illness: sepsis MI pneumonia trauma metabolic derrangements
What is the presentation of an ileus?
Similar to that of obstruction but without its clinical features on examination
nausea and vomiting abdominal distension constipation discomforts abdominal cramping decreased or hypoactive bowel sounds
BUT.. no features of mechanical obstruction such as peritoneal inflammation, hernias, rebound tenderness
What is the diagnosis of an ileus?
what other investigation may you like to perform?
It is a diagnosis of exclusion of obstruction
abdominal x-ray is diagnostic (showing no specific gas pattern and diffuse distension)
Full blood count - rule out infection
What differences would you see on x-ray for an obstructed bowel versus an ileus?
Obstructed bowel will have little to no air distal to the obstruction whereas an ileus will have a diffuse non-specific gas pattern
What is the management of an ileus?
Nil by mouth and IV fluids
NG decompression if there is significant vomiting or distension
parenteral nutrition if symptoms lasting more than three days
What is peritonitis?
inflammation of the peritoneum
What can cause peritonitis?
Perforation of the GI tract - most common
local or systemic infection
leakage of non-infectious bodily fluids- blood gastric juice pancreatic enzymes (pancreatitis)
What is spontaneous bacterial peritonitis?
Inflammation of the peritoneum caused by leakage of infected ascitic fluid due to end stage cihrossis
What are the symptoms of peritonitis?
Abdominal pain Guarding rigidity rebound tenderness fever tachycardia altered mental state
What features does spontaneous bacterial peritonitis have that peritonitis does not have?
Spontaneous bacterial peritonitis Has all the same symptoms as normal peritonitis but with additional signs of ascites cirrhosis and diarrhoea caused by intestinal hyper mobility
What is the management of peritonitis?
Broad-spectrum antibiotics e.g. cephalexin or laparotomy
What investigations is it important to carry out in spontaneous bacterial peritonitis?
Check LFT And PT/INR
Ascitic fluid analysis gram staining culture – diagnostic
blood cultures may also be useful
What is the management of spontaneous bacterial peritonitis?
Broad-spectrum antibiotics IV
if there is a hypo renal syndrome (renal impairment) – IV albumin
large-volume paracentesis may be given
Is antibiotic prophylaxis indicated for people who have had spontaneous bacterial peritonitis?
Yes and a beta-blocker may also be added
What is the definition of obesity?
A chronic adverse condition due to excess body fat mainly determined by BMI
BMI over 30
What is classed as underweight (BMI)?
<18.5
What is classed as normal weight (BMI)?
18.5-24.9
What is classed as overweight (BMI)?
25-29.9
What is classed as obese (BMI)?
30-39.9
What is classed as extremely obese (BMI)?
> /= 40
How do you calculate BMI?
Weight (KG) / [height(m)]^2
What are some Hormonal causes of obesity?
PCOS
hypothyroidism
hyper- cortical-ism
insulinoma
What are some behavioural causes of obesity?
Sedimentary
large portions
habits
What is the physiology of leptin?
What role does leptin have in satiety?
An increase in ad oppose causes leptin to be released
leptin reduces appetite
adipose is used up
How is leptin affected in obesity?
There is leptin resistance
What is the physiology of ghrelin?
What role does ghrelin have in satiety?
Secreted by a stomach acting by the vagus nerve
acts centrally on the hypothalamus to increase appetite
What role does endocannabinoids have in satiety?
Increase appetite by affecting the central nervous system a.k.a. the hypothalamus
What role does T3 have in satiety? and how?
Increases appetite
hypothyroidism causes excess energy expenditure causing weight loss
What role do peptins have in satiety?
Decrease appetite and food intake centrally and on GI organs like the pancreas
What role does insulin have in satiety?
Decreases appetite centrally
What role does cholecystokinin have in satiety?
Decreases appetite centrally
What investigations may want to undertake in an obese individual?
SBC
lipid levels
LFT – check liver dysfunction caused by fatty liver
TFTs
ECG – check for heart disease
abdominal ultrasound scan – check for fatty liver disease
What pharmacological management can you offer an individual with obesity?
Orlistat - inhibits fat absorption
2ry = liraglutide - peptide like agonist
what are the criteria to be eligible for bariatric surgery?
BMI ≥ 40,
BMI ≥ 35 and at least one or more obesity-related co-morbidities
What type of cancer is colorectal cancer?
