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Gastroenterology Flashcards

1
Q

Describe the spectrum of vomiting in children. What are some red flag signs/symptoms with vomiting?

A
  • Posseting: small quantities, comes up with air. Due to immature sphincter
  • Regurgitation: larger quantities, more forceful
  • Vomiting: forceful, large quantities of stomach contents

Red flags:

  • Bilious vomiting
  • Haematemesis
  • Projectile
  • Altered consciousness, bulging fontanelle
  • Abdo distension + constipation
  • Bloody stool
  • Faltering growth
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2
Q

List some causes of vomiting in children

A
  • Infection: Gastroenteritis, meningitis, UTI
  • Intestinal obstruction
  • Pyloric stenosis
  • Intussusception
  • GORD
  • Food intolerance, CMPA
  • Whooping cough
  • DKA
  • Drugs/toxins
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3
Q

Why is GORD common in infants? What is the prognosis?

A
  • Immature sphincter, lying down, liquid diet

- Usually resolves by 12 months due to resolution of the above causes ^

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4
Q

When is GORD problematic? What are the risk factors for severe disease?

A
  • If leading to faltering growth, dehydration, metabolic abnormality, oesophagitis, aspiration
  • RFs: cerebral palsy, prematurity, previous surgery for TOF/oesophageal atresia
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5
Q

The mother of a 4 month old girl brings her to the GP because she is concerned about the amount of milk she is bringing up after feeding. What is your approach?

A

History:

  • Onset, progression, severity (frequency, quantity), character of the vomit (colour, forcefulness)
  • Symptoms: stools, irritability, hydration, growth, abnormal movements with feeding
  • Feeding history: type, any changes
  • PMH, DHx, allergies
  • Birth, immunisations, development screen
  • Home life

Examination:

  • General exam assessing for dehydration, wellbeing
  • Abdo: palpate, listen

Ix: only if indicated

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6
Q

How would you diagnose GORD?

A
  • Usually clinical diagnosis is sufficient
  • If worrying associated symptoms eg. bloody vomiting, persistence beyond 1 year, etc then investigations may be used:
  • Oesophageal pH monitoring: for ?GORD if unsure
  • Upper GI contrast study: recurrent bilious vomiting
  • Endoscopy: blood, dysphagia, faltering growth
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7
Q

How is GORD managed?

A

Explain and reassure that it will improve. Usually no need for intervention if not causing problems
-Conservative: first line. Feed less and more frequently, upright position after feeding.
Second line: If breastfed: alginate therapy. If formula: feed thickeners
-Medical: PPIs or H2R antagonists (ranitidine)
-Surgical: fundoplication. Only if severe/persistent. Must have endoscopy first.

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8
Q

What is Sandifer syndrome?

A

Reflux episodes associated with abnormal body movements eg. back arching (opisthotonus), torticollis, etc.

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9
Q

What is pyloric stenosis? Describe the presentation

A
  • Pyloric stenosis is caused by a hypertrophy of the pylorus muscle leading to gastric outflow obstruction and forceful vomiting of gastric contents
  • Presents around 2-8 weeks with projectile (milky) vomiting, hunger, weight loss. In severe cases there may be a metabolic alkalosis (low Na and K)
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10
Q

How is pyloric stenosis diagnosed? What is the management?

A
  • Diagnosis: palpable olive mass, +/- test feed to observe gastric peristalsis. Abdo USS can be used but is not needed if history + exam suggestive. Do U+Es in all.
  • Management: IV fluid resusc + correction of electrolytes. Ramstedts pyloromyotomy is definitive management.
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11
Q

What is colic? How does it present?

A

Colic is a common condition affecting infants, which describes episodes of inconsolable crying with drawing up knees + passing large amounts of gas.
***Important to be aware of NAI in these cases

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12
Q

How is colic managed?

A
  • Reassure the parents: very common (40% in first weeks), usually resolves by 6 months
  • Info and support (NHS, health visitor)
  • Encourage parental self care!!!!!! eg. help from family and friends, taking a time out
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13
Q

Name some causes of acute abdominal pain in children

A
  • Infectious: appendicitis, gastroenteritis, pyelonephritis, UTI
  • Intestinal obstruction, strangulated hernia
  • IBD
  • Constipation
  • DKA
  • Gynaecological: cyst accident, torsion, PID
  • Urological: torsion
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14
Q

Describe the presentation of appendicitis. How is it diagnosed and managed?

