Gastroenterology Flashcards
What is possetting?
throwing up small amounts of milk together with a burp (swallowed air)
What is regurgitation
larger, more frequent losses
what is vomiting
forceful ejection of gastric contents
What does intestinal obstruction lead to?
vomioting
the more proximal the obstruction, the more prominent and bile stained the vomiting is
what is gastro-oesophageal reflux
involuntary passage of gastric contents into the oesophagus
why does gastro-oesophageal reflux occur
immaturity of lower oesophageal sphincter causing insufficient relaxation
what are baby factors contributing to reflux
fluid diet
horizontal posture
short intra-abdominal length off oesophagus
What are investigations for GOR?
24h oesophageal pH monitoring
24h impedance monitoring
endoscopy
upper Gi contrast study
what is management for GOR?
If breast-feeding:
- Breastfeeding assessment by midwife
- Alginate therapy
If formula fed:
- Review feeding hx (trial smaller, frequent feeds)
- Thickened formula
- alginate therapy
- PPI
What causes pyloric stenosis?
hypertrophy of pyloric muscle
causes gastric outlet obstruction
When does pyloric stenosis present?
2-8 weeks of age
irrespective of gestational age
what are features of pyloric stenosis?
Vomiting +
Hunger after vomiting
WL
what is management of pyloric stenosis
IV fluid resus
Ramstedt pyloromyotomy
What is a colic
common symptom complex
- typical pattern of symptoms: paroxysmal, inconsolable crying > drawing up of knees > passing excessive flatus
What is the cause of colic
GI
but no firm evidence
how do you manage colic?
reassure patients it is a common problem and resolves by 6m
sources for information / support: NHS Choices leaflet, health vitsitor
Strategies to soothe a crying infant
Look after yourself
What is the commonest cause of abdominal pain in babies
Mostly UNDIAGNOSED
What are surgical causes of abdo pain
acute appendicitis intestinal obstruction (including insussception) inguinal hernia peritonitis Meckel diverticulum Pancreatitis Trauma
What are medical causes of abdo pain
gastroenteritis pyelonephritis hydronephrosis renal calculus Henoch-Shonlein purpura
what are extra abdominal causes of abdo pain
URTI
Lower lobe pneumonia
testicular torsion
hip and spine
what are symptoms of acute appendicitis
anorexia
vomiting
abdo pain (initially central, colicky > then RIF)
what are signs of acute appendicitis
flushed face, oral fetter fever pain aggravated by movement persistent tenderness guarding in RIF (McBurney's point)
What occurs to guarding in retrocaecal appendix
absent
what is a risk in appendicitis in children and why
PERFORATUON
because omentum is less well developed and fails to guard the appendix
What are ix for diagnosing appendicitis
USS (shows thickened, non compressible appendix with increased blood flow and possible complications e.g. absess, perforation, appendix mass)
what is management for appendicitis
NBM
IV fluid
appendicectomy
what is mesenteric adenines
enlarged mesenteric lymph nodes
normal appendix
What is insussception?
Invagination of proximal bowel into distal segment
What part of the GI tract is most commonly involved in insussception?
The ileum (when it passes into the caecum at the ileocaecal value)
What is the most common cause of intestinal obstruction in neonates?
insussception
What is the presentation of insussception
paroxysmal, severe colicky pain
Pallor during the colicky pAIN
Refusing feeds
Vomiting (may be bile stained depending on location)=
Passage of redcurrant jelly stool (blood stained mucous)
What are findings of abdominal exam in insussception
Sausage shaped mass palpable (in RIF)
Abdominal distensions
What are investigations for insussception
X ray (distended bowel with no gas) Abdo USS
What is management of insussception
- Rectal air insufflation (if no signs of peritonitis)
OR - contrast enema
- fluid resus
- broad spec antibiotics
SECOND LINE: SURGICAL REDUCTION + broad spec anti bionics
What is meckel’s diverticulum=
The ideal remnant of the omphalomesenteric duct
What is the omphalomesenteric duct
Long narrow tube joining the yolk sac to midgut lumen of foetus
Made up of either gastric mucosa / pancreatic tissue
How does meckel’s diverticulum present?
severe rectal bleeding
obstruction
perforation / peritonitis if severe
How do you investigate meckel’s diverticulum
Technetium scan (shows increased uptake by ectopic gastric mucosa)
What is management for meckel’s diverticulum
Asymptomatic - no tx
Symptomatic - excision of diverticulum, lysis of adhesions
Perforation / peritonitis
What is another word for GI malrotation in neonate?