Majority are adenocarcinomas from epithelial cells
What is the most common location for large bowel cancer?
The:
What risk factors are associated with large bowel cancer/colorectal cancer?
Age- very rare under 40 APC gene mutation -a Polly process syndrome IBD obesity low fibre diet
What is the presentation of colorectal cancer?
Rectal bleeding change in bowel habits - increase frequency and loose stools hard mass on DRE anaemia weight loss
What is diagnostic for colorectal cancer?
What other tests should be performed?
CT colonography or colonoscopies with biopsy
-barium enema can also be used but it is less sensitive
in FBC showing anaemia is a red flag especially in older men or postmenopausal women
Describe the screening process for colorectal cancer?
Starts at 60 years old until 74
F IT testing done yearly
screening starts at 50 years if there is a positive family history of two first-degree relatives
In patients with IBD what is the process for screening for colorectal cancer?
Perform colonoscopy 10 years after diagnosis and then every five, three, one year depending on their level of risk
Who should you refer to 2 week wait in regards to colorectal cancer?
> 40 with unexplained weight loss or abdominal pain
50 with unexplained rectal bleeding
60 unexplained iron deficiency anaemia or changes in bowel habits
anyone with a positive FIT +/- Sx depending on age
anyone with a rectal or abdominal mass
anyone under the age of 50 with rectal bleeding and one other finding of: abdominal pain change in bowel habits weight loss iron deficiency anaemia
What are the causes of dietary diarrhoea?
Sugars dairy FODMAP gluten fatty foods Spicy foods caffeine
How do sugars cause diarrhoea?
stimulate water movement into the bowels causing loose stool
How does dairy cause diarrhoea?
Lactose can cause difficulty on digestions as an intolerance
What is the criteria for travellers diarrhoea?
Three or more unformed stools in 24 hours
plus one or more of:
- fever nausea vomiting cramps or bloody stools
during a trip abroad
What common pathogens cause travellers diarrhoea?
E. coli
Shigella
Campylobacter Jejuni
Salmonella
What are the differences in presentation between a bacterial and parasitic infection?
Parasitic infections cause persistent symptomsOver two weeks
bacterial usually lasts 3 to 5 days
What are the risk factors for contracting travellers diarrhoea?
<30y Prior travellers diarrhoea chronic disease immunocompromised travelling in hot and wet climates and endemic areas
What are indications for antibiotics in travellers diarrhoea?
Blood and fever
When would you do further testing for travellers diarrhoea?
If symptoms are severe or if antibiotics haven’t worked
What tests could you perform for travellers diarrhoea?
stool culture and sensitivity
+stool occult blood
+PCR
stool ova and parasite examination
What is the management for travellers diarrhoea?
Loperamide is used as long as there is no blood or fever which is an anti-motility drug to help cramping and diarrhoea
rehydration therapy
if symptoms are severe then use azithromycin
What commonly gives you travellers diarrhoea in terms of Food & Drink?
Ice and tapwater salad previously peeled fruits raw food unpackaged sauces and condiments Street vendors and buffets
When would prophylactic antibiotics be given for travellers diarrhoea?
For short-term critical trips or critically ill/immunocompromised patients with trips lasting less than three weeks
Why would you want to give fluids over 48 hours and replace sodium if hyponatraemic?
To avoid cerebrally oedema
What is a classic symptom of an E. coli infection?
Profuse diarrhoea
What symptom would not be present in viral/parasytic induced travellers diarrhoea?
Bloody stool
What is a classic symptom of a campylobacter infection?
Severe abdominal pain
What are classic symptoms of a shigella infection?
High fever with person blood in stool
What pathogen is cholera caused by?
vibris cholerae
What is the pathophysiology of cholera?
cholera endotoxin leads to continued activation of adenylate cyclase in the intestinal epithelial cells
this causes secretion of water and salt into the gut lumen
Which demographic does cholera usually affect?
children under five living in Endemic countries
What is the presentation of cholera?
