Gastroenterology Flashcards
What is GERD?
What is possetting?
Gastro-oesophageal reflux (GOR) is the non-forceful regurgitation of milk and other gastric contents into the oesophagus
A small regurgitation of milk after breast feeding (this is quite normal)
What are the symptoms of GERD?
- Recurrent regurgitation or vomiting.
- Witnessed episode of choking or apparent life-threatening event can sometimes occur.
- Respiratory problems (eg, cough, apnoea, recurrent wheeze and, less commonly, aspiration pneumonia).
- Typically develops before 8 weeks
What are the red flags which don’t suggest GERD?
- Frequent, forceful (projectile) vomiting - may suggest hypertrophic pyloric stenosis in infants up to 2 months old.
- Bile-stained (green or yellow-green) vomit may suggest intestinal obstruction
- Haematemesis may suggest a bleed from the oesophagus, stomach or upper gut
What are the investigations for GERD?
Not usually performed in mild cases In severe cases
FBC.
24-hour ambulatory oesophageal pH study
Usually will show frequent dips in pH <4.
Barium meal
To exclude underlying anatomical abnormalities in the oesophagus, stomach and duodenum that may cause symptoms similar to GORD
Endoscopy
Where oesophagitis is suspected.
Manometry
To assess oesophageal motility and lower oesophageal sphincter function.
What is the treatment for GERD?
- Advise regarding position during feeds - 30 degree head-up
- Infants should sleep on their backs as per standard guidance to reduce the risk of cot death
- Ensure infant is not being overfed (as per their weight) and consider a trial of smaller and more frequent feeds
- A trial of thickened formula (for example, containing rice starch, cornstarch, locust bean gum or carob bean gum)
- A trial of alginate therapy e.g. Gaviscon. Alginates should not be used at the same time as thickening agents
- Trial of a PPI
What are the complications of GORD?
- Failure to thrive
- Aspiration
- Frequent otitis media
- Barrett’s oesophagus
- In older children dental erosion may occur
What is poor feeding?
Poor feeding in infants is used to describe an infant with little interest in feeding
What are the causes for poor feeding in infants?
Premature birth
Herpes
Jaundice
Viral gastroenteritis
When should you seek emergency care for poor feeding?
- Has not fed in over four hours
- Has a fever of over 100 degrees F
- Is vomiting after feeding is vomiting blood
- Has a persistent and worsening cough
- Is crying constantly
- Has bloody stool
- Is wheezing
- Is becoming unresponsive to touch
What is the treatment for poor feeding?
Poor feeding that is caused by an infection will normally stop when the infection is treated.
Treatment is the same for other causes of poor feeding.
This can involve changing the feeding schedule to consist of smaller, more frequent meals.
It can also involve switching feeding methods from breast to bottle
How is poor feeding different to poor growth?
Poor growth can lead to a separate condition called failure to thrive, this is through lack of feeding rather than disinterest in feeding
What is pyloric stenosis?
Pyloric stenosis is a condition where the passage (pylorus) between the stomach and small bowel (duodenum) becomes narrower
What is the cause of pyloric stenosis and when does it normally develop?
Unknown
six weeks after birth
What are the symptoms of pyloric stenosis?
Begin bringing up small amounts of milk after feeding, typically 30 minutes
Projectile vomiting
Milk can curdle and become yellow in colour
Signs of dehydration include lethargy, wet nappies less frequently than normal and the soft spot (fontanel) on the top of the head may be sunken.
How is pyloric stenosis diagnosed?
- Ultrasound scan to get a picture of the thickened muscle
- Hypokalaemic and hypochloraemic
- The thickened pyloric muscle can be felt - hard lump on the right side of the baby’s stomach.
- The muscles around the stomach can be seen straining
- Examine the baby during a feed to observe any vomiting
How is pyloric stenosis treated?
Ramstedt pyloromyotomy
What is IBS?
Irritable bowel syndrome (IBS) is a long-term (chronic) disorder that affects the large intestine or colon.
IBS causes painful belly (abdominal) and bowel symptoms
What is the cause of IBS?
The exact physical cause of IBS is not known.
Children may feel IBS symptoms because of:
Problems with how food moves through their digestive system
Extreme sensitivity of the inside of their bowel to stretching and motion
Stress
Too much bacteria growing in their bowel
What are the symptoms of IBS?
