Gastroenterology: Biliary atresia, Intussusception; Constipation Flashcards
What are red flag symptoms for abdominal pain? [+]
Bilious vomiting
Previous abdominal surgery
Features of peritonitis
Blood in stool or vomitus
Features of obstruction
Distension
WL
Systemic signs
A child presents with constipation.
What are red symptoms and what could they be? [+]
Constipation from birth to first few weeks:
- Hirschprungs (distal bowel nerves don’t develop)
Delayed passage of meconium (first 48hrs)
- cystic fibrosis or Hirschsprung’s disease
Neurological signs or symptoms, particularly in the lower limbs
- cerebral palsy or spinal cord lesion
Vomiting
- intestinal obstruction or Hirschsprung’s disease
Ribbon stool
- anal stenosis
Abnormal anus
- anal stenosis, inflammatory bowel disease or sexual abuse
Abnormal lower back or buttocks spina bifida, spinal cord lesion or sacral agenesis
Failure to thrive
- coeliac disease, hypothyroidism or safeguarding
Acute severe abdominal pain and bloating
- obstruction or intussusception
Typical features in the history and examination that suggest constipation are: [+]
- Less than 3 stools a week
- Hard stools that are difficult to pass
- Rabbit dropping stools
- Straining and painful passages of stools
- Abdominal pain
- Holding an abnormal posture, referred to as retentive posturing
- Rectal bleeding associated with hard stools
- Faecal impaction causing overflow soiling, with incontinence of particularly loose smelly stools
- Hard stools may be palpable in abdomen
- Loss of the sensation of the need to open the bowels
Describe the process of desensitisation of the rectum [5]
Often patients develop a habit of not opening their bowels when they need to and ignoring the sensation of a full rectum.
Over time they loose the sensation of needing to open their bowels, and they open their bowels even less frequently.
They start to retain faeces in their rectum. This leads to faecal impaction, which is where a large, hard stool blocks the rectum.
Over time the rectum stretches as it fills with more and more faeces. This leads to further desensitisation of the rectum.
The longer this goes on, the more difficult it is to treat the constipation and reverse the problem.
What are the secondary causes of constipation in children [5]
- Hirschsprung’s disease
- Cystic fibrosis (particularly meconium ileus)
- Hypothyroidism
- Spinal cord lesions
- Sexual abuse
- Intestinal obstruction
- Anal stenosis
- Cows milk intolerance
Describe the management plan for constipation [+]
NICE produced guidelines in 2010 on the diagnosis and management of constipation in children. A diagnosis of constipation is suggested by 2 or more of the following:
Stool pattern
Symptoms associated with defecation
History
Describe how these may present in children < 1 [3]
Stool pattern:
- Fewer than 3 complete stools per week
- Hard large stool
- ‘Rabbit droppings’ (type 1)
Symptoms associated with defecation
- Distress on passing stool
- Bleeding associated with hard stool
- Straining
History
- Previous episode(s) of constipation
- Previous or current anal fissure
NICE produced guidelines in 2010 on the diagnosis and management of constipation in children. A diagnosis of constipation is suggested by 2 or more of the following:
Stool pattern
Symptoms associated with defecation
History
Describe how these may present in children > 1 [3]
Stool pattern:
- Fewer than 3 complete stools per week
- Overflow soiling (commonly very loose, very smelly, stool passed without sensation
- ‘Rabbit droppings’ (type 1)
- Large, infrequent stools that can block the toilet
Symptoms associated with defecation
* Poor appetite that improves with passage of large stool
* Waxing and waning of abdominal pain with passage of stool
* Evidence of retentive posturing: typical straight-legged, tiptoed, back arching
* posture
* Straining
* An**al pain
History
- Previous episode(s) of constipation
- Previous or current anal fissure
- Painful bowel movements and bleeding
After making a diagnosis of constipation NICE then suggesting excluding secondary causes. If no red or amber flags are present then a diagnosis of idiopathic constipation can be made.
Which regards to timing, passage of meconium, stool pattern, growth, neuro / locomotor, abdomen and diet, what would indicate if its idiopathic or other? [+]
How do you treat constipation of fecal impaction is present [4]
- polyethylene glycol 3350 + electrolytes (Movicol Paediatric Plain) using an escalating dose regimen as the first-line treatment
- add a stimulant laxative if Movicol Paediatric Plain does not lead to disimpaction after 2 weeks
- substitute a stimulant laxative singly or in combination with an osmotic laxative such as lactulose if Movicol Paediatric Plain is not tolerated
- inform families that disimpaction treatment can initially increase symptoms of soiling and abdominal pain
Describe the maintenence treatment plan for constipation [4]
- first-line: Movicol Paediatric Plain
- add a stimulant laxative if no response
- substitute a stimulant laxative if Movicol Paediatric Plain is not tolerated. Add another laxative such as lactulose or docusate if stools are hard
- continue medication at maintenance dose for several weeks after regular bowel habit is established, then reduce the dose gradually
Why are ribbons stools a red flag? [2]
Explain why the above pathologies cause ribbon stools [2]
Ribbon stools, also known as pencil-thin or narrow stools, are a red flag symptom because they may indicate a significant underlying condition such as Hirschsprung’s disease or an intestinal obstruction.
- Hirschsprung’s disease is a congenital disorder characterised by the absence of ganglion cells in the myenteric and submucosal plexuses of the distal bowel. This results in functional obstruction and severe constipation. Ribbon stools occur due to the partial blockage of the large intestine, which forces stool to become thin in order to pass through.
- Another cause could be an intestinal obstruction like a tumour or polyp. The presence of these masses can physically reduce the diameter of the colon, resulting in ribbon-like stools.