Watery diarrhoea with rice water appearance
Diarrhoea of more than 1 L per hour for a sustained period of time
evidence of severe water depletion: sunken eyes dry mucous membrane irritability significant postural hypotension a decrease in skin turgor Cap Refill of over two seconds
what investigations should you perform for cholera if available?
rapid dipstick test – diagnostic
FBC- + WCC and haemocrit (+ in vol. depletion)
serum electrolytes- check K+
urea and creatinine
ABG- acidosis if severe
ECG- low K+ causes prolonged PR and flattened T wave. Bradycardia = v bad sin
What is the management of cholera?
Aurore therapy aggressive rehydration for two – four hours followed by maintenance fluids until diarrhoea is absent
doxycycline
zinc and vitamin A supplementation children
IV rehydration can used in severe cases
is there a vaccine for cholera?
Yes it is an oral vaccine used in endemic countries
What is coeliac disease?
As systemic autoimmune diseases triggered by dietary gluten peptides
what is the pathophysiology of coeliac’s disease?
Immune activation of the small intestine is caused by gluten peptides
this leads to villous atrophy hypertrophy of intestinal crips and increases the number of lymphocytes in the epithelium and lamina propria
this causes malabsorption and systemic effects
What’s HLA does coeliac carry?
HLA DQ2
HLA DQ8
What is the purpose of the HLA proteins?
causes the gluten peptides to be presented to T cells in a manner which activates them and being in response
What antibodies are present in coeliac disease?
anti-gliadin
anti-tTG
What is the presentation of coeliac disease?
Diarrhoea
bloating
abdominal pain/discomfort
anaemic symptoms and failure to thrive in children
what investigation allows for DEFINITIVE DIAGNOSIS of coeliac?
Small-bowel histology is diagnostic
and gluten challenge
What blood tests would you want to run for coeliac disease?
anti TTG
EMA antibody (endomyseal antibody)
FBC + blood smear - microcytic
what histological findings would you find in coeliac disease?
Intraepithelial lymphocytes villus atrophy and crypt hyperplasia
How do you diagnose coeliac disease in children?
IgA tTG + EMA + HLA DG2/ HLA DG8
What is the management of coeliac disease?
Gluten-free diet
calcium and vitamin D supplements (ergocalciferol + calcium carbonate)
Do a bone mineral density scan one year after a gluten-free diet
iron supplements if anaemic
What is the management of a coeliac crisis?
Rehydration therapy with electrolyte corrections and adjunct corticosteroids if severe enough
Where can small bowel cancer occur?
Duodenum
jejunum
ileum
+ appendix
what is the most common type of small bowel cancer Of the duodenum?
adenocarcinoma
What is most common type of small bowel cancer of the appendix or ileum?
neuroendocrine A.k.a. carcinoid
What are risk factors for small bowel cancer?
Increasing age familial polyposis Crohn's coeliac diets rich in smoked foods red meats or very high fibre
What is the presentation of small bowel cancer?
Abdominal pain abdominal rash weight loss feeling or being sick Melina obstruction symptoms anaemia and associated symptoms
What investigations would you perform for small bowel cancer?
Endoscopy with histological sample
can consider ultrasound scan or CT
What is gastroparesis?
Delayed emptying of solids by the stomach in the absence of any mechanical obstruction
What risk factors are associated with gastroparesis?
Diabetes
previous gastric and pancreatic surgery
achalasia
What is the presentation of gastroparesis?
Post-prandial nausea vomiting early satiety epigastric pain fullness and bloating weight loss
What is important to roll out in gastroparesis?
Obstruction with abdominal x-ray
pancreatitis using serum amylase and lipase
Why is it important to check white cell count and gastroparesis?
White cell count elevation suggests a viral infection which can temporally cause gastroparesis
what is the management of gastroparesis?
Pro kinetic agent such as Metoclopramide or retro myosin
antiemetic
What is eosinophilic oesophagitis?
Oesophageal dysfunction caused by an immune/allergic mediated reaction causing eosinophil infiltration
What risk factors are associated with eosinophilic oesophagitis?
Family history of atopy
atopy
children and young adults
What other symptoms of eosinophilic oesophagitis?
GORD type
can have dysphagia and failure to thrive
How would you diagnose eosinophilic oesophagitis?
OGD with biopsy showing using Ophelia
OGD will have narrowing with white plaques
What is the management of eosinophilic oesophagitis?
Corticosteroid such as budesenone
What is dyssenergic defication?
Dysfunction of the pelvic floor muscles and nerves causing failure of contemporary relaxation for defication
What risk factors are associated with dyssenergic defication?