A positive diagnosis of IBS should be made if the patient has Abdominal pain relieved by defecation or associated with altered bowel frequency stool form, in addition to 2 of the following 4 symptoms:
Altered stool passage (straining, urgency, incomplete evacuation)
Abdominal bloating (more common in women than men), distension, tension or hardness
Symptoms made worse by eating
Passage of mucus
What are the investigations for IBS?
- Full blood count
- ESR/CRP
- Coeliac disease screen (tissue transglutaminase antibodies)
What is the management for IBS?
First line:
Pain: antispasmodic agents
Constipation: laxatives but avoid lactulose
Diarrhoea: loperamide is first-line
Second line:
Amytriptiline
What is gastroenteritis?
Your stomach and intestines are irritated and inflamed.
What is the most causative organism for gastroenteritis?
Rotavirus
In adults it’s norovirus or food poisoning
What are the symptoms of gastroenteritis?
- Sudden, watery diarrhoea feeling sick vomiting, which can be projectile a mild fever
- Some people also have other symptoms, such as a loss of appetite, an upset stomach, aching limbs and headaches.
What is the management for gastroenteritis?
Drink plenty of fluids to avoid dehydration
Take paracetamol for any fever or aches and pains.
Get plenty of rest.
If you feel like eating, try small amounts of plain foods, such as soup, rice, pasta and bread.
Rehydration drinks
Take anti-vomiting medication (such as metoclopramide) and/or antidiarrhoeal medication (such as loperamide) if
When should you seek medical advice for gastroenteritis?
You’re not able to keep liquids down for 24 hours
You’ve been vomiting for more than two days
You’re vomiting blood
You’re dehydrated — signs of dehydration include excessive thirst, dry mouth, deep yellow urine or little or no urine, and severe weakness, dizziness or lightheadedness
You notice blood in your bowel movements
You have a fever above 104 F (40 C)
What is constipation in children?
Constipation in children is a common problem.
A constipated child has infrequent bowel movements or hard, dry stools.
What are the symptoms of constipation in children?
They have not done a poo at least 3 times in the last week
their poo is large and hard their poo looks like “rabbit droppings” or little pellets
they are straining or in pain when they poo
they have some bleeding during or after having a poo, because their poo is large and hard
they have a poor appetite or stomach pain that improves after they poo
What are the causes of constipation in children?
- Withholding
- Not eating enough high-fibre foods like fruit and veg
- Not drinking enough fluids
- Feeling pressured or being regularly interrupted while potty (or toilet) training
- Feeling worried or anxious about something
- Family history
- Medical conditions
What is the treatment for constipation in children?
Laxatives
1) Macrogols/osmotic e.g. Movicol/Lactulose
2) Stimulant e.g. Sodium picosulfate, bisacodyl, senna
3) Osmotic e.g. Lactulose
Laxatives are normally continued even after symptoms have ceased.
Regular exercise
Drinking plenty of fluids
When should you seek medical advice for constipation?
- Fever
- Not eating
- Blood in the stool
- Abdominal swelling
- Weight loss
- Pain during bowel movements
- Part of the intestine coming out of the anus (rectal prolapse)
What is appendicitis?
The appendix is a small organ attached to the large intestine in the lower right side of the belly. When it gets infected, it’s called appendicitis.
What are the symptoms of appendicitis?
Pain in the middle of your tummy (abdomen) that may come and go.
Within hours, the pain travels to your lower right-hand side, becomes constant
Nausea and vomiting
What causes appendicitis?
When the appendix gets blocked, too much bacteria can grow and cause an infection. Some of the things that might block the appendix are: hard, rock-like stool (poop) undigested seeds swollen lymph nodes in the intestines parasites and other infections
How is appendicitis treated?
Appendicectomy
What are the bacteria in appendicitis?
E. coli
Bacteroides fragilis
What is a hernia?
Hernias develop when there is a weak area in the abdomen or a small opening in the abdominal muscles, causing the tissues below to bulge
What are the different types of hernias?
Umbilical hernias form when the opening for the umbilical cord does not closely properly, which allows the abdominal lining and bowel to bulge out to form a lump.
Epigastric hernias form when tissues joining the muscles in the upper part of the abdomen have not formed properly and allow fatty tissue to bulge out to form a lump.
What is the treatment for hernias?
Umbilical hernia
- Not noramlly repaired
- If still present at 3 years old, an operation to repair it will usually be suggested.
