Gastroenterology Learning Objectives

Question 1

To be aware of current NICE guidelines on infant feeding

Answer 1

• breast feed exclusively for the first 6 months
• first feed within the first hour w/ skin-to-skin contact

benefits:

• ideal nutrition
• reduces GI infection & NEC in preterms
• enhances relationship
• reduced risk of insulin dependent diabetes, HTN & obesity in later life
• reduced breast ca risk for mother

complications:

• unknown quanitities
• disease / drug transmission
• less flexibility
• risk of breast milk jaundice

Question 2

To be able to counsel parents on where to obtain advice / support with relation to breast feeding

Answer 2

• information pack given in the first 24 hours
• should be supported in hospital esp. with first feed
• midwife / health visitor / community nurses can help
• If weaning takes place <6 months, then wheat, eggs and fish should be avoided, as should all food high in salt, sugar or containing honey (risk of botulism)

Question 3

To have a knowledge of specialist formulas and indications for their use ie: whole protein vs semi-hydrolysed vs hydrolysed feeds

Answer 3

breast / formula feeding recommended for 12/12 w/ weaning taking place afrer 6/12

NB: pasteurised cow’s milk can be given from 12/12 but lacking so supplementation needed unless good mixed solids

• use follow-on milk
• full-fat milk up to 5 years

hydrolysed formula:

• contain cow’s milk
• proteins & lactose have been broken down = easier to digest

first milks: normal formula for babies up to 6 months (and above); second milks: help with “hungrier babies” as they take longer to digest but not suitable for young babies

soya:
- high phytoestrogen and aluminium content so not used unless recommended by doctor

Goat’s milk:
- still not suitable for CMA

Question 4

To be able to take a history to determine a differential diagnosis in cases of failure to thrive/faltering growth

Answer 4

mild = falls across 2 centiles
severe = falls across 3 centiles

causes:
Causes of failure to thrive o Inadequate intake
▪ Non-organic/environmental: inadequate availability of food, psychosocial deprivation, neglect or child abuse
▪ Organic: impaired suck/swallow or chronic illness leading to anorexia
o Inadequate retention = vomiting, severe GORD
o Malabsorption = Coeliac disease, CF, cow’s milk protein intolerance, short gut syndrome
o Failure to utilize nutrients = syndromes, congenital infection, metabolic disorders
o Increased requirements = thyrotoxicosis, CF, malignancy, chronic infection (HIV), congenital heart disease

Question 5

Understand what is meant by the term nutrition

Answer 5

= is the intake of food considered in relation to the body’s dietary needs

Question 6

Understand importance of nutrition scoring (MUST tool and paediatric equivalents)

Answer 6

Malnutrition Universal Screening Tool (MUST): a 5-step screening tool to identify adults, who are malnourished, at risk of malnutrition (undernutrition) or obese

o Step 1 - Measure height and weight to get a BMI score
o Step 2 - Note percentage unplanned weight loss and score using tables provided
o Step 3 - Establish acute disease effect and score
o Step 4 - Add scores from steps 1, 2 & 3 together to obtain overall risk of malnutrition
o Step 5 - Use management guidelines and/or local policy to develop care plan

Paediatric Yorkhill Malnutrition Score (PYMS): the paediatric equivalent of MUST
o Step 1 - Measure height and weight to get a BMI score
o Step 2 - Note percentage unplanned weight loss and score using tables provided
o Step 3 - Assess recent change in diet/nutritional support including reduced intake
o Step 4 - Note risk of being undernourished during hospital admission due to decreased intake, increased gut loss or increased energy requirement
o Step 5 - Use management guidelines and/or local policy to develop care plan

0 - low risk = routine care
1 - medium risk = observe
>2 - high risk = treat

Question 7

Understand the concept and presenting features of protein / energy malnutrition (kwashiorkor)

Answer 7

=
• Marasmus oedema is not present; skinfold thickness and mid-arm circumference are markedly reduced, and affected children are often withdrawn and apathetic; with a weight for height more than -3 SD below the median, corresponding to <70% weight for height and a wasted wizened appearance
• Kwashiorkor is another manifestation of severe protein: malnutrition there is generalised oedema, as well as severe wasting due to the oedema the weight may not be severely reduced

• Clinical feature:
o A ‘flaky-paint’ skin rash with hyperkeratosis (thickened skin) and desquamation
o A distended abdomen and enlarged liver usually due to fatty infiltration
o Angular stomatitis
o Hair which is sparse and depigmented
o Diarrhoea, hypothermia, bradycardia and hypotension
o Low plasma albumin, potassium, glucose and magnesium

Question 8

Know recommended intake for infants 0-3months, 3-6 months and 6-12 months

Answer 8

Fruit, vegetables and non-wheat cereals are suitable first weaning food the amount and variety of food should gradually be increased to include other types of cereal, dairy, meat, fish, eggs and pulse

NB: from 6 months, infants receiving breast milk as their main drink should be given a supplement providing vitamina A, C & D

signs baby is ready to wean:
o Starts to show an interest in food
o Is able to sit up although may still need some support
o Wants to chew and put objects in mouth
o Able to reach and grab accurately
o Still seems hungry after a milk feed

Weaning should begin with puried foods, which may be mixed with a little of the usual milk; a few teaspoons should be offered one a day, when the baby is not overly hungry or tired
= still getting most of nutrients from milk (500-600ml / day)
7-9 months: increase variety of foods
9-12 months: 3 meals a day as well as snack