Previous pregnancy and childbirth
chronic constipation
previous surgery in pelvic floor
What are the symptoms of dyssenergic defication?
Access training feeling of incomplete evacuation positive hard stool lesson three movements per week the use of digital manoeuvres to pass stool
What is important to rule out in dyssenergic defication?
and how would you diagnose dyssenergic defication?
obstruction - use X ray
sigmoidoscopy
What is the management for dyssenergic defication?
Improving toilet habits
increasing fibre intake
laxatives
What is hirsprungs disease?
Also all complete colonial functional obstruction associated with the absence of ganglion cells
this causes luminal obstruction
what part of the GI tract does hirsprungs disease affect?
The distal part of the colon
What nerve plexus is affected in hirsprungs disease?
The mesenteric nerve plexus
What conditions is hirsprungs disease heavily associated with?
downs syndrome
What is the presentation of hirsprungs disease?
Vomiting abdominal distension delayed meconium passage lack of desiccation explosive passage of liquid and foul stool on DRE presenting <1y
What complications can occur due to hirsprungs disease?
and why?
Enterocolitis and sepsis
stasis leads to bacterial overgrowth and secretory diarrhoea
How do you diagnose hirsprungs disease?
Contrast enema
abdominal x-ray is non-specific in young children
What is the management of hirsprungs disease?
Bowel irrigation and surgery
how do you manage hirsprungs disease complicated by hirsprungs disease?
Add antibiotics and IV fluids and decompression via colostomy before surgery
what is chronic diarrhoea?
The presence of 3+ loose stools in a day for four weeks
How do you assess chronic diarrhoea?
Determine the duration frequency pattern and severity of symptoms
ask about red flags such as bleeding weight loss anaemia
look for red flags such as masses raised inflammatory markers
check hydration status
look for potential causes in history such as foreign travel laxative use antibiotic use or other drugs
What other potential causes of chronic diarrhoea?
Ulcerative colitis
Crohn’s colitis
viral bacterial parasitic enteropathy’s
ibs
If you suspect malabsorption what tests should you run?
FBC- anaemia folate and B12 ferratin serum albumin may be low serum electrolytes such as magnesium potassium calcium zinc check INR which can be deranged can also do vitamin screen
What is tropical sprue?
An infectious malabsorption condition caused by long-term stay in specific endemic areas in the tropics
What is the presentation of tropicals sprue?
Low-grade fever
abdominal cramping and diarrhoea
hair loss and. oedema - due to low protein/albumin
signs of vitamin B12 and folate deficiency such as parlour angular chelitis
What investigations should you perform in tropical sprue?
Malabsorption screen
endoscopy with biopsy
how do you manage Topical sprue?
Folic acid plus antibiotics like tetracycline
and B12 supplements
What is Whipple’s disease?
Rare infection caused by tropheryma whipplei
What is the presentation of Whipple’s disease?
Diarrhoea weight loss arthralgia lymphadenopathy and fever steatorrhea anaemia skin darkening
How do you diagnose Whipple’s disease?
Upper GI endoscopy with biopsy and PCR
What is giardiasis?
An enteric infection caused by a protozoan Guardia lamblia
what risk factors are associated with giardiasis?
Contaminated food and water
domestic animals living in the house
What is the presentation of giardiasis?
Diarrhoea frequent belching abdominal bloating and discomfort weight loss nausea and vomiting
How do you diagnose giardiasis?
Store microscopy
how do you treat giardiasis?
Anti-protozoan therapy – metronidazole
what is the pathophysiology of lactase deficiency?
There is reduced lactase in the mucosal brush border
lactase is broken down and passes into the:
the unbroken lactose increases osmolality of the colon
it then gets broken down by bacteria in the colon
causing symptoms of diarrhoea and gas
In children what can cause a temporary lactose intolerance?
Viral (usually) enteritis/gastroenteritis
How do you diagnose lactase deficiency?
There should be no signs of malabsorption
the trial of dairy elimination
What is the management of lactase deficiency?
Dietary modification with calcium and vitamin D supplements
in infants give oral lactase as well as appropriate formula
What is a short bowel syndrome?
A substantial portion of the small intestine is absent either due to congenital or surgical causes
What is the pathophysiology of short bowel syndrome?