Epigastric hernias
- Repaired only if they are causing discomfort or getting in the way of normal everyday life and activities
Inguinal hernia
- Surgery
How is a hernia diagnosed?
The child’s doctor will be able to diagnose the hernia by a clinical examination, as it appears as a characteristic lump in the abdomen.
WHAT IS AN UMBILICAL GRANULOMA?
- These consist of cherry red lesions surrounding the umbilicus, they may bleed on contact and be a site of seropurulent discharge.
- Infection is unusual and they will often respond favourably to chemical cautery with topically applied silver nitrate.
What is inflammatory bowel disease?
Term mainly used to describe 2 conditions:
ulcerative colitis and Crohn’s disease.
What is the cause of inflammatory bowel disease?
Unknown
What are the symptoms crohn’s disease?
presentation may be non-specific symptoms such as weight loss and lethargy
diarrhoea: the most prominent symptom in adults. Crohn’s colitis may cause bloody diarrhoea
abdominal pain: the most prominent symptom in children
perianal disease: e.g. Skin tags or ulcers
extra-intestinal features are more common in patients with colitis or perianal disease
What are the symptoms ulcerative colitis?
- Bloody diarrhoea
- Urgency
- Tenesmus
- Abdominal pain, particularly in the left lower quadrant
- Extra-intestinal features (see below)
What is the difference between ulcerative colitis and crohn’s?
Ulcerative colitis is limited to the colon while Crohn’s disease can occur anywhere between the mouth and the anus
In Crohn’s disease, there are healthy parts of the intestine mixed in between inflamed areas. Ulcerative colitis, on the other hand, is continuous inflammation of the colon
Ulcerative colitis only affects the inner most lining of the colon while Crohn’s disease can occur in all the layers of the bowel walls
How is ulcerative colits diagnosed?
Endoscopy
- Colonoscopy + biopsy is generally done for diagnosis
- However in patients with severe colitis colonoscopy should be avoided due to the risk of perforation - a flexible sigmoidoscopy is preferred
- Typical findings:
- Red, raw mucosa, bleeds easily
- No inflammation beyond submucosa (unless fulminant disease)
- Widespread ulceration with preservation of adjacent mucosa which has the appearance of polyps (‘pseudopolyps’)
- Inflammatory cell infiltrate in lamina propria
- Neutrophils migrate through the walls of glands to form Crypt abscesses
- Depletion of goblet cells and mucin from gland epithelium
- Granulomas are infrequent
Barium enema
- Loss of haustrations
- Superficial ulceration, ‘pseudopolyps’
- Long standing disease: colon is narrow and short -‘drainpipe colon’
How is crohn’s diagnosed?
-
Bloods
- C-reactive protein correlates well with disease activity
-
Endoscopy
- Colonoscopy is the investigation of choice
- Features suggest of Crohn’s include deep ulcers, skip lesions
-
Histology
- Inflammation in all layers from mucosa to serosa
- Goblet cells
- Granulomas
-
Small bowel enema
- High sensitivity and specificity for examination of the terminal ileum
- Strictures: ‘Kantor’s string sign’
- Proximal bowel dilation
- ‘Rose thorn’ ulcers
- Fistulae
What is the treatment for crohns?
Maintenance:
- Azathioprine
- Mercaptopurine / Methotrexate
- TNF-alpa inhibitors (all the –imabs)
- Surgery eg. Strictures, resection
Flares:
- 7 days prednisolone then taper dose for 7 weeks
- If systemically unwell – admit for IV hydrocortisone and monitoring (incl Xrays). Supportive – fluids, transfusion if <80Hb).
- Switch to oral pred once improving or biologics if not improving
What is the treatment for ulcerative colitis?
Maintenance:
- Mesalazine (which is an aminosalicylate or 5-ASA)
- Azathioprine
- Methotrexate / Mercaptopurine
- TNF-alpa inhibitors (all the –imabs)
- Surgery eg. Strictures, resection, stoma
Flares:
- Mesalazine
- 7 days prednisolone then taper dose for 7 weeks
- If unwell – admit for IV steroids and monitoring (incl Xrays). Supportive – fluids, transfusion if <80Hb).
What is coeliac disease?
Celiac disease, sometimes called celiac sprue or gluten-sensitive enteropathy, is an immune reaction to eating gluten, a protein found in wheat, barley and rye.
What is the cause of coeliac disease?
Your genes combined with eating foods with gluten and other factors can contribute to celiac disease, but the precise cause isn’t known