Gastroenterology - Jaundice/Malabsoption/Other

Question 1

What is the difference between conjugated and unconjugated jaundice?

Answer 1

increased unconjugated jaundice means it hasn’t passed though the liver yet so due to
- too much haem break down
- problem with conjugating in the liver
when there is increased conjugated bilirubin it means it has passed through the liver but there is something preventing the secretion of bilirubin into the bile

Question 2

Why is important to check stool colour in a child with prolonged jaundice?

Answer 2

suggests bile duct obstruction

Question 3

What are the investigations used to in biliary atresia?

Answer 3

• raised conjugated bilirubin and abnormal LFTs
• fasting abdo USS may demonstrate contracted or absent gall bladder
• cholangiogram (ERCP) which fails to outline biliary tree can confirm a diagnosis
• liver biopsy (can show hepatitis)

Question 4

How does biliary atresia present?

Answer 4

mild jaundice 
pale stools
normal birth weight followed by faltering growth 
hepatomegaly 
initially splenomegaly due to HTN

Question 5

How does viral hepatitis present?

Answer 5

nausea 
vomiting 
abdominal pain
lethargy 
jaundice (30-50% do not) 
large tender liver is common and 30% will go to develop splenomegaly 
coagulation is normal 
transaminases are usually raised

Question 6

How does coeliac disease present in children?

Answer 6

profound malabsorptive syndrome at 8-24 months
after introduction of wheat containing foods
faltering growth
abdominal distention
buttock wasting
abnormal stools
general irritability

Question 7

How is the diagnosis of coeliac disease made?

Answer 7

anti-tTG serological test
then demonstration of mucosal changes on small intestine biopsy performed endoscopically
followed by resolution of symptoms and catch up growth upon gluten withdrawal

Question 8

What are the symptoms of food allergy?

Answer 8

IgE mediated (type 1) = urticarial rash, facial swelling, anaphylaxis Non-IgE mediated (type 2) = diarrhoea, vomiting, abdominal pain and sometimes faltering growth. Colic and eczema may also be present

Question 9

How are food intolerances managed?

Answer 9

avoidance of relevant food
allergic attack self management plan should be written non sedating anti-histamines can be used in mild reactions epipen (adrenaline) should be given to children with a severe reaction

Question 10

What is malabsorption?

Answer 10

disorders affecting the digestion and absorption of nutrients manifest as:

• abnormal stools
• poor weight gain/faltering growth in most cases
• specific nutrient deficiencies

Question 11

What are the causes of malabsorption?

Answer 11

coeliac disease
food allergy or intolerance short bowel syndrome (after large surgical resection)
specific enzyme deficits (lactase deficiency)
cystic fibrosis causing exocrine pancreatic dysfuntion
parasitic infections from travels abroad

Question 12

What is colic?

Answer 12

common in first few months of life paroxysmal, inconsolable crying or screaming often accompanied by drawing up of the knees and passage of excessive flatus

Question 13

How is colic managed?

Answer 13

condition is benign

support and reassure parents if severe and persistent may be due to cows milk allergy/GORD

Question 14

How can cows milk allergy be treated?

Answer 14

two week trial of cows milk protein free (protein hydrolysate) formula

Question 15

What is toddlers diarrhoea and the causes?

Answer 15

most common cause of persistent loose stools in preschool children affected children are well and thriving proportion of them may have coeliac disease or be consuming excessive fruit juice once other causes have been excluded majority of cases result from IBS equivalent and improve with age

Question 16

How can you reassure parents toddlers diarrhoea is not due to a serious underlying cause?

Answer 16

common in this age would have faltering growth if serious

Question 17

What are the presenting features of Crohns?

Answer 17

growth failure 
puberty delayed 
abdominal pain 
diarrhoea 
weight loss 
general ill health (fever, lethargy) 
extra intestinal manifestations (oral lesions, perianal skin tags, uveitis, arthralgia, erythema nodosum)

Question 18

What are the extra intestinal manifestations of Crohns?

Answer 18

extra intestinal manifestations: oral lesions, perianal skin tags, uveitis, arthralgia,erythema nodosum

Question 19

What are the differences between Crohns and UC?

Answer 19

Crohns affects mouth to anus
UC affects only the large colon
Crohns can have healthy areas between inflammation whereas UC is more uniform and uniterupted
UC often associated with rectal bleeding and blood in stool

Question 20

How does UC present?

Answer 20

rectal bleeding
diarrhoea
colicky pain
can have weight loss and growth failure although this is less frequent than in Crohns

Question 21

What are the treatment options for Crohns?

Answer 21

• remission is induced when normal diet is replaced by whole protein modular feeds for 6-8 weeks
• systemic steroids are needed if this is ineffective
• immunosuppressant medication is almost always required to maintain remission
• supplementary enteral nutrition may be required
• surgery is necessary for complications (obstruction , fistulae)

Question 22

What are the treatment options for UC?

Answer 22

• aminosalicylates are used for induction and maintenance therapy
• topical steroids can be used
• systemic steroids and immunomodulatory therapy for exacerbations
• biological therapies such as infliximab in patients with resistant disease
• surgery
• colectomy with ileostomy is severe

Question 23

How does gastritis present?

Answer 23

epigastric pain (wakes them at night)
pain radiates to back
FH of peptic ulcerationcan also have bloating and vomiting

Question 24

What is H.Pylori infection?

Answer 24

causes antral gastritis associated with nausea and vomiting identified on gastric biopsies, urease breath test and stool testing

Question 25

How are gastric duodenal ulcers treated?

Answer 25

PPIs (omeprazole) and eradication therapy (amoxicillin and metronidazole or clindamycin) stop smoking and drinking alcohol too as risk factors

Question 26

What is mesenteric adenitis?

Answer 26

presentation similar to appendicitis diagnosed in children with large mesenteric nodes on laparoscopy but whose appendix is completely normal (doubts as to whether this is acc a ting)