A
  • Presentation: acute umbilical -> RIF pain, N+V, anorexia, fever, tenderness, guarding
  • Diagnosis: clinical. Urine dip. FBC, CRP. Can use USS to aid diagnosis but is not definitive
  • Management: surgical. Make NBM, notify surgeons, give IV fluids, pain relief, IV antibiotics
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15
Q

What is mesenteric adenitis? How does it present?

A

Inflammation of the lymph nodes in the abdomen, usually viral cause.
Non-specific abdo pain, URTI and cervical lymphadenopathy

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16
Q

What is intussusception? How does it present?

A

Intussusception is a surgical emergency caused by invagination of proximal bowel into distal bowel (usually the ileum into caecum).
Presents with paroxysmal colicky acute abdo pain, vomiting and redcurrant jelly stools, abdo distension, anorexia, irritability. Can progress to shock if untreated due to necrosis + oedema of bowel.

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17
Q

How is intussusception diagnosed? Managed?

A

-Diagnosis: clinical findings + USS (target sign/donut sign) if stable. If signs of peritonitis, AXR should be done. Air/liquid enema is BEST test (most specific and sensitive)

  • Management: IV fluids. Rectal air insufflation. BS antibiotics eg. clindamycin + gent OR tazocin
  • If peritonitis/free air in abdo: surgical management
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18
Q

What can lead to recurrent intussusception? What else can this cause?

A

Meckel’s diverticulum. Can lead to intussusception, volvulus, rectal bleeding

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19
Q

What is malrotation? How does it present?

A

Malrotation occurs when there is abnormal rotation of gut during fetal development. This can cause obstruction due to Ladd bands (bits of mesentery) crossing the duodenum. This usually presents with an acute abdomen in the first days of life

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20
Q

List some causes of recurrent abdominal pain in children

A
  • Idiopathic
  • Inflammation: IBD, coeliac, gastritis and peptic ulcer
  • Constipation
  • Functional: IBS, abdo migraine, psychosomatic pain
  • Mesenteric adenitis
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21
Q

How should you manage a child with recurrent abdominal pain?

A
  • Unlikely to find an organic cause, but need to do enough to rule one out
  • Full history: pain, triggers, diet, psychosocial factors
  • Examination: general, abdo, anus (infant), growth
  • Ix: urine dip, anti-TTG, TFTs, consider abdo USS
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22
Q

Describe the presentation of IBS

A
  • Often young women with history of anxiety/depression

- Abdo pain (periumbilical, relieved by defecation), bloating and distension, altered stools eg. diarrhoea/constipation

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23
Q

Describe the presentation of peptic ulcer disease. How is it diagnosed?

A
  • Presents with recurrent epigastric pain often felt at night, radiating to the back, associated with nausea
  • Diagnosis: clinical with help of urease breath test (CLO, C-13)/stool antigen test to diagnose H pylori
  • If PPIs are not effective in relieving symptoms + antibiotics if H plyori +ve -> endoscopy
24
Q

How is peptic ulcer disease managed?

A
  • Trial of PPIs

- Antibiotics if H pylori +ve: 7 days of Amox + metro/clari

25
Q

What are some common causes of gastroenteritis?

A

Viral: rotavirus (most common), norovirus
Bacterial: Campylobacter, Salmonella, Shigella, E coli
Protozoan: Gardia

26
Q

How does gastroenteritis present?

A
  • Sudden onset diarrhoeal illness, mild fever/systemically unwell, vomiting
  • Severe abdo pain esp. Campylobacter
  • Bloody stools in some bacterial
  • Excessive flatulence in Giardia
  • Significant dehydration in severe cases esp cholera + E coli
27
Q

Which children are at a high risk of dehydration from gastroenteritis?