There is a loss of surface area causing disturbances and fluid nutrients and medication absorption
What are problems associated with short bowel syndrome?
Inability to maintain a protein energy fluid electrolytes or micronutrients balance when eating a normal diet
What is the presentation of short bowel syndrome?
Fatigue
fractures
dysuria or renal colic due to the formation of kidney stones (if there is significant fluid loss)
abnormal neurological exam a due to low vitamin a and B12
jaundice or pruritus from liver failure in consequence to long-term intestinal failure
What is the management of short bowel syndrome
Electrolyte vitamin and micronutrient replacement which may require PN feeding
What are the investigations required for short bowel syndrome?
malabsorption screen
LFT + INR
U+E
ultrasound scan and CT for kidney stones or gallstones
What are haemorrhoids?
vascular rich connective tissue cushions /structures located within the anal canal however as they enlarge they can protrude outside the anal canal causing symptoms
What are the risk factors associated with haemorrhoids?
45 to 65 years old
constipation
pregnancy
what is the presentation of haemorrhoids?
bright red blood on defecation
perianal pain or discomfort
if the haemorrhoid is thrombosed then pain and discomfort is worse
On DRE what would you find for haemorrhoids?
Tender palpable lesion
What investigations can you perform for haemorrhoids?
Anus copy exam
colonoscopies suspecting malignancy
FBC for anaemia
What is the management of haemorrhoids?
Lifestyle modification and dietary modification
topical corticosteroids
Rubber band ligation
What are anal fissures?
A split in the skin of the distal anal canal
What are the symptoms of anal fissures?
Pain on defecation very severe feels like passing shards of glass or tearing sensation
and rectal bleeding
How do you diagnose anal fissures?
Clinical diagnosis unless it has been caused by a previous treatment (anal manometry) or you suspect an anal sphincter defect then anal USS
what is the management ofAn anal fissure?
Conservative management with high fibre diets and increasing fluids
a severe surgery may be considered
What is pilondial disease?
The forceful insertion of hairs into the skin of the natal cleft above the bum
prompts of chronic inflammatory reaction and forms multiple communicated sinuses or an abscess
who is affected by pilondial disease?
Young men who tend to be more hairy
What is the presentation of pilondial disease?
Discharge pain and swelling around that area
how do you diagnose pilondial disease?
On examination you find several connecting sinus tracts and possibly an abscess
How do you manage pilondial disease?
Hair removal and local hygiene and if infected give ABx
pain relief if there’s an abscess
What type of cancer is anal carcinoma?
squamous cell
what usually causes anal carcinoma?
HPV - 16 and -18
what are the risk factors for anal carcinoma?
HIV
men who have sex with men
repeated anal trauma
exposure to those with HPV
what is the presentation of anal carcinoma?
rectal bleeding and pain
mass palpable
lymphadenopathy in more advanced
how do you diagnose anal carcinoma?
anoscopy and biopsy
but can view initially with USS - anal
what is rectal prolapse?
When the rectal wall slides out through the anus
Why does rectal prolapse occur?
Usually when the intra-abdominal pressure increases (coughing or desiccation) and due to the weakening of muscles and ligaments prolapse occurs
What are the symptoms of rectal prolapse?
mass palpable outside the rectum
What does it mean if a rectal prolapse is painful and swollen?
That it is strangulated
What is the management of rectal prolapse?
lifestyle management to decrease training if it is very severe than surgery
What medication causes constipation?
Opioids anticholinergics antispasmodic tricyclic antidepressants calcium channel blockers levodopa and other Parkinson's drugs diuretics iron supplements calcium supplements antidiarrhoeal's NSAIDs
What is laxative abuse?
The repeated use of laxatives to purge calories or food
What does laxative abuse leads to?
Dehydration
electrolyte disturbances
mineral deficiencies
constipation- due to XS stimulation causing nerve damage and thus constipation
What is angiodysphasia of the colon?
A degenerative vascular malformation of the GI tract characterised by fragile leaky blood vessels
what is the presentation of angiodysphasia of the colon?
Chronic painless low-grade and intermittent bleeding
colour of blood depends on the level of malformation:
fresh red blood – lower GI
Melena – upper GI
anaemia Sx
Rarely present with massive haemorrhage
what investigations should you perform for angiodysphasia of the colon?