VOLVULUS
What are presentations of GI malrotation in neonate?
bilious vomitng
abdo pain
tenderness
What is management for GI malrotation
Ladd procedure (detort bowel, surgically divide Ladd bands) - done laparoscopically if non-urgent, open laparotomy if urgent \+ antibiotics (cefazolin)
What is abdominal migraine’
abdominal pain and headaches
pain is usually midline and associated with vomiting and facial pallor
How do you treat abdominal migraine?
anti migraine medication
What does IBS present as
Non specific abdo pain explosive, loose, mucous stool bloating incomplete defecation constipation
How do you manage IBS
reassure
encourage pt to reduce stress
eliminate food that trigger sx
what are main causes of gastroenteritis in developed countries?
ROTAVIRUS
Other (bacterial):
- campylobacter jejune
Shigella
What is important to assess for in gastroenteritis?
DEHYDRATION for fluid replacement
What further investigation must you do for gastroenteritis
stool sample analysis
What causes coeliac disease
immunological response to gliadin
What occurs to the GI system in coeliac
Villi become shorter and then absent, leaving a flat mucosa
Whjat is classical presentaation of coeliac in children
profound malabsorption art 8-24m of age
after introduction of wheat containing food
- faltering growth
- abdo distension
- buttock wasting
- abnormal stools
- general irritability
How do you manage coeliac?
Eliminate all products containing wheat, rye, barley
Monitor body weight, height, BMI
Give calcium, vit D suppllement, conssider iron
Refer to dietician if necessary
ARRANGE ANNUAL REVIEW
What is Hirschprung disease?
Absence of ganglion cells in myenteric and submucosal plexuses in large bowel
Results in a narrow and contracted segment of large bowel
What is the presentation of Hirschprrung disease?
Neonatal: intestinal obstruction, unable to pass meconium
Childhood: chronic constipation, abdo distension, bile stained vomiting, growth failure
What occurs in PR exam for Hirschprrung disease?
Narrowed segment
Gush of liquid stool Shen removing the finger
How do you diagnose Hirschprung disease?
Full thickness rectal biopsy
Anorectal mamometry
How do you manage Hirschprung disease
Initially bowel irrigation
then SURGICAL - ANORECTAL PULL THROUGH
initial colostomy
then anastomose normally innervated bowel to anus
What is the cause fo regurgutation
GOR
Due to immaturity of LOS
What must you exclude if baby is projectile vomiting?
pyloric stenosis
How do you investigate pyloric stenosis?
Abdo exam (palpable pyloric mass in RUQ)
Perform test feed
USS
U&E (electrolyte disturbance, dehydration)
What sign do you see on abdomen ultrasound for insussception?
TARGET SIGN (double lumen)
What is eosinophilic oesophagitis?
INFLAMMATION OF OESOPHAGUS
DUE To Activation of eosinophils within mucosa/submucosa of oesophagus
Who is eosinophilic oesophagitis common in?
Children with atopy
What are symptoms of eosinophilic oesophagitis
vomiting
discomfort when swallowing
bolus dysphagia
How do you diagnose eosinophilic oesophagitis
By ENDOSCOPY
- linear furrows and trachealisation of oesophagus
How do you manage eosinophilic oesophagitis
oral corticosteroids (fluticasone / viscous budosenide)
How do you. measure dehydration in children’
By looking at degree of WL during diarrhoea illness
- <5% body weight = not clinically detectable
- 5-10% body weight = clinical dehydration
- > 10% body weight = shock
What are maintenance fluids that are appropriate for children?