A
  • Neonates esp. LBW, premature
  • Malnutrition
  • Severe vomiting (3+ times/24 hours)
  • Severe diarrhoea (6+ times/24 hours)
28
Q

Describe the management of uncomplicated gastroenteritis

A

Assess severity of dehydration/shock
-Depending on severity + ability to keep down fluids, consider need for admission for IV fluids

Reassure: most diarrhoea lasts 5-7 days, vomiting 1-3 days.
Supportive: rest, light fluids/Lucozade etc, food as able (dry eg. plain toast, crackers)
*If risk of dehydration: oral rehydration solution
Safety net: signs of dehydration/shock (decreased urine output, drowsy, pale, cold hands/feet) seek urgent attention, if lasting >7 days see GP
Prevent spread: wash hands with soap frequently esp after toilet, before food handling, no school until 48 hours after better

29
Q

The father of a 4 year old boy brings him to A&E after calling 111. The child has been vomiting for the past day and has lots of diarrhoea. What is your approach to diagnosis?

A

History:

  • Onset, progression, frequency of vomiting, character + blood, frequency of diarrhoea character + blood, eating + drinking, urine output
  • Symptoms: fever, rash, flu-like symptoms
  • Exposure to others with similar symptoms, recent travel, eating new foods, etc
  • PMH, DHx, allergies
  • Immunisations, development screen, home life

Examination:

  • A to E if acutely unwell
  • Assess severity of dehydration: level of consciousness, mucous membranes, skin turgor, feel peripheries + cap refill, abdo exam
  • Vital signs

Ix: depending on clinical indication eg. stool sample for MC&S if bloody, immunocompromised child, history of recent travel, extended illness, etc

30
Q

How do you assess for dehydration?

A

Level of consciousness: lethargic, irritable, drowsy
Colour of the skin: pale, mottled
Peripheries: warm or cool, pulses normal or weak
Cap refill
Mucous membranes
Skin turgor
Sunken eyes, sunken fontanelle
HR, RR, BP
Urine output
*Weight is the best objective measure (<5%, 5-10%, >10%)

31
Q

Describe how to use oral rehydration solution for children with gastroenteritis

A
  • Give 50ml/kg ORS prepared according to instructions over a period of 4 hours
  • Continue breastfeeding
  • Give normal fluids in addition
32
Q

When should different fluids be given to children with gastroenteritis?

A
  • Not clinically dehydrated: normal fluids
  • Not clinically dehydrated but at risk: normal fluids, consider prescribing ORS (Dioralyte)
  • Clinically dehydrated: ORS +/- normal fluids (50ml/kg over 4 hours)
  • Unable to keep down oral fluids due to persistent vomiting, or deterioration in state: IV fluids
  • Clinical shock: IV fluid challenge (20 ml/kg 0.9% NaCl), repeat as needed
33
Q

How are routine maintenance fluids calculated? What is the correct dose for maintenance fluids for a 35kg 8 year old girl?

How much fluid should be given for rehydration?

A
  • 100ml/kg/day for 1st 10 kg
  • 50ml/kg/day for 2nd 10kg
  • 20ml/kg/day for everything >20kg

35kg= 10010+5010+(20*15)= 1000+500+300= 1800ml/day

For rehydration, use maintenance fluids + 50ml/kg if clinically dehydrated or 100ml/kg if shocked.

34
Q

What is the main worry in a child that is dehydrated? What are the red flags signs/symptoms?

A

Hypovolaemic shock.
Red flags to look for in a dehydrated child: clinically unwell/deteriorating, altered consciousness, tachycardia, tachypnoea, reduced skin turgor, sunken eyes

35
Q

What are the types of dehydration?

A
  • Isonatraemic
  • Hyponatraemic
  • Hypernatraemic: uncommon, harder to identify clinically. Bad because more neuro stuff eg. jittery, seizures, coma
36
Q

Faltering growth and loose stools are signs of ___? What are some causes?

A

Malabsorption

  • Coeliac disease
  • Food allergy/intolerance eg. CMPA
  • IBD
  • CF
  • Short bowel syndrome
  • Infestation
37
Q

Explain the pathophysiology of coeliac disease

A
  • Antibodies to gliadin (protein found in gluten) form
  • Consumption of gluten causes inflammatory reaction in the mucosa of the small bowel
  • -> crypt hyperplasia, villous atrophy, infiltration of lymphocytes
38
Q

Describe the presentation of coeliac disease

A
  • Can present around weaning (8-24 months) with malabsorptive symptoms eg. faltering growth, loose stools, abdo distension, buttock wasting
  • Or later in childhood with faltering growth and nonspecific symptoms eg. abdo pain, tiredness (anaemia)
  • Later in adolescence and adulthood
39
Q

How is coeliac disease diagnosed? What is the management?