Colonoscopy / endoscopy / both– diagnostic
FBC - assess anaemia
How do you treat angiodysphasia of the colon?
Interventional endoscopy with the supportive care
What is paediatric GORD?
Reflux leading to inadequate intake or tolerance to fluids in children>1y
Why does paediatric GORD occur?
Inappropriate relaxation of the lower oesophageal sphincter due to functional immaturity
What are risk factors for developing paediatric GORD?
Prematurity
IUGR
under one years old
developmental delay (e.g. cerebral palsy)
short intra-abdominal oesophagus or other anatomical abnormalities of the upper GI tract
What is a presentation for paediatric GORD?
Stressful mealtimes with the feed time over 30 minutes
regurgitation and vomiting
abdominal pain/colic
irritability or lethargy at meals
What’s important to note in the history of a patient with paediatric GORD?
Abnormal perinatal events such as prolonged time to pass meconium
abnormal feeding patterns
an increased volume of feed
How does the presentation of paediatric GORD differ in very young/premature infants?
may present as:
apnoea
desaturation
bradycardia
How do you diagnose paediatric GORD?
Mainly through response to treatment however if you are concerned about any DD such as: obstruction aspirations pyloric stenosis oesophageal atresia
you will need to do further testing
What is the management of paediatric GORD?
Education and reassurance – advised to lie prone or laterally while awake
give feed thickening is or anti-regurgitation formula
failure to respond should prompt a trial of cows milk protein free formula
if paediatric GORD is unresponsive to nonpharmacological treatment then give PPI
What is pyloric stenosis?
The hypertrophy of the pyloric sphincter resulting in a narrowed pyloric canal
the most common cause of gastric outlet obstruction in those 2w-12w
What is a presentation of pyloric stenosis?
Numberless projectile vomiting occurring soon after feeding
peristaltic waves moving from left to right across the stomach
features of dehydration irritability failure to thrive patient
what may you feel on abdominal examination of a patient with pyloric stenosis?
An upper abdominal mass/hollow shape
How do you diagnose pyloric stenosis?
Abdominal ultrasound scan
check U+E
what electrolyte abnormalities may be present in pyloric stenosis?
hypochloremic acidosis with hypokalaemia
classic vomiting derangement
What is the management for pyloric stenosis?
IV fluids and resus
surgery
What commonly causes viral gastroenteritis in children?
Rotavirus
What risk factors are associated with viral gastroenteritis in children?
Younger than five
daycare attendance
poor personal hygiene
Winter
what is an inguinal hernia (paediatric)?
A protrusion of abdominal or pelvic contents caused indirectly by patent processus vaginalis
What are risk factors associated with paediatric inguinal hernias?
Premature
How does an inguinal hernia present in paediatrics?
Intermittent swelling in groin or scrotum and crying or straining
inguinal swelling
irritable and vomiting
Are you able to reduce paediatric inguinal hernias?
No unless opioid analgesia is used
a truly irreducible hernia requires surgery ASAP
what is the management of an inguinal hernia?
Try and reduce the hernia
wait 24-48h to resolve oedema then proceed to surgery
What are inguinal hernias associated with?
Undescended testes
What is marasmus?
Severe protein and energy malnutrition
What is the weight to height ratio in marasmus?
Abnormal
What is the presentation of marasmus?
low made arm circumference
reduced skinfold thickness
withdrawn and apathetic
What is Kwashiorkor?
Protein malnutrition
What is the weight to height ratio in Kwashiorkor?
normal (due to increased fluid)
What is the presentation of Kwashiorkor?
Oedema with distended abdomen severe wasting desquamation of the skin and hyper keratosis angular estimate hoses diarrhoea hypotension and bradycardia hypothermia
What are causes of paediatric malnutrition?
IBD coeliac cholestatic liver disease short bowel syndrome exocrine pancreatic dysfunction
What is the management of paediatric malnutrition?
Glucose and dextrose
fluids
replace electrolytes especially sodium potassium in chlorine
give micronutrients especially vitamins ADEK
small and often feeds
What is intusucception?
A common cause of intestinal obstruction in young children caused by prolapse of one part of the lumen into the adjoining part
Where is the most common location for intussusception?
Ileocecal
What risk factors are associated with intussusception?
Male
aged 6 to 12 months
What is the presentation of intussusception?