Describe whether GOR is normal in children [1]
In babies there is immaturity of the lower oesophageal sphincter, allowing stomach contents to easily reflux into the oesophagus. It is normal for a baby to reflux feeds, and provided there is normal growth and the baby is otherwise well this is not a problem, however it can be upsetting for parents. This usually improves as they grow and 90% of infants stop having reflux by 1 year.
It is normal for babies to have some reflux after larger feeds. It becomes more troublesome when this causes them to become distressed. Signs of problematic reflux include:
- Chronic cough
- Hoarse cry
- Distress, crying or unsettled after feeding
- Reluctance to feed
- Pneumonia
- Poor weight gain - need to plot weight gain
- Children over one year may experience similar symptoms to adults, with heartburn, acid regurgitation, retrosternal or epigastric pain, bloating and nocturnal cough.
What are the features of GOR in children [4]
Features:
typically develops before 8 weeks,
vomiting/regurgitation
* milky vomits after feeds
* may occur after being laid flat
excessive crying, especially while feeding
If a baby is not losing weight and you don’t suspect serious pathology causing GOR, what advise can you give parents to help? [4]
advise regarding position during feeds - 30 degree head-up
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
NICE do not recommend a proton pump inhibitor (PPI) to treat overt regurgitation in infants and children occurring as an isolated symptom. A trial of one of these agents should be considered if 1 or more of the following apply: [3]
- unexplained feeding difficulties (for example, refusing feeds, gagging or choking)
- distressed behaviour
- faltering growth
Describe what is meant by Sandifer’s Syndrome [1]
What are the key features? [2]
This is a rare condition causing brief episodes of abnormal movements associated with gastro-oesophageal reflux in infants. The infants are usually neurologically normal. The key features are:
Torticollis:
- forceful contraction of the neck muscles causing twisting of the neck
Dystonia:
- abnormal muscle contractions causing twisting movements, arching of the back or unusual postures
The condition tends to resolve as the reflux is treated or improves. Generally the outcome is good.
TOMTIP: Sandifer’s syndrome.
It is worth referring patients with these symptoms to a specialist for assessment, as the differential diagnosis includes more serious conditions such as [2]
It is worth referring patients with these symptoms to a specialist for assessment, as the differential diagnosis includes more serious conditions such as infantile spasms (West syndrome) and seizures.
A child is projectile vomiting in the second week of their life.
What is the most likely dx? [1]
Pyloric stenosis
Describe the pathophysiology of pyloric stenosis [1]
When does it most commonly occur [1]
It is caused by hypertrophy of the circular muscles of the pylorus
- Pyloric stenosis typically presents in the second to fourth weeks of life with vomiting
The pyloric sphincter is a ring of smooth muscle the forms the canal between the stomach and the duodenum. Hypertrophy (thickening) and therefore narrowing of the pylorus is called pyloric stenosis. This prevents food traveling from the stomach to the duodenum as normal.
After feeding, there is increasingly powerful peristalsis in the stomach as it tries to push food into the duodenum. Eventually it becomes so powerful that it ejects the food into the oesophagus, out of the mouth and across the room. This is called “projectile vomiting”.
Describe the typical features of pyloric stenosis [3]
What is the dx? [1]
If you performed a blood gas, what would the pH be? [1]
- ‘projectile’ vomiting, typically 30 minutes after a feed
- constipation and dehydration may also be present
- a palpable mass may be present in the upper abdomen
- hypochloraemic, hypokalaemic alkalosis due to persistent vomiting
Diagnosis is most commonly made by ultrasound.
What is the blood gas likely to be in a pyloric stomach patient? [1]
hypochloraemic, hypokalaemic alkalosis due to persistent vomiting
How do you manage pyloric stenosis? [1]
Management is with Ramstedt pyloromyotomy.
- laparoscopic pyloromyotomy (known as “Ramstedt’s operation“). An incision is made in the smooth muscle of the pylorus to widen the canal allowing that food to pass from the stomach to the duodenum as normal. Prognosis is excellent following the operation.
Dx? [1]
Intussusception
Describe the pathophysiology of intussusecption [2]
Where does it most commonly occur? [1]
Which age group is most commonly impacted? [1]
Intussusception describes the invagination of one portion of the bowel into the lumen of the adjacent bowel, most commonly around the ileo-caecal region.
Intussusception usually affects infants between 6-18 months old. Boys are affected twice as often as girls
Describe the features of intussusception
- intermittent, severe, crampy, progressive abdominal pain
- inconsolable crying
- during paroxysm the infant will characteristically draw their knees up and turn pale
- vomiting
- bloodstained stool - ‘red-currant jelly’ - is a late sign
- sausage-shaped mass in the right upper quadrant
TOM TIP: Look out for the “redcurrant jelly stool” in your exams as this indicates intussusception as a diagnosis. The other classic feature is the sausage-shaped mass in the abdomen. The typical child in the exam will have had a viral upper respiratory tract infection preceding the illness and will have features of intestinal obstruction (vomiting, absolute constipation and abdominal distention). .
Intussusception
* What is the investigation of choice and what does it show? [1]
* What is the management? [2]
ultrasound is now the investigation of choice and may show a target-like mass
Management:
- Fluid resusicitation is key
- reduction by air insufflation under radiological control, which is now widely used first-line compared to the traditional barium enema
- if this fails, or the child has signs of peritonitis, surgery is performed
Describe this US of intussusception [1]
Target like mass
What are two possible complications of intussusception? [2]
If the bowel becomes gangrenous (due to a disruption of the blood supply) or the bowel is perforated