Question 9

Recognise symptoms and signs of overfeeding

Answer 9

o Baby gains average or greater than average weight
o 8 or more heavily wet nappies per day
o Frequent sloppy, foul-smelling bowel motions
o Extreme flatulence o Large belching
o Milk regurgitation o Irritability
o Sleep disturbances

Symptoms associated with overfeeding are commonly mistaken as colic, reflux, milk protein intolerance or lactose intolerance

Question 10

To be able to take a history to differentiate simple constipation from motility disorders such as Hirschprung’s disease

Answer 10

= the infrequent passing of dry, hardened faeces often accompanied by straining or pain

normal:
infant = 4/day; by 1 yr = 2/day; by 4 yr = adult pattern

Red flag symptoms:
o Failure to pass meconium with 24hrs = Hirschprung’s disease
o Failure to thrive/growth failure = hypothyroidism, coeliac disease, other causes
o Gross abdominal distension = Hirschprung’s disease or other GI dysmolitiy
o Abnormal lower limb neurology or deformitiy = Lumbosacral pathology
o Sacral dimple above natal cleft over spine = Spina bifida occulta
o Abnormal appearance/position/patency of anus = abnormal anorectal anatomy
o Perianal bruising or multiple fissures = sexual abuse
o Perianal fistulae, abscesses or fissures = Perianal Crohn disease

Question 11

To understand the management of simple constipation / stool withholding

Answer 11

step 1: balanced diet, sufficient fluids & maintenance laxatives 
step 2 (faeces palpable in abdomen): macrogol laxative for 2 weeks 
step 3 (still not passed stool spontaneously): stimulant laxative +/- osmotic laxative
step 4 (still no success): enema or manual evac

Question 12

Be aware of features of history that differentiate soiling due to constipation and overflow and functional encopresis

Answer 12

encopresis = a toilet trained child (>4yrs) soiling their clothes - w/ constipation & overflow or without
functional encopresis: rare & ?psychological in nature
= never been toilet trained, toilet phobia, manipulative soiling or IBS

Question 13

Be aware of sources of support for children and families with soiling and encopresis

Answer 13

• GP
• paed gastroenterologist
• psychological & parental support
• support groups & online forums

Question 14

Understand aetiology, presenting features and management options of Hirschprung’s disease

Answer 14

= the absence of ganglion cells from the myenteric and submucosal plexuses in the large bowel and results in narrow and contracted segments = leads to an absence of coordinated bowel peristalsis and functional bowel obstruction at the junction between normal bowel and distal aganglionic bowel

presentation:
neonatal = failure to pass mec, intestinal obstruction, bile-stained vomit
later childhood = chronic constipation, abdominal distention, usually w/out soiling

manaegemnt:

• biopsy to determine site of transition zone
• pull through procedure (brings bowel down to anus)

Be aware of serious / life threatening complications (enterocolitis) and presenting features of Hirschprung’s disease

Question 15

Be aware of serious / life threatening complications (enterocolitis) and presenting features of Hirschprung’s disease

Answer 15

most important complication of HSD is enterocolitis= a dramatic gastroenteritic illness characterised by abdominal distension, bloody watery diarrhoea, circulatory collapse and septicaemia

Question 16

To be aware of current NICE guidelines on management of gastroenteritis including clinical examination relating to assessment of hydration

Answer 16

= inflammation of the stomach and intestines, typically resulting from bacterial toxins or viral infection, causing vomiting and diarrhoea
- common cause: rotavirus

Diagnostic indications: 
o Temperature  >38oC (<3 months) or >39oC (>3 months) 
o Shortness of breath 
o Tachypnoea 
o Altered state of consciousness 
o Neck stiffness 
o Bulging fontanelle 
o Non-blanching rash 
o Blood and/or mucus in stool 
o Bilious vomit 
o Severe abdominal pain 
o Abdominal distension/rebound tenderness 

manage w/ oral rehydration therapy / IV fluids if severe

Question 17

Understand suggestive features in history and recommended management infant with cow’s milk protein intolerance

Answer 17

• Symptoms depend on where the allergic inflammation is:
o Upper GI = vomiting, feeding adversion, pain
o Small intestine = diarrhoea, abdominal pain, protein-losing enteropathy, FTT
o Large intestine = diarrhoea, acute colitis with blood and mucus in stools and rarely chronic constipation
N.B: can occur in breastfed babies (if mum has had dairy) - presents as allergic colitis

management:
1. limit cow’s milk & soy protein intake = hydrolysed formula or maternal exclusion
2. elemental formula
NB: avoid sheep / goat’s / soy milk due to likelihood of cross-reactivity
3. consider cow’s milk protein chalenge after 6-12 months

Question 18

Understand the age range and clinical features of toddler diarrhoea

Answer 18

• stools vary in consistency from well-formed to sometimes explosive and loose
• often pale & foul smelling
• affected child is often well and thriving
• most children grow out of their symptoms but achieving faecal continence may be significantly delayed

Question 19

Offer reassurance from more serious forms of diarrhoea

Answer 19

= unlike coaliac disease, gastroenteristis, lactose intolerance, post-op bowel surgery or malabsorption, toddler’s diarrhoea has no associated symptoms and is intermittent

Question 20

Presenting features of Crohn’s & UC

Answer 20

Symptoms:
o Anorexia, weight loss & lethargy 
o Abdominal cramps 
o Diarrhoea ± blood/mucus, urgency & tenesmus 
o Fever 

GI signs: 
o Aphthous oral ulcers 
o Abdominal tenderness 
o Abdominal distension (UC>CD) 
o RIF mass (CD) 
o Peri-anal disease (CD)  abscess, sinus, fistula, skin tags, fissure, stricture