Colicky abdominal pain with flexing of the legs
normal behaviour in between episodes
vomiting
Lethargy and irritability between waves of pain
redcurrant jelly store
fever
pallor
What do you need to be careful of in intussusception?
It can cause hypovolaemic shock if perforated ischaemic or necrotic
On abdominal examination what might you feel in a child with intussusception?
RUQ or epigastric mass
How do you diagnose intussusception?
Contrast enema or ultrasound scan
if you suspect obstruction or perforation then Abdominal X Ray
What would a contrast enema show in Intussusception?
Meniscus sign- the round apex of the intussusception coiled spring sign- the oedematous mucosal folds
What are contraindications to a contrast enema?
Shock
suspected perforation
peritonitis
evidence of necrosis
What is the acute management of intussusception?
ABCD approach
fluid resuscitation and contrast enema reduction
give broad-spectrum antibiotics (clindamycin gentamicin)
if the reduction doesn’t work or the enema is contraindicated then surgical resection is used
What is the ongoing management of Intussusception?
Only really used if there are three or more occurrences
do a CT
if possible reduce it but otherwise surgical resection is needed
what causesIntussusception to occur?
Lymph-node thin payers patches often are the first part of an intussusception
a pathological lead to point (first part) can be because by cystic fibrosis and HSP if they cause bowel wall abnormalities
What is meckles diverticulum?
Common congenital malformation of the small bowel
what is the pathophysiology of meckles diverticulum?
A true diverticulum resulting from failure of embryonic tissue (vitelline duct) to obliterated in the fifth week of gestation
How does meckles diverticulum present ?
Commonly is asymptomatic, if symptoms present it is usually before two years
acute episodic painless passage of maroon blood
constipation
nausea and vomiting
abdominal cramps
How can meckles diverticulum show in adults?
Lower abdominal pain caused by diverticulitis
What is the diagnostic test for meckles diverticulum?
Technetium 99 pertechnetate scan
or CT
What complications or differential diagnoses are associated with meckles diverticulum?
and how would you manage these?
Intussusception
diverticulitis
bowel obstruction - surgery + abc (cefotaxime and metronidazole )
What would a full blood count show in meckles diverticulum?
Anaemia
increased white cell count in inflammation
What is the management of meckles diverticulum?
If asymptomatic:
no treatment is required
if symptomatic:
excision of the diverticulum
What is toddlers diarrhoea?
A chronic non-specific diarrhoea causing the passage of stools of varying consistency
it is very common
What is the pathophysiology behind toddlers diarrhoea?
Occurs due to an underlying delay in maturation of the intestine leading to intestinal hurry
Is there any malnutrition or failure to thrive associated with toddlers diarrhoea?
no
How do you manage toddlers diarrhoea
Start a high fibre diet
are any investigations required in toddlers diarrhoea?
Not really
check the toddlers awaits their growth charts and assess any signs of malnutrition
if you have any doubts do a full blood screen
What is the definition of recurrent abdominal pain?
pain severe enough to disrupt daily activities for >3m
how would you diagnose recurrent abdominal pain?
it is a diagnosis of exclusion
you want a full examination (including genital and peri anal area - GU causes and IBD signs)
and include some imagine (X Ray/less commonly CT)
also an USS to check for gallstones/obstruction
+urine cultures and dipstick
How would you manage recurrent abdominal pain?
the same as wit IBS
reassure and educate on diet
small frequent feeds
low fat and high fibre diet
can try probiotics
laxatives (fibrogel)
antispasmodics (cimetropium)
What is colic?
a symptom complex occurring within the first few months of life
What is the presentation of colic?
paroxysmal inconsolable crying with drawing of knees
XS flatulance
worse in evenings
what are the risks of colic?
in itself nothing but…
increases risk of:
postnatal depression
parental stress
increased risk of domestic abuse
what is the management of colic?
no real remedies
reassurance and lots of support
usually resolves by 4m
what could persistent (after 4m) colic indicate?
GORD
cows milk protein allergy
what is the definition of childhood obesity?
BMI>95th centile
what BMI is defines ad severely obese in children?
BMI>99th centile
what BMI is defined as overweight in children?
BMI>85th centile
What are non-environmental causes of childhood obesity?
hypothyroidism prader willi pseudohypoparathyroidism bushings injury/abnormality of the hypothalamus and pituitary
what are measurements of a Childs weight?
mid arm circumference
waist to hip ratio
skinfold thickness
what should always be checked in a child with obesity?