A
  • Diagnosis: anti-TTG antibodies (+ IgA level), also anti-EMA (endomysial antibodies). Gold standard of Dx is biopsy done under endoscopic guidance (should refer to gastro if +ve antibodies).
  • Management: lifelong total exclusion of gluten from diet. Dietician referral for education and advice. Annual review to monitor growth and antibody level.
40
Q

You are in the GP clinic. A mother of a 11 month old boy with diarrhoea and faltering growth has come in for a follow up appointment. The blood tests show high anti-tTG titres. Explain the diagnosis and management.

A
  • Blood tests show that the baby likely has coeliac disease
  • Coeliac disease is a fairly common condition (1/100), a type of auto-immune condition, which means the immune system is attacking the body rather than germs. In this case, eating gluten (found in wheat eg. bread, pasta) causes the immune system to attack the bowel
  • This causes inflammation, which is causing the diarrhoea and preventing the bowel from absorbing nutrients properly.
  • We need to refer you to the gastroenterologist (the gut doctor) for some further tests to confirm
  • The treatment of coeliac is to completely cut out all gluten from the diet for life. This is because even small amounts of gluten cause the immune system to attack the bowel. Over time, this can cause problems with growth, malnutrition, and long term inflammation of the bowel is associated with certain types of bowel cancer
  • If diagnosed, you will be referred to a dietician who will help to give advice on a gluten free diet
  • Also be seen every year to review growth and symptoms
  • Get information and support from Coeliac UK
41
Q

Describe the presentation of Crohn’s disease in children

A
  • Classically: abdo pain esp RIF, diarrhoea, weight loss
  • Also puberty delay, vitamin deficiency, bloody stool, oral ulcers, uveitis, arthralgia, erythema nodosum, fever, lethargy
42
Q

Describe the pathophysiology and hallmarks of Crohn’s disease

A
  • Inflammatory condition of complex aetiology that causes patchy inflammation of the gastrointestinal tract (skip lesions) from mouth to anus.
  • Common sites affected include the terminal ileum and caecum
  • Full thickness (transmural) inflammation, non-caseating granulomas, strictures, fistulae etc.
  • Also have raised inflammatory markers (ESR, CRP, WCC), low albumin, iron deficiency anaemia
43
Q

How is Crohn’s disease diagnosed?

A
  • Blood tests: microcytic anaemia, iron deficiency +/- other vitamins, raised CRP and ESR, low albumin
  • Endoscopy and biopsy: inflammation, ulceration (cobblestone appearance), strictures, fistulae, non-caseating granulomata
44
Q

How is Crohn’s disease managed in children?

A

Induce remission with nutritional therapy (polymeric diet) +/- steroids if ineffective (pred, IV hydrocort)

  • Can use budesonide/5-ASA (aminosalicylate) as alternatives
  • Add on azathioprine/methotrex if 2+ flare ups in 12 months
  • Infliximab for severe active Crohn’s/refractory

Prevent relapse with immunosuppressants (azathioprine/mercaptopurine)
-Methotrexate if not azathio

Surgery can be used in severe active Crohn’s/if complications eg fistulae, obstructions, etc.

General: MDT approach, education eg. recognising flare ups + what to do
Monitor growth and puberty, symptoms
NO live vaccines if on immunosuppressants

45
Q

Describe the pathophysiology and hallmarks of UC

A
  • Inflammatory condition affecting the distal colon (children often have pancolitis), causing continuous partial thickness inflammation, ulceration, and crypt damage
  • Extra-intestinal manifestations include erythema nodosum, arthritis
46
Q

Describe the presentation of UC. How is it diagnosed?

A
  • Presents with colicky abdo pain, rectal bleeding/bloody stool, diarrhoea, weight loss
  • Diagnosis: bloods for inflammation (WCC, CRP, ESR), endoscopy and biopsy for confirmed diagnosis (ulceration, inflammation, crypt damage)
47
Q

How is UC in children managed?

