Gastroenterology and Surgery Flashcards
Pathophysiology of coeliac disease…
Autoimmune disease where anti-TTG antibodies react to prolamins found in gluten, leading to invasion of epithelium in GIT causing villous atrophy
Coeliac disease is associated with…
- Family history
- Down syndrome
- Dermatitis herpetiformis
- T1DM
Features of coeliac disease…
- Pallor
- Diarrhoea
- Pale floating stools
- Anorexia
- Failure to thrive
How is coeliac disease diagnosed?
- Autoimmune assay = anti-TTG
- Endoscopy = villous atrophy, crypt hyperplasia
What is non-IgE mediated food allergy, and how does it present?
Hypersensitivity reaction that occurs hours after ingestion of food , involving the GIT.
Presentation:
- Diarrhoea
- Vomiting
- Abdominal pain
- Failure to thrive
What are the clinical features of ulcerative colitis?
- Occurs mainly in the distal colon
- Continous lesion
- Presentation = diarrhoea, bloody stools, abdominal pain, weight loss, anaemia
Diagnostic features of UC…
- Crypt abscesses
- Mucosal inflammation
- Goblet cell depletion
Management of UC…
- Topical/ oral aminosalicylate - 5-ASA, depending on extent of disease
- Surgery:
- Proctolectomy with ileostomy (whole colon removed and ileum brought out to form stoma)
- Ileoanal anastamosis (stools passed normally but more watery)
What are the clinical features of Crohns?
- Skip lesions - occur along whole GIT from mouth to anus
- Abdominal pain
- Diarrhoea
- Weight loss
- Poor growth
- Peri-anal abscesses, skin tags, fistuale
Diagnostic features of Crohns…
- Transmural inflammation
- Crypt abscesses
- Granulomas
Management of Crohns…
Inducing remission = Oral steroids
Maintaining remission = Immunosuppressants e.g. methotrexate, biological therapy e.g. infliximab
Why do babies have physiological reflux…
- Predominantly liquid-based diet
- Mainly horizontal position
- Short intra-abdominal oesophagus
Management of pathological reflux in children….
Conservative:
- Reduce over -feeding
- Thickening of foods
- Sitting upright after feeds
Medical:
- Gaviscon can be given
- Prokinetics e.g. metoclopramide
- PPIs
Surgery - indicated in resistant cases
How does pyloric stenosis present?
Symptoms:
- Projectile vomiting of large amounts - no bile present
- No diarrhoea
- Baby remains hungry and uncomfortable
Diagnosis of pyloric stenosis …
- Olive-sized pyloric mass on palpation of abdomen
- USS will show thickened pylorus and non-passage into duodenum
- Blood gas shows hypochloraemic metabolic alkalosis
Management of pyloric stenosis…
Nearly all patients require surgery for definitve management: pyloromyotomy (incision made in circular muscle of pylorus to release it )
*Need fluid resuscitation and correction of electrolyte abnormalities prior to procedure.
Key features of gastroenteritis…
- Vomiting
- Diarrhoea
- Fever
- Abdominal pain
Main causes of gastroeneteritis…
Viral:
- Rotavirus = most common in children
- Norovirus
- Adenovirus
Bacterial:
- E coli
- C diff
- Salmonella
- Shigella
Red flags for gastroenteritis…
- Severe abdominal pain
- Persistent diarrhoea > 10 days
- Very unwell
- Vomiting without diarrhoea
Management of gastroenteritis…
*Mainly dependent on child’s hydration status as rehydration is the mainstay of treatment
Mild dehydration = discharge if tolerating oral intake
Moderate dehydration = encourage oral rehydration with ORT, breastfeed, milk/water
Severe dehydration = aggressive rehydration required
What is toddler diarrhoea?
Syndrome of non-specific loose stools which may contain undigested food.
Most children are completely well and thriving and will grow out of the condition by 5 y/o.
Managed by using healthier dietary habits.
How does hypernatraemic dehydration occur?
Seen in neonates who have additional insensible fluid losses in addition to diarrhoea e.g. fever
What are the potential complications of hypernatraemic dehydration?
- May lead to cerebral shrinkage: hyperrreflexia, increased tone, altered consciousness
- Seizures
- Cerebral haemorrhage
What is Henoch Schonlein Purpura?
IgA mediated vasculitis which develops in children post-infection.
Features of Henoch Schonlein Purpura…
- Palpable purpuric rash over buttocks, extensor surfaces of arms and legs
- Abdominal pain
- Polyarthritis
- Features of IgA nephropathy
What is gastrochesis?
Small hole in the abdominal wall which allows some of the intestines to herniate through - directly exposed to air.
Treatment = surgical/ silo (abdominal contents suspended above allowing gravity to put contents back into abdomen)
What is oesophageal atresia, and how does it present?
Congenital defect causing the oesophagus to end in a blind-ended pouch rather than connecting to stomach.
Any attempt at feeding could cause aspiration pneumonia as it overflows into trachea.
What can be given if faeces are palpable on examination?
Constipation - give 2 week course of stool softener, or enema where unsuccessful.
What is Hirschsprung’s disease?
Absence of ganglions in the mysenteric plexus of the rectum and colon leading to lack of peristalsis which leads to intestinal obstruction.
