Gastroenterology and paeds surgery Flashcards
What is the presentation of constipation in children?
(reduced freq of stool compared to normal)
- < 3 stools a week
- Hard stools, rabbit dropping, difficult and painful to pass
- Abdo pain, can palpate stool in abdo
- Retentive posturing - standing/sitting w straight stiff legs, voluntarily holding in stool
- Rectal bleeding
- Faecal impaction = overflow soiling
- Encopresis
What is encopresis?
- Faecal incontinence, not pathological until 4 years old
- Sign of chronic constipation = rectum becomes stretched and looses sensation
- Large hard stools remaain in rectum and loose stools leak out = soiling
- Other causes - Hirschprung’s, ID, cerebral palsy, stress and abuse
What are lifestyle factors contributing to constipation?
- Habitually not opening bowels
- Low fibre diet
- Poor fluid intake and dehydration
- Sedentary lifestyle
- Psychosocial probs - difficult home or school environment
What are secondary causes of constipation?
- Hirschsprung’s
- Cystic fibrosis, esp meconium ileus
- Hypothyroidism, hypocalcaemia, coeliac disease
- Spinal cord lesions
- Sexual abuse
- Intestinal obstruction
- Anal stenosis
- Cows milk intolerance
What are the red flags in constipation?
- Not passing meconium w/i 48 hours of birth = CF or Hirschsprung’s
- Neuro signs, esp in lower limbs
- Vomiting - bowel obstruction and Hirschsprung’s
- Ribbon stool - anal stenosis
- Abnormal anus = IBD, anal stenosis, sexual abuse
- Abnormal lower back or buttocks - spina bifida, sacral agenesis
- Failure to thrive - Coeliac, hypothyroid
- Acute severe abdo pain and bloat - obstruction or intussusception
What are some complications of constipation?
- Pain
- Reduced sensation
- Anal fissures
- Overflow and soiling
- Psychosocial morbidity
What is the management of idiopathic constipation?
- Correct reversible factors - high fibre diet and good hydration
- Start laxatives - movicol 1st line - long term and slowly weaned off
- Faecal impaction = disimpaction regimen w high doses of laxatives - at first osmotic laxative, then stimulant if not tolerated
- Encourage and praise visiting the toilet - scheduling visits, bowel diary and star charts
How do you diagnose Hirschsprung’s disease?
- Usually presents w delay in meconium and failure to thrive so normally in 1st month but can present late rarely
- Rectal biopsy = gold standard
- Barium enema
What is Coeliac disease?
Autoimmune condition where gluten exposure causes inflam of small bowel, esp jejunum due to autoab attacking epithelial cells. Causes atrophy of intestinal villi = malabsorption of nutrients and disease related sx.
What are the ab and genetic associations in Coeliac disease?
Anti TTG and anti EMA - increase w more active disease and disappear w effective treatment
HLA-DQ2 and HLA-DQ8 (don’t know if need to know)
Always test new T1DM diagnosis for coeliac disease even if don’t have sx.
What is the presentation of coeliac disease?
- Can be asymptomatic
- Failure to thrive in young children
- Diarrhoea or steatorrhoea
- Fatigue, weight loss, mouth ulcers
- Secondary iron, B12 or folate deficiency anaemia
- Dermatitis herpetiformis - itchy blistery skin on abdo
- Abdo distension, short statue and wasted buttocks
What neurological sx can coeliac disease present with?
- Peripheral neuropathy
- Cerebellar ataxia
- Epilepsy
What are the ix into Coeliac disease?
- Need to still be on gluten inclusive diet while ix
- Basic bloods - FBC, U+E, LFT, iron, B12, folate
- Total immunoglobulin A levels to exclude IgA def
- Check for ab - serology
- OGD and intestinal biopsy - crypt hypertrophy, villous atrophy, intra epithelial lymphocytes
What are the complications of coeliac disease?
- Vit deficiency, anaemia, OP
- Ulcerative jejunitis
- Enteropathy associated T cell lymphoma of the intestine EATL
- Non Hodgkin lymphoma
- Small bowel adenocarcinoma but rare
- Hyposplenism
What is the treatment of coeliac disease?
Life long GF diet
What is the presentation of GORD in children?
- Chronic cough/hoarse cry
- Distress, crying or unsettled after feeding - normal for babies to have some reflux after larger feeds but is a problem when they are distressed
- Reluctance to feed
- Pneumonia
- Poor weight gain
- Retrosternal or epigastric pain may be reported
What are some differentials for vomiting in children?
- Overfeeding
- GORD
- Pyloric stenosis - projective vomiting
- Gastritis and gastroenteritis
- Appendicitis
- Infections - UTI, tonsilitis, meningitis
- Intestinal obstruction
- Bulimia
- Upper GI bleed
- Raised ICP
What are some red flags for vomiting?
- Not keeping down feed or forceful vom - pyloric stenosis or bowel obstruction
- Bile stained vomit - bowel obstruction
- Haematemesis or malaena
- Abdo distension
- Reduced conc, bulging fontanelle, neuro signs - raised ICP or meningitis
- Resp sx - aspiration pneumonia
- Blood in stools - gastro or cows milk allergy
- Signs of infection
- Rash, angioedema
- Apnoea - v concerning
What is apnoea?
Muscles and soft tissues of throat collapse causing total blockage of the airway for more than 10 secs
What is the management of GORD?
Simple - small freq meals, burp reg, don’t over feed, keep baby upright after feeding
Problematic - gaviscon mixed w water after feeds for a 2 week trial, thickened milk or formula, PPI when doesn’t work gaviscon doesn’t work
Severe - need to ix further = barium meal and endoscopy, surgical fundoplication
What are some complications of GORD in children?
- Reflux oesophagitis
- Recurrent aspiration pneumonia
- Recurrent acute otitis media
- Dental erosion
- Apnoea
- Apparent life threatening events
What is Sandifer’s syndrome?
Brief eps of abnormal movements associated w GORD:
- Torticollis - forceful contraction of neck muscles = neck twisting
- Dystonia - arching of back or unusual posture
Resolves as reflux improves.
What are some medical differentials for abdo pain in children?
- Constipation
- UTI
- Coeliac disease
- IBD and IBS
- Mesenteric adenitis
- Abdo migraine
- Pyelonephritis
- Henoch Schonlein purpura
- Tonsilitis
- Diabetic ketoacidosis
- Infantile colic
What are some surgical differentials for abdo pain?
- Appendicitis
- Intussusception
- Bowel obstruction
- Testicular torsion
- Ectopic
- Ovarian torsion and cyst rupture
- Meckel’s diverticulitis
- Pancreatitis
- Mesenteric adenitis