0-10kg = 100ml/kg 10-20kg = 1L + 50ml/kg for every kg over 10 20+kg = 1500 + 20ml/kg for every kg over 20
What fluids do you give to a child with shock?
Rapid infusion of 0.9% NaCL
what is the normal frequency of defecation in children?
Varies with age
infants: 4x day in 1 week
1 year old: 2x day
What is the definition of constipation
infrequent passage of dry, hardened faces accompanied by straining, pain, bleeding, and associated with hard stools
What factors precipitate constipation
dehydration
reduced fluid intake
anal fissures
anxiety /psycholocial factors
What are primary causes for constipation to exclude
hiaschprung disease
Lower SC problems
anorectal abnormalities s
Hypothyroidism, hypercalcaemia
Coeliac’s
Should you do DRE in a child
NO
How do you assess impaction in a baby
abdo palpation
will reveal small hard mass usually in LIF
How do you manage constipaation with no impaction
Maintenance laxatives - Movicol
+/- stimulant
Consider behavioural changes
What is movicol
Polyethylene glycol + electrolytes
How do you manage constipation with impaction
Movicol Paediatric Plain (2 week escalating dose)
+/- stimulant
What are behavioural changes to consider for constipation
- scheduled toileting
- bowel diary
- positive reward system
What is cow milks protein allergy
Allergic reaction of the immune system to protein in cows milk
What are symptoms in cow milks protein allergy
D&V
rash
wheezing
faltering growth
What is management for cow milks protein allergy
Breast: mother to avoid cows milk
Formula: hypoallergenic formula
+ monitor growth
How do you investigate for pyloric stenosis
- Abdo exam:; visible peristalsis, pyloric mass (like an olive) in RUQ
- Perform test feed
- USS + U&E
What are the two top causes of peptic ulceration ?
H pylori
NSAIDS
What is presentation of a peptic ulcer
- epigastric pain (wakes them up at night, radiates to back)
- bloating
- belching
- vomiting
- haematemesis
- perforation
What is the difference in presentation between gastric ulcer and duodenal ulcer
Gastric ulcer = pain worse on eating (presence of food increaases HCl production)
Duodenal ulcer = pain better on eating
How do you investigate peptic ulcer from H pylori
TEST before you TREAT
C-13 breath test (as H pylori produces urease)
OR
Stool antigen in children
What is mx for H pylori
Omeprazole + eradication therapy (amox + clary/metronidazole)
What is toddler’s diarrhoea
benign condition
due to fast transit of food through digestive system
often contains undigested foods
How do you manage toddler’s diarrhoea
no need
just plot centiles
What part of GI tract does Chron’s affect
Distal ileum / proximal colon
What is the histological hallmark of Chrons
Non-caseating epithelioid cell granulomata
What are the 4 PILLARS of treatment (medical management) for Chrons
- Steroids (predinisolone)
- immunosuppressants (azathioprine, methotrexate)
- Biological therapies (infliximab)
- aminosalicates (mesalazine)
What part of the GI tract does UC affect
COLON mucosa
What are histological fts of UC
Mucosal inflammation
Crypt damage
Ulceration
What are extra intestinal fts of UC
Mucosal inflamm
Crypt damage
Ulceration
How do you assess UC severity in children
PUCAI
Paediatric Ulcerative Colitis Activity Index
How do you manage UC
Aminosalicylate
Steroids
how do you manage anal fissure in children
Advise :
- against stool withholding
- on importance of anal hygene
Ensure stool are soft
- increase fibre
- increase fluid intake
- consider stool softener
Manage pain:
- glyceryl trinitrate intra-anally
- simple analgesia
- sit in a shallow warm bath to help relieve pain
What must you do in the annual review for coeliac disese
- check height, weight, BMI
- review symptoms
- review adherence to diet (IgA-tTG titre every 3m until normalised, and then yearly)
- consider blood tests (coeliaac serology, FBC, TFT; LFT, vit D, B12, folate, calcium, U&E)
when do you give oral vs IV fluids for rehudration
ORAL REHYDRATION is mainstay
only give IV fluids if in shock/dehydration/vomiting