Presentation of Hirschsprung’s?
- Neonatal = failure to pass meconium
- Older children = chronic constipation, abdominal distension
Management of Hirschsprung’s
Colostomy and later reversal with normal bowel anastamosed to rectum
What is NEC?
Necrotising enterocolitis - condition where a portion of the bowel will die and necrotise.
Typically occurs in premature or unwell neonates.
Presentation of NEC…
- Feeding intolerance
- Abdominal distension- rigid and tight
- Bloody stools
- Perforation and peritonitis may occur
Diagnosis of NEC…
Abdominal x-ray findings are normally diagnostic:
- Dilated bowel loops
- Pneumoperitoneum
- Rigler sign (air both inside and outside of bowel wall)
Management of NEC…
- Bowel rest - stopping enteral feeds
- Total parenteral nutrition (TPN)
- Gastric decompression with intermittent suction
- Prompt abx therapy when required
How does appendicitis present in children?
- Rarely seen in under 5 y/o
- May have central abdominal pain, migrating to RLQ
- Slight vomiting
- Pain on sitting up, walking and jumping
- Mild grade fever
Clinical features of testicular torsion…
- Peak incidence in 13-15 year olds
- Sudden onset, severe pain in lower abdomen
- Testis is swollen, red and retracted
- Absence of cremasteric reflex
Management of testicular torsion…
Surgical exploration - both testis should be fixed as there is chance of recurrence in the other testis.
What condition can present similarly to appendicitis, and how is it diagnosed?
Mesenteric adenitis=inflamed lymph nodes within the mesentery causing non-specific abdominal pain.
Normally associated with respiratory tract infection.
Diagnosis = large mesenteric nodes seen on laparotomy.
What is the pathophysiology of intussusception, and where does it most commonly occur?
Invagination of the proximal bowel into the distal segment (telescoping of the bowel) causing acute intestinal obstruction.
Most commonly ileum telescopes into caecum
Characteristic features of obstruction…
- Abdominal distension
- Constipation
- Billious vomiting
- Pain
Key features of intussusception…
- Colicky abdominal pain
- Characteristically draw knees up during bouts of pain
- ‘Red currant jelly’ stool
- Sausage shaped mass in RUQ
Management of intussusception…
- First line = air insufflation (air enema) - used to reduce
- Surgery if insufflation doesn’t work
What is intestinal malrotation?
Incomplete rotation of the bowel during foetal development which may lead to intestinal obstruction/ volvulus.
May be formation of Ladd’s bands (fibrous bands running vertically across duodenum).
How does malrotation present?
- Volvulus may form: bilious vomiting, crampy abdominal pain, abdominal distension, passage of blood in the stools
- Chronic malrotation may lead to recurrent abdominal pain
Functional causes of recurrent abdominal pain…
- Only 10% of recurrent abdominal pain in children has an organic cause…
- IBS
- Non-ulcer dyspepsia
- Abdominal migraine
- Bullying and stress
What is an abdominal migraine?
Syndrome of reccurent episodes of abdominal pain in children - treated like normal migraines.
Clinical features of abdominal migraine…
- Pain is mainly peri-umbilical in region
- Attacks last 2-72 hours
- Associated sx = nausea, vomiting, appetite loss
- NO SYMPTOMS in between episodes
What are the different classifications of neonatal jaundice, and the different causes of these?
UNCONJUGATED (pre-hepatic):
1. Physiological jaundice
- Pathological jaundice:
- Haemolytic = spherocytosis, GP6D, PKU, sickle cell
- Non-haemolytic = breast-feeding jaundice, Gilbert syndrome, Crigler Najjar syndrome
CONJUGATED (hepatic/ post-hepatic) :
- Hepatic:
- Infection = sepsis, Hep A, B, TORCH
- CF, alpha 1 antitrypsin deficiency
- TPN - Post-hepatic:
- Biliary atresia
- Choledocal cyst
Why does physiological jaundice occur?
- Results from erythrocyte breakdown due to immature liver function,
- Low conversion of bilirubin into urobilinogen in GIT therefore more bilirubin returns to circulation
- Normally presents after 2-3 days of life and disappears by day 10
How does breast milk jaundice occur?
Reduced breast milk feeding leads to reduced bowel movements to remove bilirubin from the body therefore an increase in enterohepatic circulation occurs leading to increased reabsorption of bilirubin from the intestines.
Diagnosis of neonatal jaundice…
- Serum bilirubin levels are normally adequate
- Transcutaneous bilrubinometer can be used
Signs of pathological jaundice…
- IUGR
- Signs of intrauterine infection: cataracts
- Excessive sleepiness
- Poor feeding
Management of neonatal jaundice…
- Phototherapy = first line for any newborn with bilirubin > 360micromol/L
- Exchange transfusion used when bilirubin > 428micromol/L
How can kernicterus occur?
Prolonged hyperbilirubinaemia causes bilirubin to accumulate in the grey matter oft the CNS potentially causing irreversible neurological damage.
Presentation of kernicterus…
- Decreased feeding
- High pitched crying
- Hypo/hyper-tonia
- Fevers
- Seizures
How is kernicterus diagnosed?
Physical examination will show asymmetrical moro reflex.