BP ?hypertension
what are risk factors associated with childhood obesity?
obese parents
rapid weight gain in infancy and early childhood
poor SE status
sedentary
What investigations should you perform in a child with obesity?
Fasting blood glucose
serum lipids
LFT (non-alcoholic fatty liver disease)
What is the management of childhood obesity?
Lifestyle modifications with counselling
the aim of management is not on losing weight but rather not gaining weight and allowing a child to grow into their current weight
if severely obese orlistat can be used and if old enough surgery is very rarely offered
What is a diagrammatic hernia?
Herniation of the abdominal contents through foreign men in the diaphragm
How is a diaphragmatic hernia diagnosed in infants?
Usually on antenatal ultrasound
Dan confirmed once born with chest and abdominal x-ray
What is the management of a diagrammatic hernia in infants?
NG tube + suction to prevent distension
after stabilisation surgical repair
What is the most common complication with a diagrammatic hernia in infants?
pulmonary hypoplasia due to their compression en utero
What is necrotising enterocolitis?
A bacterial invasion of ischaemic bowel wall upon bowel death
What is the pathophysiology of necrotising enterocolitis?
The bowel and immune system are immature allowing for bacterial invasions of the gut
causes inflammation and can lead to perforation
causing further bacterial invasion
eventually leads to necrosis
How does necrotising enterocolitis present?
Feeding intolerance abdominal pain and distension shiny skin on abdomen bloody stools bile stained vomit shock
What word an x-ray show in necrotising enterocolitis?
Dilated and distended bowel loops
thickened bowel walls
intramural gas, gas under the diaphragm and in biliary tree
Apart from x-ray what other quick test can show necrotising enterocolitis?
Abdominal trans-illumination
How do you manage necrotising enterocolitis?
Nil by mouth start PTN
antibiotics
ventilation and surgery
What complications are associated with necrotising enterocolitis later in life?
Strictures
malabsorption
What is gastroschisis?
Congenital defect of the abdominal wall resulting in herniation from the abdominal cavity
what is the difference between gastroschisis and omphalocele?
an abdominal sac covers the contents of an ompahloele whereas it isn’t present in gastroschisis
what are the risk factors for gastroschiasis/ompahlocele?
smoking
maternal age 20< (gastroschiaisis)
maternal age >40 (omphalocele)
Which congenital abnormalities is ompahlocele associated with?
trisomy 13, 18, 21
what other condition is usually present if theres gastroschiasis/omphalocele?
and why?
intestinal atresia
due to constriction of the mesenteric blood supply causing decreased perfusion
how are gastroschiasis/ompahlocele detected?
antenatal USS in 2nd trimester
what compound is elevated in gastroschiasis/ompahlocele?
alpha-feto protein
what test should you offer after detecting gastroschiasis/ompahlocele?
amniocentesis at 15-20w
CVS at 10-12w
what is the management of gastroschiasis/ompahlocele?
Emergancy
ABCDE
fluid resus, temperature measurements and support, bowel protection until surgery
after surgery PTN/NG feed
what does gastroschiasis/ompahlocele cause that makes it a medical Emergancy?
massive fluid and heat loss
why is recovery longer in gastroschiasis than ompahlocele?
because the lack of sac means that theres development of a thick inflammatory film over the bowels
what is intestinal atresia?
any congenital malformation resulting in bowel obstruction - either misconnection, narrowing or total block
what are the classifications of intestinal atresia?
complete incomplete mesenteric gap blind end complete apple peel syndrome multiple blockages
where does intestinal usually occur?
SI namely the ileum and jejunum because duodenal atresia is its own diagnosis
what causes intestinal atresia?
a vascular event en utero causing a decrease in perfusion and death of bowel
what is the presentation of intestinal atresia?
vomiting +/- bile
swollen soft abdomen
no meconium passage
how is intestinal atresia diagnosed?
fetal USS
+ contrast Xray after birth to confirm
usually not necessary is laparoscopy however can be used if unclear
What sign in pregnancy indicated intestinal atresia?
polyhydramnious
what is the management of intestinal atresia?
laparoscopic surgery
+stoma to allow healing
IV fluids and NG feeds