A

Depends on the severity of the disease, assessed using the PUCAI (paediatric UC activity index) -> score correlates with remission, mild, mod, severe disease

Inducing remission:

  • Mild-mod: give topical aminosalicylates, review in 4 weeks. If extensive disease, also give oral amino. If ineffective, try oral steroids (pred)
  • Severe: admit to hospital, give IV corticosteroids, consider need for surgery.

Maintaining remission: topical aminosalicylates or oral if extensive disease.
-If frequent admissions for relapses, consider immunosuppressants (azathioprine/mercaptopurine)

General: MDT approach, education, support
-Monitor growth and puberty

48
Q

Name some causes/risk factors for constipation

A
  • Low fibre diet
  • Dehydration
  • Anal fissures
  • Hirschsprungs
  • Obstruction (acute) eg. malrotation, intussusception
  • Hypothyroidism
  • Psychosocial eg. anxiety
49
Q

A mother has brought her 6 year old daughter to the GP because she has not been opening her bowels. What do you want to know?

A
  • Last time they opened, how they were like before then (eg. sudden or progressively less), straining, different behaviours when using the toilet
  • Character of stools: hardness, quantity, blood
  • Abdo pain, pain on passing stools
  • Incontinence
  • If acute: passing gas? Vomiting? Abdo pain?
  • Diet and fluid intake
  • PMH, DHx, allergies
  • Immunisations, development (esp troubles walking), social (changes at home/school)
50
Q

Describe the management of constipation

A

Conservative: diet modification, increase fluid intake, toileting habits (regular times eg post meal, star chart)
Medical:
-If no impaction: maintenance laxatives with polyethylene glycol 3350 + electrolytes eg. 1 sachet daily but tailor for regular soft stools, max 4 daily. Add stimulant as needed. Should continue for several weeks after establishing regular stools, then slowly taper and monitor. Review in 2-4 weeks.
-Disimpaction regime: starting at 2 sachets/4 if 5-12 years on 1st day, increasing by 2 every other day/every day until max of 8 or 12 a day. Consider stimulant if ineffective. Review in 1 week. Continue until soft stools passing.

51
Q

How can you diagnose faecal impaction?

A
  • Overflow soiling
  • Palpable abdominal mass
  • AXR shows faecal loading
52
Q

What are the different types of laxatives?

A
  • Bulk-forming: fybogel
  • Osmotic: lactulose, macrogol eg. Movicol (polyethylene glycol)
  • Stimulant: bisacodyl, Senna
  • Stool-softener: docusate
53
Q

What is Hirschprungs disease? How does it present? How is it diagnosed? What is the treatment?

A

A condition caused by absence of ganglion cells in the myenteric plexus of the rectum –> failure to pass meconium, obstruction (constipation, vomiting, distension)
Diagnosed with suction full thickness rectal biopsy to show absence of ganglion cells
Management: surgical removal of affected bowel (anorectal pull through)

54
Q

Describe the pathophysiology and presentation of CMPA

A

Cow’s milk protein allergy can be IgE mediated or non-IgE mediated (Type IV), which present differently.

  • IgE: acute onset N+V, skin reaction, wheeze, angioedema etc
  • Non-IgE: chronic diarrhoea, rash, faltering growth, irritability, poor feeding, bloody stool, colic, vomiting/reflux
55
Q

How is CMPA diagnosed? What is the management?

A

-Diagnosis: IgE mediated may be obvious, non-IgE should be considered if faltering growth, diarrhoea, etc. Usually clinical diagnosis with confirmation after exclusion diet

Management:

  • Referral to allergy specialist for suspected IgE mediated or severe non-IgE mediated
  • Breastfed babies: mum to exclude cows milk from diet
  • Formula fed: recommend return to breastfeeding if possible, trial of extensively hydrolysed formula eg. Aptamil Pepti, Alimentum
  • Must have a reintroduction in 2-4 weeks to confirm diagnosis. If symptoms return, keep exclusion diet
  • Reintroduction of milk products using milk ladder around 1 year

Paediatrics (13 decks)

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